Warren

One of the risks we saw relates to your point, Dr. Bergquist. These Collaboratives are fundamentally about the development of people. And what that meant particularly for MAs was they got involved with management and they moved up. That was exactly what you wanted, but it could leave a hole in the staff of the residency. So, you didn’t want to do it too much, but you wanted to encourage people.

Bill B

One of the things we discovered in our work with higher education institutions is that these regional cooperatives worked and made sense back on campus if they had the support of the people at the top of the organization. If they were indifferent to what was going on at the top, well, what’s going on is nice. Give these people a little time off. They can go to Nashville, that’s nice. Or they were frightened of it. Someone says: “These people are coming back with these weird ideas. We never should have let them head off.” Then we had some of those in leadership roles who were real champions of what was happening. And we found it made a big difference.  So it’s interesting. We’re talking about the medical assistants. In some ways what makes the difference is what’s happening at the bottom of the pecking order. In other ways, what makes the difference occurs at the top. So, is what I’m talking about also relevant in medicine?

Warren

Acutely relevant. But the question is: how do you make sure? There’s a lot of levels of agreement and you don’t really know. They can sign off. We said, well, write a letter. They can write a letter, but are they actually supportive in the end? There were some who were not supportive, but most were. But how much beyond the letter? That’s part of why we went in to get a quality director and tried to bring them into focus groups to get them more engaged. So, I think getting the champions at the upper level is critical. How you do that? And then the problem becomes one of turnover at that level. We had less turnover of program directors until the end of the collaborative, but turnover is a problem.  It’s just something you have to manage as you go.

Jeremy 

I would add to that. I think high-level leadership can do more damage and hurt you and slow you down probably more than they help you. This is often the case because they’re so distracted. You can kind of get sign off on many things. But I think that’s part of where we’re getting to. This sense of the critical mass that I’m hearing in this conversation. If you can hit a critical mass and get your own resources, then you’re not dependent on your health system’s leaders.