Strong partnerships among government, communities, philanthropies and the corporate community to facilitate actions to improve the health of employees and their communities are critical for the public health system to improve its goals." 1^(p300) Despite this proclamation from the Institute of Medicine and the efforts of Turning Point and the National Study of Partnership Functioning, 2 public health officials generally do not demonstrate effective partnership skills. Increasingly, the ability to effectively leverage community resources to tackle intransigent community issues-gang crime, domestic violence, drug abuse, teenage pregnancy-is seen as the differentiating leadership competency. For partnerships to last and have impact, the relationship has to be seen as far more than just a sharing of resources and risk. The relationship has to be an exchange of perspectives about the nature of the challenge and possible solutions such that the resultant whole is really greater than the parts.

So, we're going to review "Partnering 101: What, Why, When, Who, How" and test your perspective and skills in several Management Moment columns because this essential competency is too fundamental to just cover once. Next issue we'll examine how to select partners and manage partnerships to ensure a successful outcome.

The First Successful Ingredient of a Partnership: Humility

First, whether it is an individual or a business, an organization or a company, a church or a public health agency, the decision to partner requires humility. You have to recognize your own limitations and admit that working with another will more likely result in success than going it alone. Like the Lone Ranger understanding that he was better able to capture the bad guys in the wild, wild West with Tonto at this side, you have to appreciate that you need help to accomplish your objectives. Some professions thrive on partnerships; Rogers and Hammerstein are only one of numerous successful duos of composers and lyricists who made beautiful music together, and Bob Hope and Bing Crosby represent a long line of comedic pairs who have brought us laughter.

Humility also requires that you have an appreciation of the perspective you bring to the project, which is based upon your professional education, your age, your past experience, your gender, and your ethnic background. The true value of partnerships-which is that each organization and individual will bring their own perspective to the project-can only be realized if individuals are open to approaching a problem.

Of course, humility means not only knowing your limitations, but also knowing your strengths-as they say in marketing, your distinctive competency. What is it that you bring to the table, that you contribute that would make someone want to partner with you on a new initiative? Think about it from the partner's perspective. Would they agree that you have demonstrated expertise at working effectively with community groups or spreading a public health message or delivering services to the community? If you cannot come up with concrete examples that illustrate your distinctive competencies, then you may not be able to sell potential partners on working with you.

Honest reflection requires humility because along with your strengths, you may bring baggage to a partnership. You may have a previous history of poor collaboration or failed ventures. Of course, if you have learned valuable lessons from failed initiatives, that means you are smarter entering this new partnership and you can turn that experience into a strength-not a weakness.

One of the major lessons from Peter Senge's work on learning organizations is that organizations committed to self-improvement stop and evaluate how they are doing all the time. For learning to occur, regular reflection is a must. In partnerships, reflection often takes place in the form of debriefings after project milestones. For those debriefings to be truly insightful, the partners must come to the table prepared to honestly admit their shortcomings and failures; and those admissions can only come from partners with humility. The North Carolina Institute for Public Health had a partnership with the Research Triangle Institute and other schools on campus to conduct a feasibility study regarding establishing a national patient safety improvement corps. The intense, 9-month project was a challenge, with a director who left midway through the project and conflicting views about the intention and format of the project. Nevertheless, the partners deemed the project a huge success because the 2-hour debriefing was such a cathartic experience with partners sharing their personal epiphanies. People feel good about partnership experiences when they have learned something and there is a sense of closure and accomplishment. People bond through adversity. Structured reflection throughout the project, but especially at the conclusion, provides an opportunity for emotional bonding and healing and learning.

Sharing a Unifying, Compelling Goal

Public health partnerships form around a community need that may have been invisible to many of the partners for some time. Oftentimes, a sentinel event occurs-a crisis in funding or the unnecessary death of a teenage girl from an illegal abortion or rising community unrest leading to gang activity or a dire report rating the community as one of the worst in the state in suicide or tuberculosis or HIV-which drives partners to action. In the case of the Partnership for Migrant and Seasonal Farm Worker Health in Idaho, it was a trip to Mexico by the Boise Sunrise Rotary Club and the Executive Director of the Family Advocacy Program that made them question if their local migrant workers had as high an incidence of preventable eye disorders as they had seen in Mexico. 3

The primary responsibility of the convening partner is to illustrate the magnitude of the problem-to paint such a compelling picture-that everyone invited joins the initiative. The magnitude of the program can be conveyed through data, but humanizing this issue through stories is essential to engage people in the passion of the project.

But after seeing the problem in the community, rather than being overwhelmed by the need, the challenge is for the partners to get excited about the opportunity to improve the situation, to be stimulated to take action. What creates that positive energy? A sense of the possibilities is created by leaders who tell stories of hope. Providing examples of where other communities have tackled the problem successfully gives all the partners a sense of possibilities. One of the best ways to sell a new initiative to partners, to funders, to community leaders, is to share a success story, a program that you can use as a model. That is one of the reasons that franchises are such a successful business model for expanding from one location to numerous locations-all the key stakeholders can use the first location as a model. Starbucks-selling colored, flavored water-is just the latest example of a wildly successful food franchise that started with one location doing very well.

Partners come to an initial meeting with their own agenda for what should be accomplished on the issue from their perspective. It requires skilled facilitation for a group to coalesce around a common goal that is clear and compelling. Once that is accomplished, a partnership is formed when the members of the group dedicate themselves and resources to meaningful activities and measurable outcomes that are grounded in a compelling mission. The 24 partners in the Galveston (Texas) Community Health Access Program attribute the success of the initiative, which won the 2004 National Campus-Community Partnerships for Health Award, to "bringing the right people and organizations to the table to organize around a single goal [horizontal ellipsis] to bridge gaps in access to health care in Galveston County." 4

Sharing Risk

The third essential element of a successful partnership is shared risk. As they say in sports, everyone has to have "skin in the game." This does not mean that all the partners have the same investment or the same risk exposure, but it does mean that everyone commits resources-staff support, access to databases, connections to key community stakeholders-to make sure the venture is successful. Public health partners tend to discount their ability to contribute to a partnership because of limited financial resources when in fact their intangible resources-connections with key community leaders and organizations or access to data illustrating community need-can be equally valuable in the success of a new community initiative. When we discuss the issue of partner selection in the next column, we'll talk about selecting partners based upon their ability and willingness to contribute and share risk.

The problem with sharing risk for some partners is it makes it even more difficult to let go of the daily management of the shared project. Although a dozen or more organizations may come together to sponsor a public health community initiative, typically one of the organizations will actually take the lead providing the space, employing the managerial staff, and providing day to direction. The other partners need to view themselves in a governing role that provides strategic direction, establishes policy, and ensures financial viability, but also need to feel comfortable delegating the managerial details to the management and lead sponsor. Letting go requires trust. In our leadership courses at UNC, we regularly schedule participants to do the "Ropes Course." On the "High Ropes," when public health leaders are dangling 20 feet off the ground dependent upon teammates to guide them to other side, they learn that they have to let go of being in control and to allow others to guide them into to succeed. In order for partners to let go of how the project will be managed, they have to trust that the lead partners has the interests of the initiative first and foremost and has the skills to execute.

Building Trust

This brings us to the fourth essential element of successful partnerships: trust. First it is important to point out that trust is a function of both the person trusting (the trustee) and the person being trusted (the "trustor"). The innate perceptions and skills and history and experience of the trustee is just as important as the ability of the trustor to deliver as promised. If partners come to the potential project with a "bad taste in their mouth" from previous partnerships gone awry, their innate lack of trust and unwillingness can be just as damaging to partnership as actual failure to deliver. We all know what a fragile thing trust is. Once lost, "All the Kings' horses and all the Kings' men, couldn't put Humpty Dumpty together again." No behavior better cements trust than honesty, and no behavior destroys trust quicker than lying. In recently discussing a failed merger of two Catholic hospitals, one Sister, who was CEO of one of the organizations, said, "The issue was dead the minute we learned they had $40 million in debt they had deliberately hidden from us. We talked for several months but it was just wasted breath."

Trust is also based upon believing that individuals can and will deliver on commitments. More than honesty is required for successful execution; knowing key stakeholders in their respective organizations, being able to assess the political landscape, and having the authority to allocate resources are also important elements of trust. When partners trust, they are believing that each partner is going to follow-through, to do what they say they are going to do. And this is even more difficult because throughout the life of a project, environmental forces constantly change the options, the direction, the pace of the project.

Like a Seesaw

Trust is built by honesty and ability to execute and also by partners demonstrating a heartfelt interest in making sure all the partners are heard and considered in planning a venture. Masterful leadership is necessary to ensure that partners' expectations are realistic and that the rewards are balanced. One of the elements that a leader is striving for in a partnership is reciprocity. If you recognize the absolute importance of each partner to the success of the venture, the time will come when you will have to put your organization's interests second to the interests of the partnership in total or another partner's needs. Just like in friendship, as Stephen Covey says, you invest in others by making deposits in their emotional bank accounts so that when you want to make a withdrawal, there is a balance.

The UNC Kenan Institute and the School of Public Health established a partnership 6 years ago to offer the Management Academy for Public Health. 3 This was the first sizable partnership between these two schools in the history of the university. The original $2.8 million grant was awarded to the School of Public Health and thus the School got "credit"-in the way that universities count awards for the grant. Now, these same partners are offering the Emerging Leaders in Public Health Program 4 funded by the W.K. Kellogg Foundation, and the award has been granted to the Kenan Institute so they can get "credit" at UNC for this grant award. This is reciprocity in action.

Leadership

And finally, the essential element of a successful partnership is leadership. As the National Study of Partnership Functioning discovered from studying 66 partnerships, "Leadership effectiveness was the dimension [horizontal ellipsis] most closely related to partnership synergy. This finding is consistent with other research that has documented the importance of leadership across all phases of partnership development." 2^(p693) As Jim Collins articulates in Good to Great, 6 developing a new program or service is like getting people on a bus to go on a trip. The goal of the leader is to motivate followers to get on the bus by painting a picture of a compelling vision-an attractive destination, a reason for going on the trip, a reason for departing from their current location. Throughout the journey when there are many twists and turns and flat tires and bad roadside food and unspeakable bathroom breaks, the leader's job is to keep the group focused on the ultimate destination. It requires trust and flexibility to let go of the details as to how long the journey will take or exactly what route and to remain clear about the group's mission of staying focused on the destination.

Leaders not only motivate and engage partners, they also develop a communication strategy. Knowing how much and what the partners want to know and how involved they want to be in decision making and how often they want updates is an essential leadership skill. Trust and communication are reciprocal; with little trust, there needs to be more communication; with lots of trust, communication can be sparse. When we talk about partnership management in subsequent columns, we'll discuss tips for effective partnership communication.

In the next issue, we'll discuss picking partners and the importance of complementarity to develop the ideal partnership. In the meantime, take a moment to ask yourself these questions before you establish a partnership to address a pressing community need:

* Are you realistic and humble about your need for others to help with this initiative?

* Can you paint a compelling picture for the partners of this need?

* Are you willing to share risk?

* Are you trustworthy in partnerships?

* Are you flexible about the ways this partnership is formed, executes strategies, and measures results?

* Do you have the leadership skills necessary to coalesce a community group around a need? If not, then who can you engage to lead this dream to becoming a reality?

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