The Stew BLOG

Avoiding Stewardship Pitfalls to Design a Strategy That Can Transform Health

Ruth Wageman, Senior Scholar & Advisor | 11/20/2018

In this sixth post in our seven-part blog series, we consider some of the common pitfalls leaders such as yourself face when creating a comprehensive regional strategy to transform health in a region, and what actions your team can take to get better and better at avoiding them.  

My colleague Bobby Milstein recently drew a distinction between a single organization’s strategic plan and what ReThink Health means by the “comprehensive strategy” that is integral to transforming health. One of the primary differences is that strategy development for a region’s health transformation—and a region might include a city, county, or multiple counties—can not be accomplished by a single organization. A regional strategy requires many organizations and groups to feel ownership of a vision for health and well-being for all residents. Because these stakeholders do not answer to a single authority, success requires that they choose to work toward the same end-game and not at odds with one another.  

At the same time, every organization participating in strategy development brings its own goals and priorities. The job of establishing the conditions to work together across traditional boundaries to more successfully and creatively lead health system redesign is what we call stewardship. Stewardship is an advanced form of leadership.

Transformative change across an entire region takes collaboration at many levels. Stewards need to come to the table wearing two hats—legitimately representing their own organizations and, at the same time, serving the community and all of its members as a whole. Inevitably, these two roles will come into conflict, and stewards will, at times, need to grapple with how to simultaneously and gracefully balance both hats.

In the strategy-making process for regional health transformation, questions around stewardship abound. Among the most common are:

(1) which organizations should be involved;

(2) whether the stewards trust one another enough to make hard decisions, and are trusted by the broader community to make those decisions; and

(3) how stewards can have the greatest chance of achieving change.

If left unresolved or if poorly addressed, these questions can evolve into issues that undermine the realization of smart strategies and render a well-conceived strategy ineffective, a mere theory on paper. We address these common pitfalls below, along with observations about how to overcome them.

Pitfall #1: The participants represent too narrow or too technical a set of perspectives

This pitfall arises for a few reasons. Sometimes, a team of like-minded leaders that comes together for well-intentioned change is unintentionally full of people who share the same background or experience. In many cases, the individuals represent organizations that tackle the same or similar issues, and therefore they may lack a comprehensive view of the array of positive outcomes a broader effort could achieve. In other words, it can be a bit of a club, full of the usual suspects. Many of us are tempted to surround ourselves with like-minded people, and are comforted by doing so. But in any effort to transform health, a diversity of perspectives is essential to creating good strategy. It takes a broad group to see the entire system and how it works in all its complex parts, and to commit to a range of interconnected aspirations that a whole region can get behind.

We have seen that diverse groups, incorporating members that have contradictory perspectives or reflect different values and experiences, often will espouse different theories of system change—and the creative abrasion brought about by these diverse perspectives can result in a better thought-out, more comprehensive strategy. It takes longer, it involves intense dialogue, and it can feel conflictual. But a well-led, well-facilitated diverse team has far greater potential to devise something transformative. So it is important to ask: does our strategy team include the right people, a shared purpose, and the best structure to succeed?

For example, King County, Washington, is one of six communities participating in ReThink Health Ventures, a project designed to explore what it will take to accelerate progress for regions already on the cusp of transformation. (You might remember King County from the second post in this series, which described a cross-sector group coming together to begin to create and enact a comprehensive strategy for the region.) One of the multisector partnerships leading change in King County includes representation from the County Executive’s office, city and county health departments, local philanthropies, health care delivery organizations, social service agencies, big and small businesses, youth development groups, grassroots community organizations, and new tech companies, among others.

This kind of institutionally diverse participation is necessary to transform the health ecosystem—because a region is an ecosystem, composed of many distinct entities that depend on and interact with one another. The King County team has focused on building alignment and engagement across these groups for the benefit of the region. By authentically involving so many sectors in its planning, the team is able to more effectively pursue an ambitious vision, as many diverse and well-positioned players see themselves as critical to advancing health and well-being in the region.

How can your multisector partnership be sure to include voices from across the spectrum? You might start by mapping your stakeholders to characterize who is already involved and who else ought to be represented in your effort. Are you including residents, and, perhaps more importantly, do you know how you want to include them? Once you answer these questions, you can develop processes to habitually engage with and learn from people with perspectives absent from the core group, perhaps by hosting regular community meetings or conducting one-on-one listening campaigns with stakeholders. All of these strategies could support your effort to recruit a broader group of leaders so you can pursue a more comprehensive vision.

Pitfall #2: The partners lack the mutual trust needed to decide priorities and are at risk of committing to a portfolio of work that makes sense only to them

When we talk about a comprehensive strategy, one important aspect is the portfolio of interventions (policies, programs, and practices) that a region pursues. Earlier in this series, Tami Gouveia described the theory of system change and portfolio of interventions that make up a regional transformation strategy. Determining a portfolio and choosing what to prioritize requires trust for a few reasons.

For one, because not all concerns can be pursued concurrently, participants in a partnership need to prioritize and come to agreement, which requires a level of trust. Secondly, some choices may not align perfectly with a participating organization’s priorities or business model. Lastly, the timing, sequencing, and investment of a high-impact portfolio requires saying no to some things—or at least “not now”—and participants need to agree on these decisions. All of this requires partners to trust the intentions and capabilities of their fellow partners– trust that might not come easily. Trust in each other allows a group to more effectively navigate competing interests.  

Regional health transformation requires a multitude of people with disparate skills pursuing an audacious goal. If they are going to succeed, they need to trust each other’s intentions and capabilities. Think about NASA’s goal to send astronauts to space. The movie Hidden Figures beautifully illustrates the range of people necessary to get a rocket off the ground. Mathematicians Katherine Johnson, Dorothy Vaughan, and Mary Jackson had very different skill sets than the engineers who built the rocket, who, in turn, had very different skill sets than John Glenn, the astronaut who piloted the capsule. But each of these roles was critical, and each of the players needed to deeply and sincerely trust each other if their aspiration to reach space was to succeed. That trust didn’t come naturally, but it grew as the disparate actors repeatedly displayed their abilities and desire to contribute to the shared purpose.

Health transformation seems perhaps a bit less dramatic—and it hasn’t yet inspired an award-winning film—but the same varied skill sets and alignment of purpose are necessary. The partners develop trust in one another as a consequence of meaningful accomplishment of shared priorities.    

But trust must operate at two levels—among the partner organizations within the group, and between the wider community and the leadership group. Even if the partner organizations reach alignment of priorities, if the partnership itself is not trusted by those who make up the wider region—for example, residents or regional organizations that may not be directly involved in the partnership’s activities—they won’t take the portfolio seriously. If a partnership has ambitions to transform the health of an entire region, it must be seen as a legitimate decision-maker by a broad range of stakeholders outside of the partnership.

Trust is integral to establishing legitimacy, and legitimacy cannot be assumed; it needs to be earned. You can earn legitimacy for your partnership by engaging many different voices in strategy conversations. Make sure that people across the region understand why the current strategy needs to be reviewed or refined, and then be clear that the partnership itself is not determining the strategy but leading a process to develop the strategy. One tool that can help is our Public Narrative Toolkit, which walks through ways to motivate and engage people to lead collaborative action. When many people are involved in strategy conversations and their views inform the resultant strategy, they are better able to trust the partnership to pull all that diverse thinking together into something coherent.

Pitfall #3: The partnership fails to attain broader influence because it is overly focused on the issues its members can most directly control.

Self-help books tend to advise focusing on those aspects of our lives that we can control. This is not good advice for leading health transformation. That’s because the most functional multisector partnerships directly control very little—and what they can control themselves will usually have limited impact.

Here, we use “control” to refer to the direct implementation of programs by the partnership. While many multisector partnerships implement some programs, they also play important convening and connecting roles in their community. Through their convening role, they facilitate dialogues to help participants in the partnership, other stakeholders in the region, and even other partnerships in the region, arrive at a shared vision for regional transformation, and determine the portfolio of programs and policies that can make that vision a reality. All of the players have important roles to play in the implementation of a broad portfolio. These include redesigning, prototyping, testing, and imagining new ways of enabling health. No single group could manage all of those roles alone.

An effective multisector partnership works best by leveraging relationships and suggesting, prompting, encouraging, inspiring, or influencing others to take action. Think about the strengths of your partnership and all of the sectors that are reflected in the membership. Consider how these sectors can best work together. What will empower them to achieve more? How can your partnership support and encourage many groups to lead in support of your shared strategy?

It is commonplace for a strategy to become just a clever theory on paper, sitting on a shelf collecting dust. If you are nodding to yourself, wondering why that might be the case for your work, consider whether your partnership has been felled by any of these pitfalls. Could more effective stewardship strengthen your partnership’s effort to create a comprehensive strategy? Let us know what you think! Comment below or email us at [email protected].

Comments are closed.