We have been discussing in several Management Moments the elements of public health partnerships. Since collaboration is such a contemporary concept in public health and teams are such a focus of business success, talking about public health partnerships raises the question, "What is the difference between a partnership, a collaboration, and a team?" We have deliberately selected to focus on public health partnerships because this term refers to relationships that are longer term and external. Collaborations tend to be issue-specific and shorter term and less structured. After all, legally, a partnership is a contractual relationship between two or more parties. The reason it makes sense to think in terms of partnerships rather than collaborations is that public health leaders need to think in terms of creating enduring alliances to improve community health. These partnerships need to transcend the public health issue of the moment or latest funding stream or personal connection between two leaders and need to be deep-seated organizational commitments to diligently work together on intransigent issues.

Reflecting on whether you have the essential ingredients of a successful partnership-humility, leadership, trust, reciprocity-is a good starting point. But after that reflection, how do you select partners and then sustain those partnerships during the inevitable trials and tribulations? Most of us in public health can draw upon personal experience and identify past partnerships that have flourished and left a legacy and others that have not gotten off the ground or been strife with controversy. And sometimes it is bewildering as to what factors made the difference between being in a downward spiral and reaching lofty aims.

Selecting Partners

Without question, the key to a good partnership-like a good marriage or a good sports team or when you are on Survivor-is in whom you pick. This presumes, of course, that you get to pick. Even then, many times, it is clear that there are dominant organizations in the community that must be partners in order for an initiative to get off the ground.

What is the best way to get to do the picking? If you are the coordinating or initiating partner, you will most likely get to decide-or play a major role in deciding-who the partners are and their various roles. So this requires leaders with initiative. After all, it makes sense, if you are the host of the party, you get to decide the guest list. To be the first person on your block to know about a new initiative, you have to have connections. Today one of those connection mechanisms is through the Internet. Oftentimes, the secret to being in the know today is simply to be on the right listserves. For example, the National Association of City and County Health Officials and the Turning Point listserves both provide regular announcements about public health initiatives that might be turned into great community partnerships.

So, once you have decided to launch a new public health initiative, how do you decide whom to invite? That can be summarized in one word: complementarity. Selecting partners who balance your public health agency, who bring resources, expertise, political connections, past experience-especially in the areas where you are lacking-is the key. Part of this goes back to the earlier comments made about humility. You have to have an honest sense of your own strengths and vulnerabilities to know whom to select as a partner who will "round you out." Shel Silverstein explores the universal subject of complementarity in his children's book The Missing Piece. In the book, the main character looks like Ms PacMan running around looking for a 1/6th piece of the pie to makes it whole, which perfectly fits. Do you need a stronger connection with the emergency services community or the mayor's office or the neighborhood health centers? Select partners who balance, who complement you, who give you political strength or resources or the credibility you need to get the job done.

Like with any good party, the question with partners is not just whom to invite but how many? Because for partnerships to endure, the partners have to have a stake and a personal sense of role or purpose to maintain the commitment. And, you have to really want them to have a role more than just being letterhead on the stationary. We recently applied for a $6 million leadership grant for a specific target public health audience whom we do not know well. Within a few weeks, we pulled together five partners-a school of public health, a state agency, a medical school, a business school, and a historically black university-to customize our leadership development approach to meet the needs of the designated target audience. Every one of the partners contributed enormously to the project concept because one knew the science and another about public health at the local level and another about creating sustaining enterprises. We debated at several points whether to add more partners, but finally felt comfortable that the current partners had "all our bases covered." Plus, managing the partnership and disbursing the resources gets more complex as the partnership's size grows. It is extremely important to select the right partners and the right number of partners to get the job done efficiently.

The Center for Creative Leadership has studied leadership for 40 years and has become the font of knowledge on the subject. More recently, it has developed and explored the concept of "derailers"-those personal characteristics that cause a person to be fired, demoted. Applying this same concept, derailers of partnerships are those characteristics that you want to avoid because with them the likelihood of failure increases. Herein lies the importance of the picking the right partners. A key derailer in a partnership is just one destructive partner, one partner who detracts from the overall sense of energy to accomplish the mission, who divides the partners into factions, who sees the glass as half-empty rather than half-full. Another partnership derailer is the lack of an acknowledged credible lead partner. It is important to point out that the initiating partner-the organization that calls everyone together initially-may not emerge as the ideal lead partner. This is when egos and self-promotion and other destructive personal behavior can derail a partnership-but that is another whole Management Moment column.

Setting the Stage

Nothing dooms a partnership more than inappropriate expectations. The challenge is to be realistic about outcomes, but at the same time have lofty aims. Partners when invited to participate in an initiative want to know what role you envision for them and failure to ask or answer that question will inevitably be problematic.

A quick story might illustrate the importance of creating realistic expectations. A phone call came in a few years ago to the North Carolina Institute for Public Health (NCIPH) from the Research Triangle Institute (RTI), asking NCIPH to partner on a proposal. On hearing this news, some NCIPH staff came forward with warnings about working with RTI on this project because the experience with the development of a recent proposal had not gone well. NCIPH had gone into the partnership expecting to do the majority of the project only to be disappointed when the budget revealed that NCIPH would only be doing about 20% of the work. But upon further reflection, the NCIPH staff admitted that they had embarked on the project and then spent intensive hours working on the grant application without ever really knowing how much of the project NCIPH would actually do. Thus, the advice they gave was to ask RTI from the onset how much of the project they envisioned NCIPH would actually do.

And, this story had a happy ending. With this sage advice, when asked during the first telephone conversation, RTI staff explained that they wanted NCIPH to do the vast majority of the project-probably 80%. Not only did RTI/NCIPH get selected for this national grant but also the partnership was deemed highly successful by all the parties. And, when the project ended, at the debriefing, the comment was made that the distribution of work between the partners proved surprisingly close to that initial off-the-cuff estimate from the very first conversation. How often do we jump at the chance to participate in a new community initiative without even asking a simple question about what-and how much-our role might be? In our haste to do good for the communities we serve, we oftentimes leave staff in the dark. Perhaps most telling from the RTI example was that staff indicated that they did not think it was their place to ask how much of the project NCIPH would be doing-they thought that leadership should ask the question. Some mistakenly thought leadership had asked the question and that the understanding was that NCIPH would play a major role. False expectations lead to disappointment. But the dire consequence of disappointment is the unwillingness to work together again, to partner on other initiatives. There is a value to tenured staff, but one of the liabilities is the memory of disappointment in relationships, which lingers and casts a pall over future opportunities The simplest way to avoid this problem is for leadership to ask the question, "What do you envision our role would be on this project?"

Staff is expecting leadership to play that role of understanding scope, scale, and some rough idea of roles of the partners. The most probable reason for reticence to ask the question is that it may seem greedy or selfish to ask the question. But, it is not. It is businesslike and professional to want to understand the depth of the pool before you jump in with both feet.

Designing Governance

Clarity about governance versus management among all the partners is essential for a partnership to be sustainable. After all, every organization that is invited to the table has a primary mission, every person has a "day job" that feeds his or her family. So what you are expecting is their engagement in a project that is tangential-but not central-to their being. This means that as the initiating partner, your job is to create an efficient way for the partners to meaningfully participate, to have a sense of ownership but not to be burdened unnecessarily.

Not-for-profit leaders are trained in understanding the role of governance as opposed to management, and a lack of clarity about the distinction will result in role confusion and micromanagement and lack of strategic thinking. If the governing board starts managing, not only will it lead to confusion and stress and discontent among staff who think management is their job but also the governing board will then not have its eye on the ball, will not be strategic in its thinking. In short, if the partners are managing the project, they have no time left to do the really hard job, which is to be strategic and policy-oriented and to tackle the tough external issues-like securing resources. It is inevitable that if you take governing boards' management information, they will manage-and as the lead partner, you want them to govern. So, when establishing a partnership, agreement about the way that the partners will govern the partnership is the foundation for the future. How do you do this?

Yes, a partnership needs a mission and vision statement. This may seem trite, but the process of agreeing on words that describe who you are and where you are going will be one of building consensus about identity. And that should be done expeditiously and tersely and posted prominently. There is tremendous value in a crisp, clear mission and vision statement. One sentence, few words. NCIPH's mission statement is "Serving the state, leading the nation." That sums it up, we want to serve North Carolinians but to do so in a way that lights the path for others in public health.

Perhaps more important is real agreement on outcomes or measures of success. Ask the partners, if we are really successful in 5 years, what will have happened? What are the concrete, visible outcomes that we can expect will clearly spell success? A decade ago, a dozen of the leading children's hospitals got together to form BENCHmark,1 a project to share outcome and performance data to determine best practices. The first meeting at a central airport conference room consisted of the organizations rapidly committing to participate, then to hire the consultant (who was standing in the hall) and then listening and concurring with the consultant's approach and timeline for the project. The partnership was rapidly executed, and within 2 years, the partnership was receiving national acclaim and being asked to speak and write about its success. The disconnect became apparent when the leaders who had been in that airport conference room were interviewed 2 years into the project and they had widely divergent ideas about whether the partnership had been successful. The reason for this was quite simple. Virtually no time had been spent reaching agreement on the outcomes expected from the partnership. Thus, with a dozen different reasons for participating-for putting money on the table and spending hours collecting data-there were a dozen different ideas about what the outcome, the final product was actually going to look like. Some had in mind a Picasso whereas others wanted a Rembrandt and others Chagall. Ultimately, there was a sense that the partnership had been a missed opportunity to powerfully shape the respective hospitals and the quality of care they delivered. Everyone agreed that the partnership had painted a picture but the value was harshly debated because after all, beauty is in the eye of the beholder.

Some of this disconnect is language. We talk about a partnership producing regular reports to the community but do not hold in our hands some sample reports and agree on a common format and length and style and purpose. The word "report" conjures up different mental images about what that outcome will be like-and what it will accomplish. So being concrete in expected outcomes is essential. How much do we think diabetes will be reduced if we launch this initiative? By when? How will this be measured?

Early on in a project, the way in which the partners will govern the project must be established. Who will be the lead partner? How often will the partnership meet? What types of strategic information do the partners want to know? What decision-making process do they want to have? Five years ago, the Centers for Disease Control and Prevention, the Center for Creative Leadership, UNC's Kenan-Flagler Business School, and UNC's School of Public Health began working together on the Public Health Leadership Institute (http://www.phli.org). From the inception of the partnership, monthly meetings were held with clear agendas around strategic issues of concern to the partners. Meanwhile, management decisions were made by the director and a regular operations task force. Over time, the partners' comfort with the direction of the partnership meant that meetings could be held bimonthly instead of monthly and could be shortened to an hour. In the process of sharing information and decision making, trust was built that enabled the partnership to not only govern this program effectively but also strategize about leveraging this project to expand to provide other programs and services. And, after all, that is the ultimate outcome of a successful partnership, that the partners value each others' contribution, feel good about the accomplishment, and want to work together again to leverage their resources to improve community health.

Selecting the right partners, creating realistic expectations, and establishing a partnership governance structure are the key elements to successful partnership execution.

It only takes a Management Moment to reflect on selecting the right partners, structuring expectations, and creating the right governance processes. For more information about NCIPH, go to http://www.sph.unc.edu/nciph.

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