Lessons on Effective Collaboration From the California Health Workforce Project

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For decades, California, like much of the United States, has struggled with gaps in its health care workforce. Today, seven million Californians live in Health Professional Shortage Areas—a federal designation for counties experiencing shortfalls of key health care providers. These shortages disproportionately affect California’s low-income population and Latinx, Black, and Native American communities, and are most severe in some of California’s largest and fastest-growing regions, including Los Angeles, San Joaquin Valley, the Inland Empire, and most rural areas.

The crisis is expected to worsen in the next decade as the state’s population continues to age and grow more diverse and as Baby Boomers in the health workforce retire. By the year 2030, California faces a shortage of 4,100 primary care providers and 600,000 home care workers and will have only two-thirds of the psychiatrists it needs. These deficiencies will exacerbate already serious problems with rising health care costs, timely access to care, and disease prevention.

California, in many ways, is a microcosm of the nation. One report estimates the United States will struggle to hire the 2.3 million new health care workers it will need by 2025. While every state is unique, California's efforts to expand its health workforce could help show the way forward for the rest of the nation.

To find long-term solutions to the workforce crisis, the California Health Care Foundation, California Endowment, The California Wellness Foundation, Blue Shield of California Foundation, and the Gordon and Betty Moore Foundation came together in 2017. It was the first time all five foundations had collaborated on an initiative. As contributors to the project, the authors' collective work included helping with project design and product review, overseeing and supporting grantees and partners, editing and distributing a final report, and analyzing the entire undertaking to suggest improvements for future multi-funder collaborations.

Though the foundations shared a common aim, their priorities and approaches were different. Some primarily wanted to improve access to health care services. Others wanted to address the ethnic and racial diversity of the health workforce or increase the number of non-clinical staff, such as community health workers or peer specialists.  However, they all agreed on the need for collaboration.

The foundations began by creating a commission of prominent, diverse leaders from California's health, education, employment, labor, and government sectors to signal the gravitas and complexity of the issue. Among them were Janet Napolitano, president of the University of California—a major health provider and America's largest health sciences education system—and Lloyd Dean, president and CEO of Dignity Health, one of the state’s largest health systems and health employers. The commission's job was to craft authoritative recommendations for solutions and to inspire bold action by the new governor, legislators, and other stakeholders.

The foundations also formed a grantee team, headed by two experts on health workforce issues, who would facilitate the commission and produce written recommendations based on the commission’s deliberations.

Questions quickly arose among the three core groups—the funders, the commission, and the grantee team— about who had the power and responsibility to make decisions.

The commission's structure amplified the complexity. It included a plenary table, three topical subcommittees, a technical working group, and a stakeholder engagement team. This approach improved the inclusivity and productivity of the commission, but introduced a challenge: Which of the hundreds of recommendations offered up should the commission prioritize for action? An ambitious timeline added to the pressure—the funders wanted the recommendations completed within 18 months to ensure the newly-elected governor of California could factor them into his first budget.

In terms of outcomes, the project helped to generate $300 million in new health care workforce development funds in Governor Gavin Newsom’s inaugural budget, spurred a new wave of legislative activity, and raised the visibility of health care workforce issues across California. Yet there were many challenges along the way, some of which were avoidable. The complexity of the project and partnerships at all levels posed difficulties. As a result, the funders ran into significant overruns in both time and budget. These experiences gave us insight into solving complex problems through multi-funder projects—observations that may prove particularly useful as the world continues to fight the COVID-19 pandemic, climate change, racial injustice, and other complex issues. Three lessons stand out:

1. Clarify Everyone's Expectations and Assumptions at the Start

It is important in complex collaborations to make sure all participants understand that they may not achieve every one of their individual goals, or that some objectives may be reached in ways they find less than ideal. Of course, the first step to communicating those caveats is learning what people's individual aims and expectations actually are. In retrospect, we should have done more to surface this information early on so we could better manage differing perspectives on key aspects of the project, such as the role of participant input, product quality versus timeliness, and balancing evidence of impact with emerging innovations.

Here are some steps to take to clarify where everyone stands:

• Early in a project, determine whether any funders have specific outcomes and processes in mind, and delve into the perspectives and potential biases shaping these expectations. Encourage all parties to share their priorities and assess whether they are agreeable to everyone involved, compatible with the project's goals, and practical to achieve. If they are not, be prepared to either negotiate a compromise—being clear about what you are and are not willing to give up—or decide on an alternative funding strategy for the project. If the funders are seeking to achieve a specific outcome, devote significant time at the beginning of the effort to define and document the desired outcomes, success metrics, deliverables, timelines, and skills that grantees should possess.
• Have early conversations about the perspectives and biases that affect each funder's determination about what is important in terms of desired outcomes and process. This creates a chance to discuss uncomfortable topics and make compromises.
• Funders should describe how they perceive the resources they are bringing to the table. Some define resources as dollars. Others add subject matter expertise and relationships into the calculation.
• Have candid conversations about the equivalency of financial contributions, and if and how they should impact decision-making or accountability. Funders with smaller endowments or payouts may feel their contributions are equal to larger investments by funders with greater resources.
• Funder-to-funder negotiations can be challenging, particularly if staff come from different levels of an organization, or if a project's high-profile or risky nature increases the consequences for participants in the case of failure. Consider hiring an outside facilitator free of such dynamics to help funders reach agreement.
• Provide an exit route. Difficult upfront conversations and compromises may make some funders think twice about their participation. Give them the time to assess their involvement and make sure that leaving a collaboration is acceptable.

2. Establish Clear Internal Roles and Processes

Some funders preferred a hands-off method with their grantees and weren’t accustomed to active collaboration or giving direction. Others were used to working hand-in-hand with grantees and having a high degree of input into decisions and products. The group never fully discussed these differences, nor their decision-making processes, accountability structures, or how to respond to things going wrong. The presence of grantee co-leads and commission co-chairs—effectively creating three leadership groups without clearly defined authority or well-mapped relationships to one another—exacerbated the confusion. As a result, the funders failed to name issues as they arose, all of them stepping back and assuming someone else was in the lead as the project went off track.

To ensure clarity about roles, decision-making authority, and work processes, we suggest taking these steps:

• Determine the roles of the various funders and articulate their responsibilities. It is important that one of them serve as project lead. At a minimum, the organization taking on that responsibility must accomplish two tasks: ensure that all funders’ voices are heard, and confirm and communicate funder-related decisions.
• Figure out who speaks for each funder and how the funders will make decisions. Are all decisions to be made by consensus? Will the “votes” be equal or proportional to resources contributed? Does each organization or each representative get one vote? Does the project lead have the authority to make certain types of decisions after consulting with the other funders?
• Define and document decision-making responsibilities among the larger group of funders, grantees, and other involved groups. Which decisions will require consensus and among whom? To whom can some be delegated?
• Again, provide an exit route if disagreements cannot be resolved.

3. Work With Grantees in a Smart and Consistent Way

Due to a need to move quickly and the rarity of renowned experts in health workforce issues, the funder group used an informal process rather than a competitive bidding process to select a grantee team. That led to the funders foregoing the creation of a formal document that defined the grantee’s expected scope of work, roles, responsibilities, project management expectations, and deliverables. This lack of clear expectations from the funder group was exacerbated by the fact that the grantee lacked expertise in process management. Once the project was in motion, it became difficult to step back to establish guidelines for the work as daily tasks demanded the attention of funders and the grantee. The funder group and grantee focused on moving forward quickly and didn't pause to adjust the plan, budget, or timeline. They failed to decide how to incorporate an influx of new ideas and had only abstract conversations about the final deliverables, leaving room for too many different interpretations. As a result, the first draft of the commission’s report was different in structure, content, and formality than some of the funders expected. They believed the report needed significant work before it could be published. That and other factors caused the funders to dramatically restructure the project for the final stretch.

To ensure ongoing alignment between grantees and funders regarding expertise, expectations, and deliverables, we suggest taking these steps:

• Use a competitive bidding process to vet and select your grantee. This helps clarify, for both the funders and grantees, success indicators, scope, deliverables, timelines, process, and skill sets. Even if the funder group has a grantee in mind, the discipline of developing the request for proposal enables funders to test their assumptions.
• Ensure the funder group is clear on the mechanics of evaluating bids and selecting the grantee. Who will determine selection criteria? Who will ultimately make a decision?
• Consider the grantee’s relevant management expertise—including their skill in designing collaborative work processes, running meetings, delegating decision-making authority, and selecting and prioritizing recommendations. Not all subject matter experts possess management expertise or have skills in facilitation, both of which are essential for the success of complex, multi-stakeholder efforts.
• Funders and grantees should agree on: the manner, frequency, and content of grantee progress reports; whether payments should be tied to milestones and deliverables; standards for the quality of deliverables; a process for documenting and deliberating on requested changes to scope, deliverables, and budget; and communication norms.
• Funders' project oversight must include: regular references to a project schedule when assessing whether everything is on track and on time; a process for handling project changes that accounts for the impacts on the budget, schedule, and deliverables; and a deadline, no later than halfway through the process, for a grantee to present a mock-up of a final product to project leaders.
• Funders should use common language in their contracts with the grantee to enforce and codify expectations, and ideally have shared deliverables, timelines, and aligned payment dates.

The Importance of Planning Ahead

There was wide agreement among the funders that collaborations like ours require a much greater investment in initial planning than we had anticipated. When analyzing the execution of the initiative with an outside consulting firm, we determined a project of this complexity would require roughly 18 weeks for planning and onboarding alone. That is a daunting but necessary period of time. It provides the space to ensure that everyone involved—from funders to grantees to commission chairs to subcommittee chairs—shares a vision of success and a detailed map for achieving it. That entails establishing clarity on how decisions will be made and by whom, and providing the ability for any participant to pause or adjust their contributions—or leave the project altogether.

Shortchanging initial planning will generate risks that take even more time to fix once the project has launched. It may also damage foundation relationships or limit the impact of the work. These insights have improved our ongoing work with grantees to improve California's health workforce. We hope they help the broader funder community as it takes on social issues that require similarly complex collaborations.

Read more stories by Karin Bloomer, Kathryn Phillips & Earl Lui.