Exploring Proxy Measures of Mutuality for Strategic Partnership Development: A Case Study

Abstract

Partnerships between academic and clinical-based health organizations are becoming increasingly important in improving health outcomes. Mutuality is recognized as a vital component of these partnerships. If partnerships are to achieve mutuality, there is a need to define what it means to partnering organizations. Few studies have described the elements contributing to mutuality, particularly in new relationships between academic and clinical partners. This study seeks to identify how mutuality is expressed and to explore potential proxy measures of mutuality for an alliance consisting of a hospital system and a School of Public Health. Key informant interviews were conducted with faculty and hospital representatives serving on the partnership steering committee. Key informants were asked about perceived events that led to the development of the Alliance; perceived goals, expectations, and outcomes; and current/future roles with the Alliance. Four proxy measures of mutuality for an academic–clinical partnership were identified: policy directives, community beneficence, procurement of human capital, and partnership longevity. Findings can inform the development of tools for assisting in strengthening relationships and ensuring stakeholders’ interests align with the mission and goal of the partnership by operationalizing elements necessary to evaluate the progress of the partnership.

Keywords

partnership proxy measures mutuality academic–clinical partnership

Introduction

Fragmentation of clinical and population-based services continues to be a major barrier in health care and public health (Institute of Medicine, 2012). National health care reform measures associated with community benefit have prompted more hospital administrators to collaborate with public health institutions (Ainsworth, Diaz, & Schmidtlein, 2013; Jackson, 2012; Song, Lee, Alexander, & Seiber, 2013). Increased interest in community health improvement through collaborative action has been implemented through “academic–clinical” or “academic–practice” partnerships (Davies & Bennett, 2008; Michener et al., 2012; Morse, 2003; Rycroft-Malone et al., 2011). Within these partnerships, universities and health care entities work collaboratively to provide experiential or service learning for students interested in medicine, nursing, and allied health professions (Dobalian et al., 2014; Niederhauser, 2016). Additionally, these partnerships plan, implement, and evaluate evidence-based interventions and policies that reduce health care disparities and lower hospital expenditures (Niederhauser, 2016; Prochaska et al., 2009; Redman-MacLaren et al., 2012; Roussos & Fawcett, 2000; Westfall et al., 2013).

A growing area of interest in partnership research is understanding factors that contribute to “healthy” sustainable working relationships. Regarding coalitions, Foster-Fishman, Berkowitz, Lounsbury, Jacobson, and Allen (2001) refer to relational capacity as the ability of a group of people to develop a shared vision, to balance and share power in decision making, and to create a climate that fosters positive external relationships where values and diversity are respected. Lasker, Weiss, and Miller (2001) discuss mutual benefit as “synergy,” the power to combine perspectives, resources, and skills of a group of people and organizations. In contrast, mutuality is the “growing process” over time that involves the shared interest of two people or entities (Partnership Forum, 2008). Brinkerhoff (2002b) states, “Embedded in mutuality is a strong mutual commitment to partnership goals and objectives, and an assumption that these joint objectives are consistent and supportive of each partner organization’s mission and objectives” (p. 22). Each partner reflects on his or her intentions and motivations, develops ground rules, and compares missions, values, and identity for common ground (Partnership Forum, 2008).

From a community research perspective, mutuality is noted as an indicator of successful partnerships employed in community-based participatory research, community-engaged research (CEnR), and community-engaged scholarship (CES). Although distinct, these approaches are rooted in the concept of mutuality as the cornerstone to targeting population health. In community-based participatory research, mutuality has been described as the integration of knowledge and action among individuals working in a collective manner. Working collaboratively with community organizations enhances the capacity for researchers to improve the health of community members (Ahmed & Palermo, 2010). Partnerships using a CEnR approach have developed culturally appropriate initiatives, health care services, and policies that reduce disparities in health care. In this approach community stakeholders are equitably engaged as partners in each phase of the research process (Clinical and Translational Awards Consortium, 2011; Khodyakov, Mikesell, Schraiber, Booth, & Bromley, 2016; Watson-Thompson, 2015). Employing CEnR has increased the community’s understanding of the benefits of research and the academician’s ability to address community priorities (Ahmed & Palermo, 2010). Mutuality is also an important component of CES between a university and a community organization, particularly for service learning (Carnegie Foundation, 2014). Such efforts have enriched research opportunities and activities that allow students, community residents, and faculty to address critical societal issues while strengthening civic responsibility (Carnegie Foundation, 2014). CES also involves trainees in mutually beneficial relationships with community members and organizations and often combines aspects of other types of scholarship, including teaching and research, with community service and action (Meurer & Diehr, 2012).

Despite the clear value of mutuality observed in prior coalition and community research (Brinkerhoff, 2002b; Foster-Fishman et al., 2001; Lasker et al., 2001), there is little information regarding how academic–clinical partnerships recognize and share this value. Methodology for measuring mutuality is another aspect that remains unclear. From a management perspective, administrators who provide human resources for operationalization and implementation of partnerships often want to know if such arrangements affect their “bottom line” and are producing results in an “organic” manner. Evaluation tools exist for measuring partnership functioning, partnership synergy, and trust; yet these assessments do not clearly indicate how to adequately measure mutuality (Butterfoss, Goodman, & Wandersman, 1996; Goodman & Wandersman, 1994; Lasker et al., 2001). This study identifies how mutuality is expressed and explores potential proxy measures of mutuality for an alliance consisting of a local hospital system and a School of Public Health (SPH), one example of an academic–clinical partnership. Research questions were the following: In what ways was mutuality expressed by stakeholders who are actively involved in a partnership aimed to improve population health between a SPH and a nonprofit hospital? What are potential proxy measures that should be considered in assessing overall impact resulting from this partnership if mutually beneficial?

Community Context: Indiana University Health Bloomington and Indiana University School of Public Health-Bloomington

Indiana University (IU) Bloomington is a suburban-rural campus with over 3,000 full-time faculty members and over 40,000 students. The SPH’s mission is “to promote health among individuals and communities in Indiana, the nation, and the world through integrated multidisciplinary approaches to research and creative activity, teaching, and community engagement” (Indiana University School of Public Health Bloomington, 2014, p. 1). The School has a long-standing history of actively engaging the community in research and teaching and makes a substantial investment in consistently tracking partnerships between faculty and public, private, and voluntary organizations.

IU Health Bloomington (IUH-B) is one of 21 hospitals within the IU Health system. Its mission is to “improve the health of patients and community through innovation and excellence in care, education, research and service” (IU Health, 2014). While the larger IU Health system works collaboratively with the IU School of Medicine, IUH-B seeks to create more formalized partnerships that addresses population-based needs of residents in southern Central Indiana. As a result, the SPH-B Dean and IUH-B CEO invested human and financial resources to create a more formalized partnership, known as the IUH-B/SPH-B Alliance. The Alliance sought to create a shared collaborative space where community, faculty, staff, and students advance population health through CEnR. Their work is driven by shared goals (1) assess and track economic impact and sustainability, (2) incorporate evidence-based practices in clinics and the community over time, and (3) use findings from basic and social science research that can be translated into practical applications and policies for enhancing population health and well-being.

For Alliance members, motives for combining efforts were lucid since both organizations play integral roles in population health, specifically in assessing community needs and implementing evidence-based practices that improve clinical and community interventions. From the SPH-B’s perspective, ongoing demonstration of collaborative efforts among faculty and with the community is an institutional goal (Council on Education for Public Health, 2014). From the IUH-B’s perspective, a growing need exists to provide patient-centered care at all levels (IUH-B, 2012). Uniting partners with a common interest in population health but with different approaches can be challenging. For this partnership to flourish, there was a need to determine measures to assess mutuality in order to track Alliance growth and development. Hence, this study explored how mutuality is expressed in a clinical health care institution–academic institution partnership.

Conceptual Framework: Causal Chain for Relationship Outcomes

In 2002, Brinkerhoff adapted a partnership assessment approach, Traditional Causal Chain, to emphasize relationship outcomes and assess partnership work in progress. This model was selected because of its emphasis on assessing relationship perfomance of developing partnerships. The traditional causal chain model proposes five areas of assessment (1) compliance with prerequisites and success factors in partnership relationships, (2) degree of partnership practice, (3) outcomes of the partnership relationship, (4) partners’ performance, and (5) efficiency. Partnership practice is assessed according to the presence of its two defining dimensions, which include mutuality and organization identity (Figure 1). This article will focus on key indicators of mutuality. For the purpose of partnership practice, mutuality is defined as horizontal, as opposed to hierarchical, coordination and accountability, and equality in decision making (Brinkerhoff, 2002a). According to Brinkerhoff, common indicators of mutuality in partnership include equality in decision making, resource exchange, reciprocal accountability, transparency, and degree of partner representation and participation in partnership activities. These indicators provided the framework for formulating five qualitative interview questions in which responses would provide a basis for operationalizing mutuality in an academic–clinical partnership.

Figure 1

Causal Chain for Relationship Outcomes

Method

Key informant interviews (N = 12) were conducted with all senior administrators who serve on the Alliance steering committee (SPH-B faculty, n = 7) and (IUH-B administrators, n = 5). Senior administrators were selected as target participants due to their involvement in developing the partnership. We received a 100% response rate. Participants were asked about perceived events that led to the development of the Alliance, perceived goals and expectations, resource acquisition and allocation for development, perceived outcomes, and their current and future Alliance role.

Data were independently transcribed and analyzed by two researchers from the study team. All transcripts were read through and hand-coded individually by each researcher. Coding of transcripts occurred in three phases. First, in vivo coding (using participants’ own language/direct from transcript) was conducted to identify mutuality-related ideas (Saldana, 2009). Next, focused coding was used to categorize in vivo codes based on similarities and differences in thoughts, events, and processes (Saldana, 2009). Researchers then compared results from the two coding phases. Frequencies were calculated and discussions to address discrepancies occurred. Finally, selective coding was conducted to identify key factors or areas connected to mutuality. Researchers discussed relationships and connections between categories along with the core themes that described mutuality. Researchers reached a consensus about the most prominent categories with 86.7% interrater reliability. All protocols and procedures were approved by the institutional review boards of the authors’ institutions.

Results

Table 1 presents illustrative responses from key informants. In general, all participants used “alignment,” “common interest,” and “mutual interest/benefit” to define mutuality. In addition, participants voiced the importance of “mutuality” as a shared interest in building and enhancing a formal infrastructure within their respective organizations that fosters continual cooperation and collaboration. Several participants believed that building and enhancing infrastructure allows interdisciplinary and interprofessional discussions to occur. These discussions reflect their shared goals related to improvement in population health and rural health. One SPH-B key participant suggested,

Table 1

Theme Development (From In Vivo to Themes)

Themes	Categories	Focus Codes Identified Count (%)	Examples of In Vivo Codes From Transcripts
Policy directives	Organizational (accreditation)	5 (41.7)	Forming into a formal School of Public Health as of 2012; transition from HPER to School of Public Health; New School of Public health now serves as a catalyst
Policy directives	Governmental (Affordable Care Act)	3 (25.0)	Not necessarily a problem but changes to the health care system/policy; as we grow as a health care system in the State and with some governance in common, it makes sense for each of us; more accountability for the hospital due to Affordable Care Act
Community beneficence	Community health benefit	10 (83.3)	Commitment to health and well-being in the community; make a difference in terms of health and well-being of surrounding community; goal of population, community health, and health promotion; big picture in terms of helping the local community and the state
Community beneficence	Community presence	4 (33.3)	Responding to city and community needs; realization that the role of SPH is to enhance health in community and state; allows SPH to move into the community; goal to have a larger community presence
Procurement of “capital”	Human capital	10 (83.3)	Human resources such as professors and students; competent individuals such as staff, faculty, students, and researchers; faculty and students; human resources, that is, professors and students, staff time from both IU Health and the IU School of Public Health; working with dieticians to collect pilot data
	Administrative Champions	5 (41.7)	Keeping the ship afloat while other people do the fun stuff; supporting these types of projects; upper level support; being a part of the big picture; silent champion
	Financial capital	7 (58.3)	Financial resources for longevity; start with a small amount of seed money; funding for pilot projects; funding for faculty and staff/personnel; seek external grant funding
Partnership longevity	Outcome driven projects	8 (66.7)	Pilot projects; success of initial projects; each project will have a product or outcome; projects need to have identifiable outcomes
	Direction of partnership	5 (41.7)	Depends on the development of the partnership and the role they would like for our office to play; depends on the projects selected as we move forward; change will depend on the direction of the study; depends on whether or not my interests are aligned with the future projects; my role will really depend on the direction of the partnership

NOTE: HPER = Health, Physical Education, and Recreation; SPH = School of Public Health; IU = Indiana University.

If we want to be engaged in these rural communities, the public health infrastructure is largely the health care infrastructure. And so if we want to be effective in truly operating in this region, IU Health has to be our partner.

Mutuality was also expressed as the potential to reciprocate resources that “benefit” each partner, especially as commonalities are revealed through dialogue. The following are statements by academic and hospital partners:

We had one meeting and as a result of that meeting it became clear that we shared mutual goals, our objectives were similar. They needed public health representation; we needed access to clinical populations and preventive services. (SPH-B member)

The SPH is about translation of community interactions . . . I think the opportunity of having a new SPH here is certainly a catalyst for all this and having a dean who is interested in community, collaboration, and translational research. (IUH-B member)

Potential Proxy Measures

In further capturing participants’ views, four themes emerged regarding perceptions of “mutuality” to consider in assessing overall impact resulting from a mutually beneficial partnership: policy directives, community beneficence, procurement of human capital, and partnership longevity (Figure 2).

Figure 2

Proxy Measures for Mutuality

Policy Directives

Policy directives was defined as directional changes resulting from internal and/or external policies affecting the organization. This theme consisted of organizational and governmental influences. Examples of key informant descriptions of organizational influences included “transition [into] a new school of public health now serves as a catalyst” and “in the transition from inpatient to outpatient and post-acute and really starting to do some things that can make a difference.” Responses from key informants regarding governmental influences were the result of policies such as the Affordable Care Act (ACA) and Council on Education for Public Health Accreditation. Key informants commented, “Not necessarily a problem but changes to the health care system/policy” and “more accountability for the hospital due to ACA.” One key informant stated,

I think the other clear part of it was, because of the ACA, nonprofit hospitals had increased expectations around public health.

These comments suggested that while there is a clear interest in community health, the term community is integrated with ideals from both local and national perspectives.

Community Beneficence

Community beneficence was defined as a responsibility to conduct research and inform practice in the best interest of the community’s health, considering two factors: community health benefit and community presence. Examples of key informant descriptions of community health benefit include “commitment to health and well-being in the community” and “the big picture in terms of helping the local community and the state.” Members of the partnership conveyed the need to make an impact on the health of the local rural community as well the larger global community. For example, one IUH-B key informant stated,

Our mission has included global communities, not just southern Indiana, but we are obviously particularly interested how we can make a difference for our community for the health and well-being and meanwhile, kind of reduce the cost, and also deal with health disparities.

Community presence was described by key informants as “realization that the role of SPH-B is to enhance health in community/state” and “allows SPH-B to move into the community.” Members from both partners within the Alliance expressed a need for a larger presence and collaborative community-focused effort. For example,

The [S]chool needs to get out into the community to be able to achieve their mission. (IU SPH member)

Being able to be seen with the people that we serve or that we come in contact with. (IUH-B member)

Procurement of Capital

Procurement of capital was defined as the resources necessary to formalize and sustain the partnership. These resources were defined as two forms of capital, human and financial, plus administrative champions. Descriptions of human capital by members of the partnership include “competent individuals such as staff, faculty, students, and researchers” and “staff time from both IU Health and the IU School of Public Health.” One IUH-B key informant further described it as,

It’s the human capital that the school has. It’s the expertise and core competencies that the school has within both faculty as well as students.

In addition to resources in the form of human capital, financial capital was also discussed. Financial capital was described by members as “financial resources for longevity,” “funding for pilot projects,” and “funding for faculty and staff/personnel.”

As an addition to staff and financial resources, members of the Alliance recognized the need for support from upper level management in the form of administrative champions. Examples of key informants’ descriptions of administrative champions are “supporting these types of projects,” “upper level support,” “being a part of the big picture,” and “silent champion.” Key informants from both partners identified themselves as administrative champions.

Partnership Longevity

The final proxy measure, partnership longevity, included three categories: outcome-driven projects, direction of the partnership, and long-term relationships. These categories appeared to be outcomes of the partnership. The first category, outcome-driven projects, included descriptions such as “pilot projects” and “success of initial projects.” Based on these responses, there was a consensus among key informants that items listed under outcome-driven projects can be defined as tangible deliverables resulting from the partnership.

The second category under partnership longevity was direction of the partnership. Key informants defined their role within the partnership and how they perceived their role to evolve over time. Examples of how key informants expressed this theme include “It all depends on the development of the partnership and the role they would like for our office to play” and “depends on the projects selected as we move forward.”

The final category, long-term relationships, was identified as a benefit resulting from the partnership. Key informants described long-term relationships as “long-term relationships as oppose to short-term” and “long-term relationship with IU, with each partner benefiting from the relationship.” These responses are indicative of a vision for a sustainable partnership that will continue to evolve beyond the duration of current projects.

Discussion

In this study, we discovered that the Alliance’s shared interest in partnership is about strategically connecting resources into supporting an infrastructure that affects rural and underserved communities. We also developed a working definition of mutuality. As expressed by these public health and health care leaders, mutuality involves conducting congruent activities that align with and benefit the overall mission of the partnership. Members described mutuality as a shared interest in building and enhancing a formal infrastructure within respective organizations that fosters continual cooperation and collaboration to achieve mutual benefit. This description of mutuality aligns with those from supporting literature (Brinkerhoff, 2002a; Lasker et al., 2001; Kellner & Thackray, 1999). However, this study is novel in that responses generated from the Alliance led to identification of four proxy measures that could allow future partnerships to evaluate their progression in developmental stages.

Procurement of capital was parallel with indicators of mutuality presented by Brinkerhoff (2002a): resource exchange and reciprocal accountability. Brinkerhoff acknowledges that not all resources are material. For the Alliance, identifying staff and faculty to lead the partnership was just as essential as financial resources. Likewise, because staff and faculty were identified from both partners, there was an expectation that each organization would be responsible for ensuring staff accountability and participation in activities to support the partnership. This resource exchange also seem to contribute to the absence of power struggles within this partnership that has been acknowledged in other partnerships cited in the literature (Derkzen, Franklin, & Bock, 2008). For the Alliance, each partner had an equal opportunity to contribute personnel who could offer their partner’s perspective.

Proxy measures identified by the Alliance that were not characterized as indicators of mutuality by Brinkerhoff (2002a) were policy directives, community beneficence, and partnership longevity. Based on descriptions from the Alliance, policy directives and community beneficence were reasons to establish the partnership. Rather than serving as indicators for mutuality, these areas may be prerequisites for the Alliance to attain mutuality. Conversely, partnership longevity may be an outcome of the partnership opposed to being an indicator of mutuality.

Numerous studies have recognized mutuality as an important component to partnership (Butterfoss et al., 1996; Goodman & Wandersman, 1994; Lasker et al., 2001); however, for our case study, it is unclear if mutuality is an input (i.e., necessary ingredient needed at the start of the partnership) or a result (i.e., evidence of potential outcomes) of collectively working to accomplish mutual aims. Partnerships with diverse individuals from various disciplines capture multiple yet unique perspectives, which may influence the ways mutuality is perceived. In our study, mutuality was rooted in creating a formal infrastructure that supports resource sharing. Thus, it appears that mutuality for this new partnership is not an input or output but characterized by key activities being implemented throughout the progression of the partnership.

Implications

Findings from this study will be useful for the Alliance to conduct a full assessment of its impact. At that time, it will be important for the Alliance to have baseline data to determine if the outcomes of the partnership align with the proxy measures identified in this study. The next steps will be to determine whether the proxy measures identified from this formative evaluation will allow us to effectively assess mutuality within this partnership and ultimately contribute to the success of this and other new partnerships seeking to track their progress. For now, this study serves as formative research that provides the Alliance with a means to prospectively think about process evaluation that will allow the partnership to assess desired results.

As the Alliance develops deliverables, this study will serve as a benchmark for determining progress made toward achieving objectives set by each partner. It is also an opportunity to assess whether the shared vision and initial ability to balance and share power in decision making continue within this partnership. From the SPH-B’s perspective, assessing productivity is beneficial for accreditation purposes. As a newly accredited SPH, monitoring and evaluating the benefits of partnerships help satisfy accreditation standards for the school by providing research service learning opportunities and meeting public health competencies for faculty and students (SPH-B, 2014). From the IUH-B’s perspective, monitoring partnership success means ability to track community benefit in their priority areas: mental health and addiction, access to health care, obesity and diabetes, chronic disease and management, and senior health (IUH-B, 2012). Also, documenting partnership activities provides the community support requirements for the Internal Revenue Service’s (1969) community benefit standard (Somerville, Nelson, & Mueller, 2013). This policy requires hospitals to demonstrate the promotion of health for “a class of persons that is broad enough to benefit the community” (Internal Revenue Service, 1969, p. 2).

The next steps for the Alliance should include developing a performance-monitoring tool that will allow partners to strategically identify areas that emerge from hospital and community interests. Performance-monitoring tools allow partnerships to assess their performance from the beginning, allowing them to adapt. Prior studies evaluating health partnership success indicate that partnerships with an organized structure and use documentation, such as a performance-monitoring tool, exist for longer periods of time and are more likely to achieve their goals (Butterfoss, 2007; Butterfoss & Francisco, 2004; Nowell & Foster-Fishman, 2010). This is a new partnership (the study began 6 months into initiation). As the partnership progresses in its work, members will need to measure its effectiveness on health promotion programs/interventions developed from the partnership.

Findings of this study could be valuable in preparation for process evaluation for newly established partnerships. As partnerships between academic- and clinical-based service organizations continue to arise, it will be imperative to assess if activities to support the partnership objectives are congruent. Identification of potential proxy measures may perhaps not only facilitate monitoring and tracking the progression of a mutually beneficial relationship but also measuring the depth and breadth of that relationship. Similar to the Alliance, partnerships that develop a benchmark for documenting their progression will ideally be able to indicate the mutual benefits of that relationship to stakeholders. Further exploration is needed to assess the utility of the mutuality proxy measures in an evaluation tool to assess the strength and progression of the partnership. Additional research is also warranted to determine if the proxy measures can be used to evaluate mutuality in other academic–clinical partnerships.

Study limitations have been considered. This study makes use of qualitative codes to quantify differences in partnership development perspectives. In doing so, the study capitalized on a small sample size. Future studies should consider a larger sample if results are to be used for analyses. This study focused on one partnership, and results may not generalize to other partnerships. We believe the limitations do not outweigh the relative contribution of this study.

Conclusion

Although mutuality is acknowledged by many partnerships as key to sustainability, few studies have defined key measures. This study identified four potential key proxy measures of mutuality. Findings from this study can inform the development of tools to strengthen relationships and ensure stakeholders’ interests align with the goals of the partnership by operationalizing key elements necessary to evaluate the progress of the partnership. This study can also provide the basis for understanding whether and how mutuality really matters in improving population health outcomes in academic–clinical partnerships.

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