Leading in Public Health through Collective Impact

Introduction
Non-profits have worked in silos for many years to address specific issues and have seen successful results. Though silo work produces success, there are more social factors that contribute to sustaining outcomes, especially in the public health sector. To better address social issues across the board, a company named FSG (Foundation Strategy Group) created the Collective Impact (CI) model (Turner et. al, 2010). This model is expected to be the future of public health leadership, and the model fits into Institute for Alternative Futures’ (IAF) Public Health 2030 Scenarios to address population or community health to stray away from isolated impact and work together to utilize resources (Institute for Alternative Health, 2014). Collective Impact is utilized to move agencies out of silos and integrate efforts to improve topics like health, homelessness, addiction, and educational success. This framework is forecasted to be the future in public health leadership as it addresses community health in a collaborative format that mixes both public and private sectors. Leadership styles can vary in Collective Impact efforts, but transformational leadership is very relevant in addressing complex and social issues. In this chapter, we examine the Collective Impact (CI) Model and transformational leadership.

Background
Many nonprofits currently work in a category of “isolated impact” where it appears to be necessary to work with a single issue, but social problems are often very complex and require collaboration between multiple organizations. Isolated impact may contribute to temporary fixes, but there are typically multiple factors that cause the issue to reoccur (Kania & Kramer, 2011). Collective Impact recognizes that there is not one agency or organization who can solve social issues single-handed. One of the first documented implemented efforts of CI was by the Greater Cincinnati Foundation with their Strive initiative. Strive is an initiative in Cincinnati and Northern Kentucky that took the Collective Impact approach to address the student achievement crisis and successfully improved 34 of the 53 success indicators (Turner et. al, 2010). The recent push of “from cradle to career” has motivated many agencies to align by realizing changing one aspect on the educational continuum does not fix the problem. All aspects of the continuum must improve together to make an impact. They found that to observe improvements in students, it involved after school efforts, tutoring, nutrition, etc. More than 300 agencies and organizations were involved in the effort to improved student achievement through high school and set them up for college experience (Kania & Kramer, 2011).

Collective Impact is an emerging paradigm to address systemic changes. The CI framework relies on having “backbone organizational support” to ensure the effort creates progress and impact. A backbone organization ultimately guides the vision and strategy and supports the aligned activities by the overall coordination of the program/project (Kania & Kramer, 2011). In addition to backbone leadership, there are a few added requirements for the CI to be implemented; these include a common agenda, shared measurement, mutually reinforcing activities, and continuous communication (Kania & Kramer, 2011). If efforts do not have these five key elements, then CI may not be the most suitable framework. A project cannot use the CI framework unless all of those involved have a similar idea of the issue and ways of solving the issue with steps agreed upon. A shared agenda involves establishing boundaries or scope of the project and develop a strategic action plan (Kania & Kramer, 2011). It is necessary to work through challenges and put them aside so that the group does not dissolve or lose sight of the common vision.

Shared data is the only way to measure success consistently across the board; this could be one of the most difficult implementation steps. It is critical to consistently measure the same indicators to continue on a shared path and vision, as well as benchmarks. Shared data can identify patterns, strengths, and weaknesses while keeping those involved accountable for their part (Kania & Kramer, 2011).

Social issues are interdependent, therefore each entity involved has a different role to play, but it is necessary for all those involved to have a part that falls under the mutually reinforcing plan of action. CI is successful when there is clear coordination between all involved, rather than involving as many partners as possible (Kania & Kramer, 2011).

The most successful CI initiatives have multiple years of meetings and shared language, vocabulary, and visions (Kania & Kramer, 2011). In order to be successful, the initiatives had to learn to communicate effectively and learn to set their personal agenda aside for a solution that worked better. All interests are taken into consideration, but continuous communication allows for no single entity to be favored. The key to constant communication is the face-to-face conversations held at meetings. Kania & Kramer studied how the effective initiatives had the top-level leaders from each organization at in-person structured meetings. In many cases, such meetings are delegated to lower level staff and result in frequent absences (Kania & Kramer, 2011). By having leaders actively involved, there is a better likelihood that the project will have impact and success.

There are three phases to CI. The first phase is initiating action through identifying those to be involved, collecting data on the known issue to identify the known gaps, and facilitate community outreach (Hanleybrown, et al., 2012). After that is done, the framework moves into the second phase of organizing for impact. This is where a backbone organization and common agenda is identified, as well as establishing the shared metrics that will be used (Hanleybrown, et al., 2012). The final phase is sustained action and impact. In this phase there is continued engagement from the community and continual data collection to track progress. It is important to remain aligned with the initial scope of the project during this phase. Goals should be set at the beginning but may be flexible later on as long as they were established as critical points of success (Hanleybrown et al., 2012).

Collective Impact is an innovative approach to social change, but since introducing the framework early thinkers are now identifying “mindset shifts” as a critical component. These shifts include “who is engaged, how they work together, how progress happens” (Kania, Hanleybrown, & Splansky, 2014). To start, it is important to involve the correct people and cross-sectional organizations. Successes will happen, but it is important to not have individuals take credit when it is a joint endeavor; instead, all credit should be shared (Kania, Hanleybrown, & Splansky, 2014). Integrity to the framework is one of the most important aspects to funders. When money is put on the table, it is important to not use CI as a buzzword and stay true to inter-agency approach. The last mindset shift is moving from technical solutions to adaptive work (Kania, Hanleybrown, & Splansky, 2014). The social sector has always involved technical approaches but when using CI, there is not a known solution so there is a need to constantly learn and adapt. In many cases, CI stakeholders are encouraged to not look for the “silver bullet solution” but think of it as a “silver buckshot” that includes how everyone’s work fits into the larger puzzle (Kania, Hanleybrown, & Splansky, 2014).

Strengths
Across many public and private sectors, many health care professionals have common agendas that lead to mutually reinforcing activities; this alignment results in the collective impact framework and aims to make social changes that are longer lasting. This concept is now transitioning from the education realm to nutrition, including obesity, and is proving to be the future of healthcare (Boyce, 2013). For example, the United States Breastfeeding Committee (USBC) is currently using CI to create PSE changes to increase breastfeeding rates and eliminate disparities (Boyce, 2013). Funders also want to focus more on projects that achieve the most progress towards social problems instead of an isolated and narrow focused. This supports more groups to collaborate on their shared agenda to progress in creating solutions to social issues/concerns (Boyce, 2013).

Collective Impact is complex, but transparency can help combat that anticipated barrier. Every organization involved can benefit and learn together which leads to coordinated responses. Since CI aims to address social issues, there is not a predetermined solution and requires multiple players including government, private, and nonprofit sectors (Kania & Kramer, 2013). Creating a common agenda is an essential component of CI, but this step does not mean that there is a common solution; it means that everyone has a common understanding of the problem. Complexity is reduced when the collaboration realizes the common goals or possible steps to achieve the common goal (Kania & Kramer, 2013).

Also, there is a benefit to have cross-sector partners so that viewpoints are represented, specifically non-profits and funders. Rather than viewing CI as a solution, the CI Forum encourages viewing CI as a “collaborative problem-solving process (Collective Impact Forum).”

Weaknesses
While equality is the aim, the process needs to go one step further and think in terms of equity. While CI is normally aimed for the top levels of the organizations involved, community members need to be engaged to be most impactful. This thought process is normally overlooked, but for the community to feel they are fully heard, it is critical for participation and ownership. Frameworks like Community-Based Participatory Research (CBPR) can sometimes be better suited due to the interest in the community working with higher powers and officials.

One common example of such a structure is HEAL MAPPS (Healthy Eating and Active Living: Mapping Attributes through Participatory Photographic Surveys) presented by OSU Extension and the Kirwan Institute (FORC). Community members conduct the research about the strengths and barriers related to food access, food quality, and physical activity in areas where they live by mapping their routes and taking pictures along the way. The viewpoints are then turned into a story map and presented to community stakeholders; the issues identified can be tackled through CI (FORC).

Leadership is a critical point that is not initially addressed in the CI framework. Not only does the leader have to facilitate and manage, they also must convey a shared focus. This can be difficult among participants and their organizations, but commitment to transformational change can keep everyone aligned (Collective Impact Forum).

Co-production and Transformational leaders are typically more productive in the leader role for a CI project (Batalden et al., 2016). Transformational leaders are known for their charisma and inspiring followers (Northouse, 2015). These styles can complement the framework by followers staying motivated to produce change, especially those tied to a moral or value issue. Co-production has been used in many healthcare settings to ensure better patient involvement. Services are seen to be coproduced when producers and consumers both provide input on the product (Batalden, et al., 2016). CI could implement such concepts to have input and engagement from the community members to ensure sustainability.

While CI does indeed result in changes, the framework does not address the systems or policy changes to make impact sustainable without dispute. Changes in the environment can be enough for short term changes, but to see longstanding issues across a community, there needs to be more systemic practices put in place. CI could achieve such changes if policy makers and elected officials are stakeholders represented in the initiative, but the framework itself does not specifically point to policy for social changes (Wolff, 2016).

CI currently also does not have research to back up such practices and only has a few case studies to explain the successes of implementing. The concept of CI was not introduced until 2011 and has been deluging in Public Health ever since (Kania & Kramer, 2011).

While the popularity increases, more evidence is needed to support such complex and innovative thinking. The Collective Impact Forum is now a resource for many from do’s and don’ts to a small selection of featured case studies. Many large agencies, including United Way, are training partners on the CI framework to help serve communities and build off their mission of improving the common good in every community (Collective Impact Forum). Funders, including the Robert Wood Johnson Foundation, are looking more for innovative solutions that embrace collaboration (Boyce, 2013). With all the recent attention, it is only a matter of time for the published research to convert this weakness into a strength.

Additionally, backbone organizations are assumed to have sources to funding. Since many backbones are nonprofits, most apply for sufficient funding to truly carry out the desired project through grants or supply in-kind services, neither of which is permanent and sustainable. Due to the mix of public and private sectors in this framework, it is critical to be aware of potential conflicts of interest, mainly pertaining to the private sector and academics that have specific perspectives (Boyce, 2013).

Luckily there are a few opportunities for backbones to ensure the project has enough money to function. First, there are some initiatives that used “shared backbone” strategies, meaning there are two organizations that collaborate to become the lead on the project. This can combine financial resources as well as expertise in different subjects (Turner, et al., 2012). Secondly, as previously mentioned, funders are now looking for collaborative efforts and grantees that have the CI frameworks in place while applying for grants.

CI, Community Coalition Action Theory (CCAT), Quality Improvement, CBPR: Similarities and Differences among Models
Health promotion has been finding success among collaborative models for some time, but the most developed in terms of track-record is the Community Coalition Action Theory (CCAT). This theory helps support the Collective Impact framework, but there has not been significant research conducted over the success of the initiative. Like Collective Impact, CCAT promote collaboration to sustain change across multiple sectors while removing silos and duplication of efforts (Flood, et al., 2015).

One main difference between CI and CCAT is that CCAT focuses on community member involvement instead of CI model of public-private partnerships. The CCAT approach emphasize community residents’ involvement, which is opposite of the CI involvement of CEOs or leaders of organizations from the community involved (Flood et al., 2015). CCAT also focuses on sustainability regarding PSE change interventions and advocacy. The focus on advocacy and policy change that CCAT presents can “increase community capacity [while improving] health and social outcomes (Flood et al., 2015).

Tenderloin Healthy Corner Store Coalition Case Study
The case study of Tenderloin Healthy Corner Store Coalition, explained how CI was not planned, but the sense of urgency aligned with the framework. The coalition stemmed from the high rates of chronic disease and a tobacco-free initiative, which also led to the discovery of the food access and poor nutrition issues (Flood et al., 2015). The coalition trained five Tenderloin residents on food systems to become advocates, officially named “Food Justice Leaders.” This setup fell under Community-Based Participatory Research (CBPR) and took a bottom-up approach (Flood et al., 2015). The residents then took their findings and needs to policy makers. By doing this, officials are more likely to stand behind such efforts because there is community ownership of the problem, and they want to see change; in turn, this can become more successful and result in more sustainable changes (Flood et al., 2015).

As most would expect, they still encountered issues with funding and shifting mindsets, especially business owners. With some tweaking, they found that CI can be used for health education and promotion programs (Flood, et al., 2015). Tenderloin also had success because of the early recognition of silo work for tobacco, nutrition, and preventable disease. They did not have a defined leader per-say at the initiation of the coalition, but her influence and creation of the Food Justice Leaders fit into the CI framework as such (Flood et al., 2015). From there, the residents in combination with community organizations already conducting silo work created the coalition. Because of the involvement from public-private sectors, and the common agenda, the Tenderloin coalition moved from a CCAT approach into CI (Flood et al., 2015).

For many local and state health departments, there has been a push to address complex demands in innovative ways as we move towards accreditation. The San Francisco Department of Public Health’s (SFDPH) Population Health Division used the accreditation process as a promoter in restructuring the organization. In the process they found that Collective Impact was a “quality improvement framework applied to complex social problems (Aragon & Garcia, 2015).” They then produced the Health Equity X (HEX) model to serve as a visual representation on how complex, diverse, and connected all groups are, but it also can organize collective thinking (Aragon & Garcia, 2015). As SFDPH discovered, collective impact “complements other community-engagement approaches,” but will be of great use to public health due to many players having a common agenda and based on quality improvement (Aragon & Garcia, 2015).

As SFDPH pointed out, Collective Impact does have similarities to quality improvement frameworks. According to IHI, a quality improvement project determines specific aims, establishes measures, and selects changes (Institute for Healthcare Improvement). Setting the aim is basically making a SMART (Specific, Measurable, Achievable, Relevant, Timely) goal, like Collective Impact’s shared agenda. Establishing measures is simply that, trying to find ways to measure if the change actually improved the problem presented. CI takes the measuring concept a step further to have all agencies involved agreeing to track and measure in the same ways. Selecting changes in the IHI model is answered by asking “what change can we make that will result in an improvement (Institute for Healthcare Improvement)?” That step of quality improvement is present in CI’s key conditions of mutually reinforcing activities, and continuous communication.

Personal Relevance
After attending a training program on Collective Impact, I realized that it was the missing piece to help bring my vision to life in the community of Greene County, focusing on food access and insecurity. My career had led me to research areas where I found food deserts and abundances of dollar stores, like the Tenderloin neighborhood in San Francisco. This led to my role in co-initiating the Greene County Local Food Council. There was no doubt from the beginning that community members wanted to see change, but it was difficult for everyone in the room to agree completely. The group was comprised of educators, city officials, agricultural producers, public health employees, food pantries, and many others, but all viewed food access differently. Some saw economic development, while others saw improving health disparities and chronic disease. After months of discussions, the group had great ideas, created a mission and vision for the council, but there was no clear direction on how to implement any changes.

A few members of the council attended Collective Impact training, and suddenly it made sense; combine resources for a shared backbone support with projects of interest/focus to achieve smaller levels of documented success to support future funding opportunities. Greene County Public Health in combination with OSU Extension met to bring all the voices together, including health, nutrition, agriculture and natural resources, and economic development. The first project of interest for the council was implementing community gardens after completing community readiness assessments.

The leadership strategically selected the community gardens to begin the project to keep all established working groups involved in some sort of aspect and eliminated opportunities of favoring a single agenda. Adding a garden to a neighborhood in a food desert helps with food access and health, while getting food producers or Master Gardener Volunteers involved, teaching communities to make their own sustainable fresh food systems. At the same time, it also allows elected officials to gain more perspectives from community members on what they value and opportunities for future economic development, like creating farmers’ markets.

While the Greene County Local Food Council project fits well into the Collective Impact model, there were some concerns. The main concern was funding. A group creating a coalition coming together to solve social issues do not necessarily do so with funds at the initiation.

For this project we were mainly providing in-kind services with support from an outside grant. Second, the group struggled to find ways to collect and share measurable data. While many members of the council were collecting their own data, we still struggled on how we all collect the same measurable to know the impact on the social issue and not just the action item at plan. Lastly, we did want as much community say as possible, so we started with readiness assessments to see if we were problem-solving in a manner that agreed with residents of the community. Once we got the community buy-in, the council then shifted to having the community residents take ownership of projects to truly make the changes sustainable.

Leadership and Collective Impact
Successful leaders of CI projects are curious. They embrace uncertainty, but it never deters them from the end destination (Kania & Kramer, 2013). Leadership in these models relies greatly on goal-setting. Path-goal theory can explain how CI works. Leaders motivate followers in a way that are preferred by the followers to successfully reach the end goal. CI is complex, as it is trying to solve social issues together so there are often obstacles that are encountered. In path-goal theory, the leadership removes such obstacles while defining goals, clarifying the desired path, and provides support (Northouse, 2015). Leaders following the path-goal theory are also described as being directive, supportive, participative, and achievement-oriented (Northouse, 2015). Directive leaders are clear in expectations and performance standards, while supportive leadership focuses on remaining approachable by treating followers as equals. Participative leaders would be preferred for CI frameworks because they value the ideas and opinions of followers; in CI, all agencies have value, and it is imperative that there is not one voice that is always valued over another. Achievement-oriented leaders emphasize high work ethics and excellence, but they also display that they have confidence in the followers that they can achieve the highest levels of success (Northouse, 2015).

Collective Impact also is described as a transformational change, therefore supporting transformational leadership. Transformational leadership is described as “a process that changes and transforms people. It is concerned with emotions, values, ethics, standards, and long-term goals” (Northouse, p.162). Like path-goal leaders, transformational leaders are charismatic and influence followers to achieve the highest level of work/success as possible.

In terms of motivation, transformational leaders empower followers and encourage them through change. Also, “they attempt to raise the consciousness in individuals and to get them to transcend their own self-interests for the sake of others” (Northouse, p.176). Transformational leaders also create a vision by combining interests of various individuals involved. This created vision serves as the guide for all to follow, just like a shared agenda in CI projects (Northouse, 2015).

The other correlation between CI and transformational leadership is that this leadership does not provide a clear set of instructions on how to conduct tasks, instead, it is a generalization that is adaptable (Northouse, 2015). By prescribing specific tasks the project can feel too restricting. In life and public health, there are constant changes so allowing for such complications can help the project become more relevant and individualized for the community. Like previously mentioned, CI is viewed as collaborative problem-solving which needs to be tailored for each specific community to serve those effected (Collective Impact Forum).

Summary
As Collective Impact theory is emerging, we can compare how these efforts differ from other forms of collaboration which can be identified through the five key conditions: common agenda, shared measurement, mutually reinforcing activities, continuous communication, and backbone support. These factors combined provide the platform for larger success in social progress, but there is more needed for effective population level changes, one being that the project focuses on equity, including class and race. Collective Impact must adapt to the needs of the community while building trust and relationships with residents and partner agencies (Kania and Kramer,2011).

Collective Impact is a framework that has crossed into many topic areas to address and problem solve social issues. Public Health has worked in silos for many areas in what is now defined as isolated impact. While individual areas have achieved successes and improvements, there is a lack of systemic change because most issues span across multiple areas. CI was created to encourage collaboration to fix social issues, rather than temporarily fixing one issue at a time (Hanleybrown, Kania, & Kramer, 2012).

While CI has strengths, including preference in funding opportunities and the public-private cross sector involvement, there are some challenges to using this approach. Most stem from community involvement from residents rather that CEOs and leaders of agencies involved in the collaborative effort (Flood et al., 2015).

To truly have sustainable change, residents are encouraged to be involved, and the collaboration should promote a system and policy change. Collective Impact is evolving and becoming more relevant. Community-Based Participatory Research (CBPR) has been using community involvement to conduct evidence-based practices and taking into to leadership and stakeholders to see change (Flood et al., 2015). Others have argued that CI is a type of quality improvement project because both have a specific aim, form of measure, and select a change to see impact and change as a result. The Community Coalition Action Theory also exhibits similarities to CI in that they both encourage collaboration and removing silos to improve the well-being of the community (Flood et al., 2015).

Leadership plays a large role in the effectiveness and success of CI projects. Leaders are there to motivate, direct, and able to set goals for followers. The path-goal theory helps explain CI since leaders motivate followers so that they feel capable of doing the work and achieve results to improve the social issue identified (Northouse, 2015). Transformational leadership is also preferred due to the similarities in this style and the design of the CI framework: creating a vision using opinions from all involved, motivating to work at follower’s highest levels to improve the common good and generalized guidelines to transform for the community (Northouse, 2015).

Collective Impact will be discussed heavily in the future of Public Health and population health management. Public Health 3.0 will focus on communities working as a cross-sectional collaboration, including a mix of private and public stakeholders to improve the social determinants of health, much like CI. Also, shared data is represented in the proposed scenario to share across communities to assess the level of change and how it increases equity (U.S. Department of Health and Human Services).