Factors contributing to successful interorganizational collaboration ...

Original Research

Factors Contributing to Successful Interorganizational Collaboration: The Case of CS2day

CURTIS A. OLSON, PHD; JANN T. BALMER, PHD, RN; GEORGE C. MEJICANO, MD, MS Continuing medical education’s transition from an emphasis on dissemination to changing clinical practice has made it increasingly necessary for CME providers to develop effective interorganizational collaborations. Although interorganizational collaboration has become commonplace in most sectors of government, business, and academia, our review of the literature and experience as practitioners and researchers suggest that the practice is less widespread in the CME field. The absence of a rich scholarly literature on establishing and maintaining interorganizational collaborations to provide continuing education to health professionals means there is little information about how guidelines and principles for effective collaboration developed in other fields might apply to continuing professional development in health care and few models of successful collaboration. The purpose of this article is to address this gap by describing a successful interorganizational CME collaboration—Cease Smoking Today (CS2day)—and summarizing what was learned from the experience, extending our knowledge by exploring and illustrating points of connection between our experience and the existing literature on successful interorganizational collaboration. In this article, we describe the collaboration and the clinical need it was organized to address, and review the evidence that led us to conclude the collaboration was successful. We then discuss, in the context of the literature on effective interorganizational collaboration, several factors we believe were major contributors to success. The CS2day collaboration provides an example of how guidelines for collaboration developed in various contexts apply to continuing medical education and a case example providing insight into the pathways that lead to a collaboration’s success. Key Words: interorganizational, collaboration, continuing education, health professions, interprofessional, case study, smoking cessation

Introduction Continuing medical education’s (CME’s) transition from an emphasis on dissemination to changing clinical practice has made it increasingly necessary for CME providers to develop effective interorganizational collaborations. There are several reasons why we believe a focus on improving practice requires a more collaborative approach. First, interventions aimed at practice change almost invariably must be more Disclosures: The authors report that the conduct of the presently reported study was funded by Pfizer, Inc. Dr. Olson: Assistant Professor, Department of Medicine, Office of Continuing Professional Development in Medicine and Public Health, School of Medicine and Public Health, University of Wisconsin–Madison; Dr Balmer: Associate Professor, Director of Continuing Medical Education, University of Virginia School of Medicine; Dr. Mejicano: Professor, Department of Medicine, Associate Dean for Continuing Professional Development School of Medicine and Public Health, University of Wisconsin–Madison. Correspondence: Jann T. Balmer, PO Box 800711, Charlottesville, VA 22908; e-mail: [email protected]. C

2011 The Alliance for Continuing Medical Education, the Society for Academic Continuing Medical Education, and the Council on Continuing Medical Education, Association for Hospital Medical Education. r Published online in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/chp.20143

complex, multidimensional, and resource intensive, making it less likely that the requisite capabilities and resources will reside in any one organization. Second, change in practice may require change in systems, which often entails collaboration with a practice or health care organization. Third, practice change involves complex interventions in complex systems, and collaboration brings together partners with different and valuable perspectives on how to frame the practice change problem and who can provide a more extensive repertoire of strategies that might be used to address it. In addition, in a period of shrinking funding for CME and increasing health care needs of an aging population, there is an imperative to achieve greater efficiency by integrating and coordinating the efforts of multiple stakeholders who share the goal of improving the quality of patient care (eg, health care organizations, state and local governments, patient advocacy groups, professional societies). Collaboration between organizations has the potential to make interventions more cost-effective by reducing redundancy of effort, and produce greater value by capitalizing on the strengths of the partners. Although interorganizational collaboration has become commonplace in most sectors of government, business, and academia,1 our review of the literature and experience as practitioners and researchers suggest that the practice is less widespread in the CME field. The scholarly CME literature

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Olson, Balmer, and Mejicano

on interorganizational collaboration is limited, despite calls for a more collaborative approach to CME going back many years (see, for example, Moore et al’s 1994 article on a new paradigm for CME2 ) and an Accreditation Council for Continuing Medical Education accreditation criterion that encourages providers to “[build] bridges with other stakeholders through collaboration and cooperation” (Criterion 20).3 A PubMed search revealed that of the published articles addressing the topic of collaboration or partnership in the CME context, most focus on collaboration between the health professions4 or between researchers and rural communities,5 not collaboration between organizations. Two exceptions are projects reported by Pyatt et al6 and Shershneva et al.7 The former provided an example of interorganizational collaboration but did not directly address success factors. The latter identified shared goals, agreement on process, and clearly defined roles as important factors for collaboration involving a CME provider and rural primary care clinic aimed at improving hypertension management. Fortunately, there are major studies reported outside the medical education literature that identify guidelines for and provide models of success.8−11 The absence of a rich scholarly literature on establishing and maintaining interorganizational collaborations to provide continuing education to health professionals means there is little information on how guidelines and principles for effective collaboration developed in other fields might apply to continuing professional development in health care and few models of successful collaboration. The purpose of

this article is to address this gap by describing a successful interorganizational collaboration and summarizing what was learned from the experience, extending our knowledge by exploring and illustrating points of connection between our experience and the existing literature. We begin by describing the collaboration and the clinical need the collaboration was organized to address, and reviewing the evidence that led us to conclude the collaboration was successful. We then discuss, in the context of the literature on effective interorganizational collaboration, several factors we believe were major contributors to success. The CS2day Collaboration The CS2day (Cease Smoking Today, www.cease smoking2day.com) collaboration was created by 9 partner organizations (TABLE 1) with an interest in creating a national educational initiative aimed at addressing a major public health problem: tobacco smoking. The cornerstone of the collaboration’s educational initiative was a heavily researched evidence-based practice guideline published by the US Agency for Healthcare Research and Quality, initially published in 2000.12 It challenged health care professionals to identify the tobacco use of every patient at each visit and employ an evidence-based intervention strategy for treating tobacco dependence. This approach was organized around 5 key steps: Ask, Advise, Assess, Assist, and Arrange follow-up, also known as the 5 A’s.13 In 2007, when the

TABLE 1. Partner Organizations in the Cease Smoking Today Collaboration

Organization

California Academy of Family Physicians

Description

Not-for-profit professional organization, accredited continuing medical education provider

CME Enterprise

For-profit medical education company, accredited continuing medical education provider

Healthcare Performance Consulting

For-profit consulting firm

Interstate Postgraduate Medical Association

Not-for-profit educational association, accredited continuing medical education

Iowa Foundation for Medical Care

Not-for-profit quality improvement, care coordination, and medical information

provider

management organization Physicians’ Institute for Excellence in Medicine

Not-for-profit subsidiary of the Medical Association of Georgia, accredited continuing medical education provider

Purdue University School of Pharmacy and Pharmaceutical Sciences

Public university, accredited continuing pharmacy education provider

University of Virginia School of Medicine—Office of Continuing

Public university, accredited continuing medical education provider

Medical Education University of Wisconsin (UW) School of Medicine and Public

Public university, accredited continuing medical education provider

Health—Office of Continuing Professional Development in Medicine and Public Health

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JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS—31(S1), 2011 DOI: 10.1002/chp

Successful Interorganizational Collaboration

collaboration was forming, it was known that within the year a major update to the 2000 guideline would be released.14 The CS2day collaboration undertook a coordinated national effort to reduce the number of persons who smoke in the United States by facilitating the dissemination and implementation of these tobacco guidelines. The collaboration’s vision was an environment in which every smoker who wants to quit can do so with appropriate support, tools, and resources. It sought to realize this goal through a program of traditional and nontraditional educational activities aimed at multiple levels, including the individual provider, clinical team, and health care organization. The collaboration worked to improve identification and tracking of smokers, increase the use of counseling strategies, and support the appropriate selection and use of pharmacologic and nonpharmacologic therapeutic options to help smokers quit. Evidence of Success One measure of the collaboration’s success is its reach and scope of activity. As of September 2011, CS2day had reached over 48,000 clinicians from all 50 states and 68 foreign countries via certified education and derivative resources that include 282 live activities, 5 comprehensive performance improvement projects, 44 enduring activities, 8 educational exhibits, and a Web-based toolkit comprising 89 educational resources. Data on the educational outcomes of the initiative show that participants scored higher than a comparison group on measures related to 6 of 7 competencies. The majority of participants who responded to commitment to change questions reported actual and intended practice changes consistent with desired outcomes. Performance outcome measures used in 3 of the performance improvement (PI) activities showed variation in degrees of practice change, with greater improvements observed in 1 activity (9.0% to 36.2% mean improvement in compliance across 8 measures) and increases in mean compliance across all activities.15 A formative evaluation of the collaboration as a collaboration was conducted by one of the authors (CO) and an independent education consultant at the end of 2008 to assess the status of the partnership and identify potential areas of concern and opportunities for improvement. An adapted version of the Wilder Collaboration Factors Inventory incorporating both closed- and open-ended questions was administered online to the 9 partner organizations (TABLE 2). The Wilder instrument was the product of an extensive review and synthesis of the literature on factors influencing the success of collaborations between not-for-profit organizations, government, and businesses, originally published in 199216 and updated in 2001.10 For the CS2day survey, a total of 23 individuals representing all 9 organizations responded. As FIGURE 1 shows, there was a high degree of satisfaction on all dimensions assessed by the survey. Comments offered by the respondents suggested that although there appeared

to be no widespread concerns about the functioning of the group, some partners identified areas needing improvement, such as more communication about the programmatic activities of each of the partners, better documentation of partner expectations and requirements, and ensuring the survival of the collaboration after the initial funding runs out. However, the overall assessment of the survey respondents was highly favorable, as exemplified in the following comment: This has been an incredible learning experience for us as an organization, and for me personally. The opportunity to work with smart, dedicated partners and their teams has been tremendous. And an unintended consequence has been the friendships developed over the work.

Factors Influencing Success of Interorganizational Collaborations Our review of the collaboration literature identified 4 major studies of success factors that we thought were especially applicable to CME. The results of these studies are summarized and compared in TABLE 3. Perhaps the most widely known source on factors influencing the success of interorganizational collaboration is the seminal work done by Mattessich et al,10 which served as the foundation for the Wilder inventory described above. In 2000, Austin8 published The Collaboration Challenge: How Nonprofits and Businesses Succeed Through Strategic Alliances, containing descriptions of case studies of interorganizational collaboration. This work included a set of guidelines—the “Seven C’s of Strategic Collaboration”—for use in planning and assessing interorganizational alliances. Ovretveit et al11 examined evaluation results from assessments of interorganizational quality collaboratives such as the Institute for Healthcare Improvement’s Breakthrough Series.17 They identified several challenges that must be met to ensure the success of collaboratives and, from these, generated a list of recommendations for increasing the likelihood of success. In the nursing literature, Casey9 published a review of the literature aimed at identifying key factors for successful interorganizational partnerships and exploring how these factors apply in the context of organizations that provide midwifery and nursing education. The following sections discuss the major factors we believe were important to the success of the CS2day collaboration, highlighting points of connection with the factors identified by these four studies. Factors Influencing the Success of the CS2day Collaboration Based on the ongoing internal discussions among the CS2day partners, formal evaluations of the collaboration’s functioning, and our own critical reflections on the history of the CS2day initiative, we identified several factors that appeared to be major contributors to the success of the collaboration.


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Olson, Balmer, and Mejicano TABLE 2. CS2day Collaboration Survey Items

Dimension

Survey Item

Trust

Individuals involved in the CS2day collaboration always trust one another.

Respect

I have a lot of respect for the other people involved in this collaboration.

Inclusiveness

All the organizations that we need to be members of this collaborative group have become members of the group.

Benefit

My organization has benefitted from being involved in this collaboration.

Time

The organizations that belong to our collaborative group invest the right amount of time in our collaborative efforts.

Commitment

The level of commitment among the collaboration participants is high.

Timely Decision Making

When the collaborative group makes major decisions, there is always enough time for members to take information back

Flexibility

There is a lot of flexibility when decisions are made; people are open to discussing different options.

Role Clarity

People in the CS2day collaborative group have a clear sense of their roles and responsibilities.

Decision-Making Process

There is a clear process for making decisions among the partners in this collaboration.

Adaptability

This collaboration is able to adapt to changing conditions, such as fewer funds than expected, changing political climate,

to their organizations to confer with colleagues about what the decision should be.

or change in leadership. Work Load

This collaborative group has tried to take on the right amount of work at the right pace.

Pace of Work

We are currently able to keep up with the work necessary to coordinate all the people, organizations, and activities related

Communication

People in this collaboration communicate openly with one another.

Leader Communication

The people who lead this collaborative group communicate well with the members.

Knowledge of Goals

People in our collaborative group know and understand our goals.

Reasonableness of Goals

People in our collaborative group have established reasonable goals.

Dedication to Success

The people in this collaborative group are dedicated to the idea that we can make this project work.

Comparison to Other

No other organization in the CME field is trying to do exactly what we are trying to do.

to this collaborative project.

Collaborations Resources/ People Power

Our collaborative group has adequate “people power” to do what it wants to accomplish.

Skills of Leaders

The people in leadership positions for this collaboration have good skills for working with other people and organizations.

The Choice of a Clinical Focus “Choosing the right subject” has been identified as a major challenge for collaborations.11 We believe the choice of tobacco smoking as a clinical focus was one key component of our success. There were several aspects of tobacco that align well with characteristics of “good subjects”: • An important problem.11 A strategic approach to choosing clinical topics for continuing medical education begins with the identification of an important public health need linked to one or more professional practice gaps.18,19 With the possible exception of obesity, it is difficult to identify a health threat that is more potent than tobacco smoking. Tobacco smoking is the single most preventable cause of death in the United States.20 Changes in smoking cessation rates directly affect overall life expectancy, respiratory diseases including chronic obstructive pulmonary disease, smoking-related malignancies, coronary artery disease, stroke, low-birth-weight babies, hip fracture, and peptic ulcer disease.21 S6

• A specific problem. In general, initiatives that address specific subjects relating to clinical practice and treatment processes (such as tobacco cessation) are more likely to succeed than those focusing on broad subjects, such as “improving coordination between primary and secondary care.”11 • Strong, credible evidence of effective interventions.11 Both the 2000 and 2008 tobacco guidelines were the product of systematic review and analysis of hundreds of rigorous studies and were created under the auspices of the US Agency for Healthcare Research and Quality; the Centers for Disease Control and Prevention; the National Cancer Institute; the National Heart, Lung, and Blood Institute; the National Institute on Drug Abuse; the Robert Wood Johnson Foundation; the American Legacy Foundation; and the University of Wisconsin School of Medicine and Public Health’s Center for Tobacco Research and Intervention. The pedigree of these guidelines and the exceptionally robust body of research that informed them helped to form a compelling rationale for choosing smoking as the clinical focus of the collaboration. • Evidence of gaps between desired and actual practice.11 Our review of the literature found there was strong evidence that



FIGURE 1. Mean Partner Ratings on Multiple Dimensions of CS2day Collaboration (n = 9). Survey Based on the Wilder Collaboration Factors Inventory

a clinical performance gap still existed in relation to the 2000 guideline.22−24 Among the findings were that about one-third of primary care physicians did not consistently address smoking status with their patients; 26% of primary care physicians did not advise each patient to quit smoking; smoking cessation counseling occurred in 23% to 46% of visits to primary care providers; only 2% of smokers received pharmacologic support; and only 8% of primary care physicians followed up with smoking patients.25 In addition, we anticipated that the updated guideline would introduce changes in recommended practices, creating new guideline performance gaps. • Motivation for change.11 We assumed that virtually all health care professionals were already highly aware of the health effects of smoking and the importance of helping their patients quit, and that their interest in making changes in their practice might be enhanced with the release of the new guideline, an assumption that was borne out by our needs assessment and evaluation data. As a result, we expected that the CS2day program would be able to attract health care professionals who thought making changes were important and who would be motivated to take action. • A connection between purpose and people.10 Many of the individuals involved in the collaboration had a strong personal and emotional connection to its mission—as current or former smokers, as friends or relatives of people who had suffered the health consequences of smoking or had tried unsuccessfully to quit, as health care providers who knew well the challenges of encouraging their patients to quit and stay quit.

Environmental Factors8 There were several environmental factors that we believe were also highly relevant to the success of the collaboration as well. The Center for Tobacco Research and Intervention (CTRI), located at the University of Wisconsin–Madison, was the lead organization in the development of the 2000 and 2008 tobacco guidelines. Staff members at CTRI served as scientific advisors to the CS2day initiative, vetting educational content and providing ongoing consultation on the tobacco cessation research. The physical proximity of CTRI to the UW Office of Continuing Professional Development

in Medicine and Public Health and a history of formal and informal relationships between the 2 units greatly facilitated communication and coordination of efforts. The impending nationwide release of the updated tobacco guideline was another key environmental factor. Its release meant that there would be a need for a large-scale dissemination and implementation effort. For the 2000 guideline, CTRI had primary responsibility for dissemination, and it was anticipated that the Center would have a similar role with regard to the update. Importantly, CTRI was not opposed to CS2day’s proposed role in dissemination and implementation of the guidelines, since the support of key opinion leaders and organizational stakeholders both within and outside of a collaboration is considered an important factor in successful collaboration.8 One fortuitous event was the approval by the US Food and Drug Administration in 2006 of a new pharmacologic agent for use in smoking cessation. This agent employs a unique mechanism of action, working as a partial agonist for selective nicotinic acetylcholine receptor subtypes, which means that for many patients, their “cravings” are greatly reduced. The new guideline added this medication to nicotine replacement and antidepressant medications, providing a broader range of pharmacologic options for smoking cessation. We believe these environmental factors were an important source of clinician motivation to change. In 2007, the conventional wisdom was that the momentum created by the release of the 2000 guideline was ebbing. Most of the smokers who were good candidates for successful quit attempts had already given up smoking, and clinicians and patients alike were becoming fatigued with repeated attempts to motivate smokers to make a change. However, the convergence of the release of an updated guideline containing new evidence about effective health care professional interventions and the incorporation of novel and combination pharmacologic and nonpharmacologic therapeutic options into the guideline combined to give both clinicians and smokers new reasons


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for hope and create an environment favoring a national educational initiative on smoking cessation. Organizational Structure and Processes8,9,11 How collaborations structure themselves and the policies and procedures they put in place are also key factors for success. Early on, the group recognized the need for an organizational

structure and administrative mechanisms that supported the work of the collaboration without imposing an undue burden on partner resources. The collaboration addressed this need by creating a governance and oversight framework incorporating processes for decision making, fiscal administration, management, communication, and conflict resolution. The design of the governance structure for the partnership was crucial to the success of the collaboration. The group felt it

TABLE 3. Comparison of 4 Models of Effective Interorganizational Collaboration

Source

Context

Mattessich10,16

Collaborations between nonprofits, government

Austin8

Collaborations between

Ovretveit et al11

Quality collaboratives∗

nonprofits and businesses

sectors of nursing and

organizations Factors influencing success of collaborations

Collaborations between education and health care

agencies, other

Focus

Casey et al9

midwifery education Questions for partners to assess a collaboration

Guidelines for successful collaboration

Key factors in interorganizational partnerships

Method

Review of the literature

Case studies of successful collaborations

Common findings from

Review of the literature

evaluations of collaboratives

Findings Purpose

Clarity of purpose (eg,

Factors related to purpose

written purpose

(eg, concrete, attainable

(eg, evidence change is

statements, function and

goals; shared vision;

effective, proposed change

relative importance of

unique purpose)

is important, motivation to

collaboration) Organization

achieve change) Factors related to process and structure (eg, clear roles and policies, member

Communication

Communication between

Relations

Defining roles and making clear what is expected Ensuring teams have

stake in process and

measurable and achievable

outcome)

targets

Factors related to

A partnership framework (eg, shared goals, governance structures, power sharing) Equity and involvement in decision making Communication and

partners (eg, respect and

communication (eg, open

interaction within the

trust between partners,

and frequent

partnership

constructive criticism,

communication; formal

communication channels,

and informal

coordinated strategy) Interpersonal

Choosing the right subject

Connection with purpose and

communication) Factors related to

people (eg, personal/

membership

emotional connection to

characteristics (eg, mutual

subject, interaction

trust, appropriate

between senior leaders,

members, ability to

interpersonal bonds)

compromise)

Trust and valuing the partner

(Continued)

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TABLE 3. Continued

Source

Partner Alignment

Mattessich10,16

Austin8

Congruency of mission,

Ovretveit et al11

Casey et al9

Ensuring participants define

strategy, and values (eg,

their objectives and assess

mutual understanding of

their capacity to benefit

each partner’s business,

from the collaborative

alignment with mission and strategies of each partner, shared vision) Commitment to the partnership (eg, level of organizational commitment, trend in organizational investment) Team Building/

Ensuring team building and

Development

preparation by teams for the collaborative Equipping teams to deal with data and change challenges Motivating and empowering teams

Partner Learning

Continual learning (eg,

Enabling mutual learning

learning to collaborate,

rather than carrying out

growth within

teaching

collaboration, assessing learning from collaboration) Change

Planning and learning for

Management

spread

Leadership and managing change

Learning and planning for sustaining improvements Other

Creation of value (eg, how

Factors related to the

partners benefit,

environment (history of

benefit/risk balance, equity

collaboration, social and

in benefits, new value

political climate)

created by collaboration)

Factors related to resources (eg, funds, staff, materials, time; skilled leadership)

∗

“A [quality] collaborative brings together groups of practitioners from different healthcare organisations to work in a structured way to improve one aspect of the quality of their service.” (Ovretveit11(p34) )


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was essential to create a structure that provided for consistent and effective leadership, management, and administration, while remaining responsive to changing needs of the partners and external conditions. To that end, the partners created a 4-person executive committee vested with responsibility for overseeing the initiative, with members selected by the partners. Agenda items for the executive committee and all-partner meetings could be suggested by any partner, but were most often identified by the executive committee. An explicit goal within the collaboration was to create structures that allowed power sharing, recognized as a success factor for collaborations.9 All decisions affecting the CS2day collaboration as a whole allowed the participation of all the partner organizations. One person from each of the 9 organizations was designated as the voting member. Most decisions were made by consensus, although the group did employ majority rule when consensus was not attainable. With regard to fiscal management, 1 partner served as the “banker” for the collaboration. With the approval of the other partners, they implemented processes that ensured effective fiscal management and accountability across the many components of the initiative. Clearly defined and transparent processes for the submission and approval of budgeting for program components (direct resources) and administrative support (indirect resources) were important in creating and sustaining the trust that is recognized as critical to successful collaboration.8,9 The CS2day collaboration was fortunate to have a single primary funding source in industry, which served to simplify financial and reporting requirements. This funding was augmented and expanded, with financial and in-kind resources provided by each of the CS2day partner organizations. No attempt was made to systematically document partner contributions, but attention was paid to issues of equity, fairness, and ability to contribute.

Shared Vision and Purpose8,10,11 A commonly identified success factor is having a shared purpose that is clear and well aligned with the mission, strategies, and values of each of the partners. An important step was getting the 9 partners to develop a shared vision for the CS2day program and the scope of the activities it would encompass. When the collaboration began, there were divergent opinions on nearly all the critical questions, including the goals, scope, strategy, and target audience for the initiative. We used a 3-round modified Delphi Process led by one of the authors (CO) to clarify our shared vision for the initiative, prioritize goals and objectives as well as target populations, identify programmatic elements, establish general strategies for facilitating practice change, and outline an approach to outcomes assessment. The willingness of the participants in this process to remain open to others’ perspectives, advocate for their own ideas, and, as needed, to compromise in order to maintain group cohesion8 were essential to the success of the Delphi Process. S10

The outcome of this process was a formalized guiding framework, within which all partners agreed to operate. The scope of the initiative provided opportunities for each organization to contribute from their primary areas of strength (eg, research capacity, expertise in outcomes assessment, grant writing, content mastery, technical know-how, networks of learners, connections with health care organizations across the country). Communication8−10 There were several communication challenges that the collaboration needed to address across the life of the initiative. This included how communication among the partners would be managed and the choice of internal and external communication channels. Initial planning sessions were conducted face-to-face, with all partners represented. We believe these early face-to-face meetings were essential not only for working through several key issues but also for helping to transform the group from an aggregate of individuals into an effective, functioning team.11 These meetings were also forums in which subject matter experts such as representatives from CTRI worked with the group to help integrate the scientific evidence into the planning process. Monthly conference calls and semiannual face-to-face retreats were held by the group to deal with routine business and major issues. Frequent calls and e-mail communication, along with use of a digital file-sharing tool (BaseCamp), provided access to critical information. As the collaboration progressed, uniform marketing templates, a logo, standardized reporting forms, and support materials were also created and utilized consistently. Additionally, a strategic plan to disseminate information about both the process and the outcomes of the initiative was developed and included presentations at regional and national continuing education forums. Although, as our formative evaluation results indicated, communication was a persistent challenge for the group, these actions helped to ensure that the essential communication needs were met. Measurable and Achievable Targets11 An early priority for the partners was to ensure that there was both clarity and accountability with regard to expectations of each of the member organization. This was achieved in large measure through the use of formal project management structure that incorporated measurable targets11 that were established for each of the partners with their input. This structure made it possible to coordinate and monitor the progress of work against deadlines, actively manage the financial aspects of the initiative, and ensure that the collaboration’s business was accurately tracked, recorded, and archived in a central location. Measurable educational outcomes were also a key component of the CS2Day educational program. One of the group’s early decisions was to develop a comprehensive formative



and summative evaluation plan that would allow the group to monitor program performance and make adjustments where needed. This plan included a common set of evaluation measures at the levels of participation, reaction, learning, competence, behavior, and patient outcomes.15

Creation of Value8,10 To be successful, collaborations must provide valuable benefits to both the member organizations and the major stakeholders they serve.8 We considered it important, therefore, that there were several candid discussions about what could be expected from each partner organization and the anticipated benefits. In the CS2day collaboration, we took 2 actions that we believe were major facilitators to this process. We began with the assumption that each organization brought unique strengths and abilities to the initiative. This allowed all partners to contribute value to the collaboration in ways that were aligned with their capabilities and resources. In terms of giving value back to the partner organizations, there was a conscious commitment among the group members to ensure that all partners benefitted and that the distribution of benefits was both transparent and equitable. Funding was an obvious component of the value proposition and exchange between partners and the collaboration as a whole, but there were many other benefits—for example, (1) access to a common set of instructional materials and other resources (a toolkit) developed specifically for the CS2day initiative by the partners according to their specific areas of expertise (eg, Web site development, video production, and graphic design), and (2) the opportunity to learn from others in the collaborative (eg, learning how to apply CME research findings to a specific context) and learn together, providing the opportunities for mutual learning that Ovretveit et al11 identified as a success factor for quality collaboratives. Another factor affecting the success of the collaboration was risk tolerance. Each of the partners was asked to contribute to launching this endeavor even though the benefits of contributing were neither immediately apparent nor assured. Because the expectations of partners evolve during the formation of an effective collaboration and conditions change over time, each partner had to periodically reassess cost/benefit ratios and ensure ongoing alignment with their mission, priorities, and capacity.

Conclusion There are several studies reported in the literature that can serve as sources of guidelines and recommendations for successful interorganizational collaboration. Although developed in other contexts, our analysis suggests that these guidelines and recommendations can be applied to interorganizational collaborations focused on continuing education of health professionals. The CS2day initiative provides a case

Lessons for Practice •

There are several studies reported in the literature that can serve as sources of guidelines and recommendations for successful interorganizational collaboration.

•

Although developed in other contexts, these guidelines and recommendations can be applied to interorganizational collaborations focused on continuing education of health professionals.

•

The CS2day initiative provides a case example of how guidelines for collaboration developed in various contexts apply to continuing medical education and offers insight into the pathways that lead to successful collaboration.

example illustrating how guidelines for collaboration developed in other contexts apply to continuing medical education and offers insight into the pathways that lead to successful collaboration. The collaboration literature helps to explain how and why this partnership allowed several organizations, all leaders in their respective fields, to unite around a common passion and mission to reduce the number of tobacco smokers in the United States. Some of the success factors identified in the literature did not figure prominently in our analysis of the CS2day collaboration, perhaps because they emerged from somewhat different contexts. It is also possible that we have taken for granted success factors (such as the political climate) that others would consider remarkable. Subsequent studies of interorganizational collaboration in the continuing education context will shed light on that question. A convergence of factors gave the CS2day partners the opportunity to pursue a public health–focused educational initiative targeting physicians and other health care professionals. The CS2day consortium created communication, governance, and decision-making processes through the active participation and consent of the partners. The 9 organizations comprising the CS2day initiative formed what we believe is a unique collaboration that incorporated—and also created—best practices in continuing medical education to address a critically important public health issue. As our outcomes data suggest, the ultimate result is that thousands of physicians are now providing more effective care to the tobacco smokers in their practices.

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