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A Joint Project o Tides and The Caliornia Endowment
THE EXPERIENCE To daTE oF THE CoMMUNITY CLINICS INITIaTIVE
Success Factors for a Multifaceted
Social Change Initiative
Creating
CurrentsoInfuence:
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CREaTINg CURRENTS oF INFLUENCE: SUCCESS FaCToRS FoR a MULTIFaCETEd SoCIaL CHaNgE INITIaTIVE
Hw cn philnthrpic investments in scil chne crete br n eep chne? This
evlutin brie utlines hw the Cmmunity Clinics Inititive (CCI), jint prject Ties
n The Clirni Enwment, hs been successul in ectin such chne within the
cmmunity clinics el in Clirni. The ctrs tht hve emere s bein instrumentl
t this success cn inrm the esin n implementtin ther philnthrpic inititives
n rntmkin erts.
In the pes tht llw, we rst prvie shrt escriptin CCI, its evlutin n its impcts. We then
iscuss the ctrs tht emere s criticl r chievin eep, systems-level chnes n er sme summry
refectins t te.1
a Successul Philnthrpic Ert
1 A major source o inormation or this evaluation brie is a recent BTWinorming changereport, Currents o Infuence: The Broader Impacts o the Community
Clinics Initiative, which was inormed by123 key inormant interviews (47 ocused exclusively on the broader impacts o CCI and 76 interviews addressing
specic program components o CCI as well as CCIs broader impacts) and a review and analysis o a substantial number o relevant documents (e.g., previous
CCI evaluation reports and studies).
THE CALIFORNIA ENDOWMENT & TIDES
The Caliornia Endowment is a statewide health oundation whose mission is to expand access
to aordable, quality health care or underserved individuals and communities and to promote
undamental improvements in the health status o Caliornians. The oundation has provided over
$98 million in unding or the Community Clinics Initiative since 1999.
Tides is a nonprot organization based in San Francisco that works with individuals, groups and unders
to implement programs that accelerate positive social change in the nonprot sector. As a project o
Tides, the Community Clinics Initiative receives operational capacity, program design and grantmaking
support as well as opportunities or shared learning and knowledge creation with Tides other projects
and initiatives.
1
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THE EXPERIENCE To daTE oF THE CoMMUNITY CLINICS INITIaTIVE
Revitlizin Clirni Clinics
TCE initiated CCI in 1999 as a one-time grantmaking
program with a ocus on preparing clinics inormation
systems or the new millennium (Y2K). From this initial set
o grants, CCI grew into what is now a $98 million initiativethat has provided multiple types o support, including 737
grants to approximately92% o Caliornias 180 community
clinics and 16 networks o clinics. As shown in Exhibit 1,
9% o unding goes to CCIs own operations (e.g., salaries,
benets, rent). Administrative ees, evaluation and learning
and knowledge sharing each comprise 3% o CCIs expenses.
Learning and knowledge sharing involves maintaining CCIs
online community, called the Community Clinic Voice, and
engaging in applied research. The remaining 82% o unds
goes directly to grants, training and technical assistance
and convenings or three broad ocus areas: inormationtechnology (IT), major capital and clinic leadership.
exhibit 1
Allocation o CCI Funds: 1999 through August 2007
Inormation
Technology*
57%Major Capital
22%
Operations9%
Administrative
Fees
3%
Evaluation
3%
Learning &
Knowledge
Sharing
3%Clinic
Leadership
3%
* This inclues expenses r Y2K rnts, dt & Qulity n
Strteic Investments.
CCI, jint prject The Clirni
Enwment (TCE) n Ties, is prtnership
esine t strenthen the cpcities
Clirni cmmunity clinics n helth
centers.
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CREaTINg CURRENTS oF INFLUENCE: SUCCESS FaCToRS FoR a MULTIFaCETEd SoCIaL CHaNgE INITIaTIVE
REVITaLIZINg CaLIFoRNIa CLINICS
2 Most recently, CCI released a request or proposals or a new unding stream, Networking or Community Health. This two-year program will provide
between 10 to 20 grants o up to $200,000 each to help clinics build their capacity to catalyze, manage and sustain networks with community partners. The
ultimate goal o the program is to position clinics as centers or community health in their communities.
exhibit 3
Community ClinicsInitiative ProgramTimeline
19992000Y2K Grants
20002005Inormation Technology
Program
20032006Strategic Investments
Program
20032008Major Capital
Investments Program
CCI has provided unding and support in ve ocus areas, as
depicted in Exhibit 2: inormation technology, technology-enabled quality improvements, clinic leadership, major
capital investments and strategic investments in collaborative
IT or community clinic networks and their members.2
Beyond the direct and immediate impact o grants, the
eects o the ve grant oci have combined their infuence
to create cumulative or synergistic impacts broader than
any one unding stream as well as ripple eects caused by
individual unding areas.
The unding fows rom TCE through Tides, which serves as
the Initiatives program partner, to the CCI sta and othersat Tides who together have designed an operational structure
and undertaken distinct practices to implement the Initiative.
CCI sta strengthen the unding streams by undertaking
activities that support and enhance their work; these include
direct grants as well as other value-added types o support
such as technical assistance, applied research and convenings.
From CCIs inception, CCI has had a broad vision to
improve the overall health o poor and under-resourced
communities. While there has been no overall long-
term blueprint dictating how the Initiative would be
implemented, one working principle has guided the process:
to strengthen the internal capacity and external linkages o
community clinics and clinic networks, and thereby move
the community clinics eld. In general, CCIs progression
can be characterized as more iterative and evolutionary
than heavily scripted or prescribed. A timeline o CCIs
programming rom its inception is shown in Exhibit 3.
CCI OPERATIONAL STRUCTURE & PRACTICES
(structure, vernnce, stn, pprch n cst)
exhibit 2
Community Clinics InitiativeStructure and Focus Area
BROADER CCI IMPACTSClinic Prctice Philnthrpy Public Plicy
Grant Focus Areas
InormationTechnology
Major CapitalInvestments
Technology-EnabledQuality Improvements
Clinic
Leadership
Strategic
Investments
Value-added Support
grntmkin Technicl assistnceavccy Cmmunictins Intellectul Leership
applie Reserch Cnvenins
3
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THE EXPERIENCE To daTE oF THE CoMMUNITY CLINICS INITIaTIVE
REVITaLIZINg CaLIFoRNIa CLINICS
20032009Clinic Leadership
Program
20052008Clinical Systems
Learning Community
20052009Funders Fostering
Technology or Quality
20062009Caliornia Networks
or E.H.R. Adoption
20072009Networking or
Community Health
The Ripple Eects o CCIs Initial Investments in ITSince CCIs rst IT investments in 1999,
ripple eect hs ccurre lein t
new prrms, the expne invlvement
uners cuse n imprvin the
technlicl bilities Clirnis
cmmunity clinics n the use technly
t imprve cre. ater the riinl Y2K
rnts, CCI cntinue t supprt iniviul
clinics with the l risin ll clinics t
bsic level IT inrstructure. In 2003,
CCI shite their unin pprch t cusn supprtin ewer rniztins tht cul
serve multiple clinics t enhnce rech
n impct. Thruh this cllbrtive
IT pprch the Strteic Investments
(SI) Prrm, CCI pplie key lernins t
their next ste prrmmin, which
cuse mre intensively n technly-
enble qulity imprvement thruh the
evelpment centrlize centers r
electrnic helth recrs (E.H.R).
CCI evelpe prtnership with the
Clirni HelthCre Funtin n the
Blue Shiel Clirni Funtin t
evelp three-yer, $4.5 millin prrm,
Clirni Netwrks r E.H.R. aptin
(CNEa). CNEa prvies rnt unin n
technicl ssistnce t ster clinics
evelpment cllbrtive strteies
r mel cmmunity-bse technly
prrms n shre pplictins n
services r E.H.R.
In 2005, CCI wre the Rew
Cmmunity Helth Clitin (RCHC) rnt
t estblish the Clinicl Systems Lernin
Cmmunity (CSLC) t brin tether clinic
st t shre lernins n best prctices
run clinicl IT intertin n prcess
reesin. a subcmmittee this Lernin
Cmmunity, the Clinicl Mesures grup,
cuse n estblishin level t
stnriztin run pririty clinicl
res (e.., ibetes, wmens helth,
hypertensin) with the purpse ccurtely
cllectin, trckin n nlyzin clinicl
t. ater but tw yers, the Lernin
Cmmunity becme s successul tht
ther clinics run the stte wnte t
jin. This mmentum cntribute t the
Clirni HelthCre Funtin unin
new sttewie inititive clle accelertin
Qulity Imprvement thruh Cllbrtin(aQIC), which is nw c-ste by RCHC
n the Clirni Primry Cre asscitin.
CSLC cntinues their wrk uner the aQIC
umbrell with brer inrstructure n
mre clinics invlve in settin sttewie
t stnriztin mesures.
Grants to strengthenindividual clinics
IT systems
Grants to strengthencollaborative ITamong clinics
Grants to strengthentechnology-enabled quality
improvement programs
Y2KGrants
IT ProgramStrategic
InvestmentsCaliornia Networksor E.H.R. Adoption
Clinical SystemsLearning Community
Accelerating QualityImprovement through
Collaboration
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CREaTINg CURRENTS oF INFLUENCE: SUCCESS FaCToRS FoR a MULTIFaCETEd SoCIaL CHaNgE INITIaTIVE
Impcts & accmplishments
CCI has had a big impact on leadership in
clinics via CCIs medical director trainingprogram and other work. The level o discourse
has changed. They have helped to create a
culture that expects engagement between
clinical and administrative olks and thats a
real paradigm shit.
Funder
dierent cets CCIs rntmkin emnstrte prun impct nt nly n the
iniviul rntees, but mre brly n cmmunity clinic prctice n, t lesser eree,
n their unin n plicy envirnments. Tether, these brer impcts hve clesce t
infuence the el cmmunity clinics in Clirni.3 Belw we prvie hihlihts
CCIs key ccmplishments.
3 During the same time period as this Initiative, many o the community clinics and clinic networks received unds rom government and other private sources.
To dierent degrees, a portion o these unds supported similar activities as CCI.
New capacities within clinics.Through multiplewaves o unding or IT and successive iterations o change,
CCI advanced IT use in clinics to prooundly alter not only
clinics administrative unctions but also the availabilityand quality o inormation that clinicians can bring to bear
in consulting rooms as they diagnose and treat patients.
Technological upgrades supported by CCI have built clinics
capacity to collect, store and use data to improve operations
and health outcomes in grant-unded clinics. In many
clinics, a redistribution o management responsibilities has
accompanied the changeswith the IT projects, many clinic
physicians roles shited rom working almost exclusively with
patients to assuming more signicant leadership roles in clinic
management. Further, CCIs unding and technical assistance
or major capital campaigns enhanced clinics inrastructure as
well as their und development capacity and their ties to their
communities.
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THE EXPERIENCE To daTE oF THE CoMMUNITY CLINICS INITIaTIVE
Stronger, more integrated networks
among clinics.Beore CCI, clinics tended to workin isolation rom each other with ew opportunities or
inormation exchange except at the executive director level.
The learning culture o CCI opened up more avenues
or inormation exchange. In addition, CCI deliberately
provided support to create more ormal collaborations
among clinics as a means o advancing capacity on a multi-
clinic basis. By using IT to improve clinic management,
inormation sharing and collaboration has increased at
dierent levels o clinic administration; thus CCI has
intensied collaboration at the executive and medical
director level and extended it downward to include more
levels and unctions.
IMPaCTS & aCCoMPLISHMENTS
Helpe the ntinl philnthrpic nity
rup grntmkers in Helth (gIH)
enhnce their wn knwlee but
cmmunity clinics, which hs been
cnveye t ther untins thruh
vriety meths. Mst recently, gIH
prtnere with TCE n CCI t hl tw-
y site visit r pprximtely 30 uners
rm run the cuntry in which CCI
shre their HIT rntmkin strteies
n experiences. CCI st cntinue t
supprt prticipnts lernin thruh
subsequent llw-up ui cnerences
n ne-n-ne meetins.
assiste uners in Clr n Hwiiin evelpin technicl ssistnce
cpcity n expertise within their sttes
by cnnectin them t CCI technicl
ssistnce cnsultnts.
Prvie input t ther untins
resultin in the replictin CCI
cmpnents. Fr exmple, the Clr
Helth Funtin recently lunche n
inititive cuse n cmmunity clinics.
Use $1 millin philnthrpic
investment t secure $20 millin r
the Helthy Clirni Ln Prrm,
thus incresin the vilbility lns
rm privte leners r mjr cpitl
investments mn clinics.
Infuence the ecisin t mke $40
millin in tx-exempt bns rm the
investment un Wellpint/Blue
Crss Clirni mre ccessible t
cmmunity clinics.
Three reinl unersL.a. Cre, Kiser
Permnente Suth n Unihelthc-
spnsre n electrnic helth recrs
(E.H.R.) rum in suthern Clirni
mele n n erlier ne spnsre by
CCI. This le t cretin n unin
with pprximtely $2 millinthe
Builin Clinic Cpcity r Qulity
(BCCQ) prrm, which use ssessment
tls evelpe by CCI n the Clirni
HelthCre Funtin t etermine the
reiness pprximtely 50 clinics
t tke n E.H.R. prjects. Bse n the
success this prject, ther uners
n vernment encies hve shwninterest in expnin the BCCQ mel
reiness ssessment.
Examples o CCIs Impacts on Philanthropy
Greater attention rom the philanthropic
and public policy sectors. CCI did not initiallyintend to infuence other oundations, but as the Initiative
became an increasingly important inormation and intellectual
resource or grantmakers working with community clinics,
CCI enhanced the visibility and stature o community
clinics among oundations. CCI has assisted oundations in
enhancing their understanding and support o community
clinics and partnered with oundations to leverage CCI
knowledge, experience and unds. CCI also increased
the visibility o community clinics among policy-makers,
enhancing attention to clinics health inormation technology
(HIT) needs and the relationship between IT and quality o
care. CCI has also helped to establish clinics as knowledgeable,
credible resources and testing grounds or moving HIT
orward in both the public and private sectors.
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Stronger eld identity and increasedstature as a eld. With deep roots in localcommunities and the particular populations that they serve,
community clinics were slow to converge and develop an
identity as a eld. CCI nurtured clinics sense o being a
eld by bringing them together, continually talking to them
and treating them as a eld and using data to refect on the
eld as a whole. This growing identity as a eld has been
intensied by the increased visibility o community clinics
among other oundations and in the public policy domain.
IMPaCTS & aCCoMPLISHMENTS
Cllbrte with the Ntinl asscitin
Cmmunity Helth Centers (NaCHC) t
spnsr n prvie testimny t Cpitl
Hill brien n the benets n brriers
cin cmmunity clinics s they seek t
use HIT systems t imprve cre.
Cntribute t the cretin HIT
psitin t Helth Resurces n Services
aministrtin (HRSa) thruh public n
privte iscussins with ency st,
plicy cnvenins n the prvisin bth rl n written testimny.
Inrme n ene ntinl level
plicy experts, such s dr. dvi Briler,
the rst U.S. ntinl crintr r HIT.
Submitte invite testimny t the
Huse Wys n Mens Cmmittee t
recmmen inclusin cmmunity
clinics lnue in prpse sety net
n HIT leisltin (e.., Kenney n
ginrich bills).
Prtnere with ther uners n clinics
t retin the public plicy lw rm
Mntt, Phelps n Phillips, t exmine
the reultry envirnment Meici
t supprt HIT investments; publictin
will be relese in the ner uture.
Prticipte in Clirni stte
summit, ln with ther untin
representtives n helth cre inustry
executives, t inrm the Unersecretry
Helth n Humn Services nMne Cre n stte HIT pln.
Examples o CCIs Impacts on Public Policy
The CCI sta is very dedicated about bringing
this issue o clinics and (health inormation
technology) into the national spotlight. CCI
has been there to push the Health Resources
and Services Administration (HRSA) tomove orward and they have served as an
inormation resource, documenting the special
case o health centers, pushing the idea that
they cant be lumped in with other health care
providers in any HIT adoption plan because
clinics have unique needs.
Policy-maker
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THE EXPERIENCE To daTE oF THE CoMMUNITY CLINICS INITIaTIVE
10 Fctrs r Success
Key Structure & Management Practices
1 Housing the Initiative at Tides.A key considerationor any unding program or initiative is whether itwill be managed rom within a oundation or whether the
oundation will use a vehicle such as a program partner
or an external program oce. When initiating unding
or clinic inormation systems at the turn o the century,
TCE needed an organization that could serve as a respectedand ull-service intermediary to quickly move dollars out
the door, and chose Tides. Tides expertise includes deep
philanthropic experience translating ideas into grants, an
institutional capacity or grantmaking and a wide range
o support services or nancial, legal and human resource
needs. Also signicant in achieving broader impacts in
philanthropy have been Tides well-established relationships
and credibility as a steward o philanthropic unds. With the
evolving nature and scope o CCI, this experience, expertise
and agility have continued to be assets or achieving impacts.
For example, the ability o Tides to accept unds rom otherphilanthropists or collaborative projects acilitated the
quick start up o Caliornia Networks or Electronic Health
Records Adoption (CNEA), a program that was incubated at
CCI and is described later in this evaluation brie.
2 Relationship building and collaboration. Networking,relationships and collaboration acilitated theachievement o many o the broader impacts, particularly
moving the changes rom individual grantees to the eld
level. CCI sta promoted these activities through many
methodsstructuring some grants to include collaboration,convening countless meetings and conerences and attending
and organizing othersand by being perceived as good
collaborators and relationship builders themselves. These skills
were especially important to contributing to broader impacts
in philanthropy where infuence is primarily exerted laterally.
The evlutin CCI ientie ten key ctrs tht cilitte sinicnt chne r
cmmunity clinics n their envirnment (Exhibit 4).
3 Supporting innovation. Throughout the Initiative,CCI sta have pushed grantee clinics and clinic networksto change, advance and take the steps, even when they are
risky, that get them closer to their goals. The CCI sta have
typically been several steps ahead o clinics and has used the
variety o tools available to them to induce and exhort clinicsto advance. They have also provided support or those clinics
that are the greatest risk takers, encouraging them to take the
steps with high potential or advancing the eld.
exhibit 4
Contributing Factors to CCIs Success
Key Structure & Management Practices
1 Husin the Inititive t Ties, ull-service intermeiry
2 Reltinship builin n cllbrtin3 Supprtin innvtin
4 Inusin knwlee n emphsis n lernin
7 Refective prctice
6 Reltinship with The Clirni Enwment
A Fluid Design
7 an emerent style
8 gvernnce n input rm the el
Change Accelerators
9 The ctlytic nture the interventin
10 Hih se interventin
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CREaTINg CURRENTS oF INFLUENCE: SUCCESS FaCToRS FoR a MULTIFaCETEd SoCIaL CHaNgE INITIaTIVE
4
Inusion o knowledge and emphasis on learning. CCI
employed multiple strategies or gathering and inusingknowledge into the Initiative and extracting inormation to
inorm next stepsor example, convening grantees, unding
collaborative learning and communication vehicles and using
an evaluation that provided process as well as outcome data
in real time. At the beginning o CCI, very little research
existed about the community clinics eld. As a result, CCI
both commissioned and catalyzed research to create a growing
body o knowledge about community clinics. An important
cluster o impacts on grantees internal practice ocused on
learning to manage transormative change, to expect that
change is a normal part o doing business and to engagein iterative learning processes. CCI sta both eased and
accelerated grantees learning processes through their timely
inusion o data, knowledge and expertise. For example,
CCI promoted peer-to-peer learning, hired consultants to
provide technical assistance through the capital investments
improvements process and made supplementary grants (e.g.,
or a change management consultant) to strengthen grantees
capacity to meet their goals.
10 FaCToRS FoR SUCCESS
For The Endowment to multiply its resources
by contracting out its Initiative was a good way
to go. It doesnt make sense or a oundation
to carve out or hire sta or a limited time
initiative. CCI has a very capable team with
top-notch people. They are knowledgeable
about the clinics and act as guide, under and
provider o technical assistancegiving tough
love when needed. It has been an extensionprogram or us or community clinics in
Caliorniato get an understanding as close
to the ground level as you can get. It has been
a wonderul model.
Funder
5Reective practice. The CCI management team itsel
engaged in an intensive learning process by constantlycollecting, analyzing and using data and eedback about
their grants, the state o the eld and where new money and
energy should be invested. Additionally, CCI sta eectively
modeled refective practice or clinics. This refective practice
has been done ormally through the evaluation process and
commissioned research and inormally through meetings and
discussions with practitioners, outside experts and observers
o CCI. As a result o these practices, a continuing quality
improvement process has been integrated into Initiative
management which helps to determine the next steps and
unding oci or the Initiative. Most recently, CCI conveneda series o gatherings with a diverse set o community clinic
leaders, TCE sta and others involved in movement building
with low-income populations to determine the most eective
use o remaining CCI unds. This iterative discussion
process culminated in the start o CCIs new unding
stream, Networking or Community Health. This program
ocuses on supporting clinics to strengthen networks with
community partners and position clinics as centers or
community health.
6Relationship with The Caliornia Endowment.
Underlying all o the actors mentioned above has been
the critical infuence o CCIs relationship with TCE. In
implementing CCI, TCE ceded considerable authority to
Tides to supplement its grantmaking with many orms o
value-added activities to address key needs and opportunities
as they arose, thus acilitating not only the accomplishments
o individual grantees but the broader impacts o the
Initiative as well. O particular note are the discretionary
unds that CCI has been able to use to urther collaboration,
technical assistance and learning among grantees. Refective
o this relationship, a member o the TCE Board o Directors
was always a ormal member o the CCI steering committee,
and TCE sta attended CCI steering committee meetings as
a learning partner and content resource or this endeavor.
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THE EXPERIENCE To daTE oF THE CoMMUNITY CLINICS INITIaTIVE
10 FaCToRS FoR SUCCESS
What has come out o CCI, or us and or other
health centers and health center networks
in Caliornia, is that the level o collectivediscourse about these issues is just light years
ahead o where it was even twelve months
ago. The CCI sta has been incredibly engaged
in this really complicated back-and-orth
about What are we doing, why are we doing it
and how do we ensure that were using these
resources to really improve care?
Grantee
A Fluid DesignIn addition to the attributes o success identied above, the
evaluation identied two more nuanced actors related to the
Initiative design. While these actors have clearly contributedto the success o CCI, they also have a shadow side that
must be managed to avoid dragging down the positive side,
which continues to predominate in CCI.
7An emergent style. CCI can be characterized as havingan emergent style. Rather than operating rom the outsetwith a blueprint providing precise inormation about how
and when unds would be released, how grants would be
supported with value-added activities and when the Initiative
would conclude, CCI has gone through an iterative design
and implementation process with several rounds and dierenttypes o unding. Part o CCIs success has resulted rom this
open-ended quality o the Initiative that has allowed, and
perhaps necessitated, that CCI sta stay close to the grants,
talk with grantees, listen and learn. Throughout this process,
CCI continually identied additional supports to benet
grantees, build on their current level o accomplishment and
address key challenges.
an imprtnt impct n ripple eect
CCIs prrmmin hs been the increse
prtnership uners run technly-
enble qulity imprvement r cmmunity
clinics. In 2005, rup uners cme
tether t rm the Clirni Helth
Funers Strtey grup (CHFSg) n crete
cmmn rmewrk6 t uie HIT unin
mn Clirni untins n ther
public n privte uners. Nw knwn s
the Funers Fsterin Technly r Qulity(FFTQ), this rup pprximtely 17
uners meets reulrly t shre inrmtin
but their HIT unin experiences, ientiy
unin ps n crinte unin
erts s relevnt. While they ene in
their wn iniviul technly-enble
qulity imprvement inititives t lcl,
reinl r stte levels, they utilize their
shre rmewrk n cmmunity
prctice t lin unin pririties n
prctices n, in sme cses, cllbrtively
un prjects. The rup hs urtherexpne their reltinships t inclue
seminnul meetins with stte vernment
representtives t shre HIT knwlee n
prctices.
CCI plys n imprtnt rle in FFTQ by
prviin stn supprt n leership
t the rup. The members ree tht CCI
is in unique psitin t serve in this rle
iven its strn rniztinl inrstructure
n experience n expertise in HIT unin;
sme escribe hw their prjects hveevlve rm CCIs initil IT wrk.
Aligning Funding Streams: Funders Fostering Technology or Quality
6 Caliornia Health Funders Strategy Group. (2006).A Strategic Framework: Technology-Enabled Quality Improvement or Caliornias Community Clinics.
San Francisco: Object Health.
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CREaTINg CURRENTS oF INFLUENCE: SUCCESS FaCToRS FoR a MULTIFaCETEd SoCIaL CHaNgE INITIaTIVE
8Governance and input rom the feld. From its
inception, CCI had a structure in place to gather inputrom the eld through its steering committee which was
composed o community clinic leaders and a representative o
TCE. This committee created credibility or the Initiative as it
got underway and provided valuable input and guidance to CCI
sta in the early phases o the Initiative. Overall, the benets o
this structure have provided important, relevant input or CCI
sta and created a sense o ownership and empowerment within
the community clinics eld. This has kept CCIs thinking
closely tied to the needs o community clinics.
10 FaCToRS FoR SUCCESS
While this emergent style resulted in some o the strengths
o the Initiative, the shadow is that Initiative observers andCCI sta both speculate that the ocus and strategies or
specic types o unds, such as IT, would have diered i the
ull amount and duration o unds had been known at the
Initiatives launch. The lack o a ully developed blueprint
infuenced other aspects o the Initiatives implementation as
well, or example, relying on a small core sta with external
consultants brought on or key areas o expertise as needed.
Although CCI has been successul within this emergent style,
this actor emphasizes the need to nd the right balance
between determining initiative architecture in advance and
learning through the process o implementing grantmakingprograms.
CCI lunche the Mjr Cpitl Investments
Prrm in 2003 with the intent helpin
clinics strenthen their inrstructures
thruh cilities n un evelpment.
T increse the eectiveness the cre
rnts, they esine the Prrm t inclue
multiple types vlue-e supprts. CCI
intentinlly structure rirus pplictin
prcess tht require ptentil rntees t
evelp unrisin, business n strteic
plns. applicnts withut the necessry
cpcity n stmin t unertke cpitl
cmpins n prjects ten receive
rnt t strenthen specic spects their
rniztin n better psitin themselves
r the next run mjr cpitl rnts.
Thruhut the pplictin prcess n
urin the rnt cycle, rntees benete
rm ne-n-ne technicl ssistnce
rm tw externl cnsultnt cmpnies,
Cpitl Link n Cpitl Incubtr, s
well s CCI st. Technicl ssistnce
prviers ssiste clinics by prviin
vriety supprts such s nncil
nlyses, reiness ssessments n
cpitl prject wrk pln sessins. This
technicl ssistnce helpe t blster the
eectiveness cre rnts by ensurin tht
rntees h ccess t relible inrmtin
t strteiclly strenthen their prjects
n rniztins mre brly. In itin
t the ne-n-ne technicl ssistnce,
CCI hel n nnul seminr tht prvie
venue r peer refectin, shrin n
lernin mn mjr cpitl rntees,
technicl ssistnce prviers n CCI
st. These seminrs prvie CCI with n
pprtunity t keep rntees inrme but
current reserch they h cmmissine,
incluin prrm evlutin nins. The
seminrs ls llwe rntees t her rm
experts within the el n urther evelp
knwlee, skills n supprts relte t
their mjr cpitl erts.
CCI Strategy: Oer Complementary Supports
Research &Inormation
Dissemination
RigorousApplication
Process
TechnicalAssistance
SupplementaryGrants
Seminars
GRANT
CYCLE
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THE EXPERIENCE To daTE oF THE CoMMUNITY CLINICS INITIaTIVE
4 For comparisons and contrasts, the evaluation included a review o our philanthropic initiatives with a similar budget size, a duration o at least ve years,
multiple strategies (e.g., a combination o grantmaking, technical assistance, applied research, convenings, etc.), targeted constituencies and a ocus on
organizational capacity/eld building.
Although the benets o this structure have outweighed the
downsides, there are also shadows o this actor to consider.One has been that the need or input into the Initiative
changed over time, necessitating a dierent type o structure
and the disbanding o the original committee. Although the
Initiative was able to preserve a sense o trust and collegiality
with leadership rom the eld, and CCI participants generally
understood the reasons or this shit, changing the governance
structure midstream was risky and unsettling.
Some Initiative observers have pointed to another potential
drag on change caused by this committee structure, which
is over-reliance and responsiveness to the eld. According tothis point o view, those who will be doing the changing (in
this case, community clinics and their leaders) may not have
a vision or change that is as bold or expansive as the vision
held by external observers and experts who hold less o a stake
in the status quo. CCI has needed to nd a balance between
the voices o insiders and outsiders in designing and
implementing the Initiative. This illustrates the importance o
considering a variety o perspectives and approaches to creating
change without becoming beholden to any one point o view.
Change AcceleratorsFinally, in comparing CCI to other large philanthropic
initiatives, two additional actors emerged with important
implications or CCI and its success.4
9 The catalytic nature o the intervention. The primaryintervention o CCI was the introduction o technologicalchange in clinics and groups o clinics. I interventions, like
chemicals, were categorized according to those that are inert
and those that are reactive, technology would clearly all into
the reactive category. Each new technological advance igniteda series o chain reactions that resulted in changes in many
aspects o clinic organization and unctioning, in the ways
that clinics work together and, ultimately, in the eld.
CCI has had a huge impact on clinics in
Caliornia. Their strategy was accomplished,
which was to bring the clinics up many notches
in terms o their advancement, level o
sophistication and use o technologygetting
the medical directors, the entire executive
teams, and the entire health centers more
engaged in technology. As a result, CCI is
responsible or moving the clinic industry way
urther down the road in technology, and that
is a very signicant accomplishment o this
Initiative.
Grantee
10High dosage intervention. CCI can be characterized ashaving achieved a high-saturation, high-intensity impactby reaching most o the community clinics in Caliornia not
just once but multiple times. Among Caliornias community
clinics and clinic networks, most have received at least one
CCI grant, many have been awarded multiple grants and some
clinics have received as many as ten grants.
10 FaCToRS FoR SUCCESS
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CREaTINg CURRENTS oF INFLUENCE: SUCCESS FaCToRS FoR a MULTIFaCETEd SoCIaL CHaNgE INITIaTIVE
Summry Refectins n
Questins T Cnsier
ManagementGiven the nature o the intervention, what is the best
management and governance structure?
DosageWhat kind o dosage is desirable? Can a one-time
intervention or many organizations work, or would it be
better to ocus on a higher dosage with a smaller number o
organizations?
BalanceWhat is the right balance between prescription rom the
outset and learning and evolving as you go?
Added ActivitiesWhat activities beyond direct grantmaking would add value
to the intervention?
Change ManagementTo what extent will other changes be ignited, and should a
change management process be built in?
Tolerance or RiskWhat is the level o tolerance or innovation and risk, and
how does that align with the ocus and type o initiative
support?
Refection, Learning and CommunicationTo what extent do refection, learning and communicationacilitate intended outcomes and how will those qualities be
built into the initiative?
CollaborationHas adequate time and support been included or
relationship building and collaboration among grantmakers
and grantees?
This evlutin brie hs escribe ten ctrs criticl t the success CCI. These ctrs
re imprtnt t tellin n unerstnin the stry this ne Inititive, n we believe
they cn be useul t ther inititives n unin prrms. at minimum, the list this
Inititives success ctrs cn help rntmkers n evlutrs ientiy key imensins
inititives r cnsiertin.
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THE EXPERIENCE To daTE oF THE CoMMUNITY CLINICS INITIaTIVE
No single blueprint or success could ever be drated to apply
to all grantmaking situations. However, given the nature o
deep, challenging problems that philanthropy is addressing,
grantmakers and their partners can learn rom successes
such as CCI. We hope these evaluation ndings will spark
urther conversation and analysis o initiatives and unding
programs to ultimately build a body o knowledge about
successul interventions that achieve deep and meaningul
social change.
Fr mre inrmtin r questins but this brie, cntctKim ammnn Hwr t khwr@btw.inrminchne.cm.
aitinl inrmtin but the Cmmunity Clinics Inititive n
BTW inrmin chne is vilble t their respective web sites,
www.cmmunityclinics.r n www.btw.inrminchne.cm.
We were always impressed with the way [CCI
sta] were able to absorb the inormation to
really get a sense o whats happening in the
eld, to be able to marry a strategic perspective
and talk with us about whats happening in the
trenches and will this really work? to adjust
and change and innovate. It was great to see
that they werent encumbered with any kind obureaucracy or impediments to innovation.
Consultant
SUMMaRY REFLECTIoNS aNd QUESTIoNS To CoNSIdER
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CoMMUNITY CLINICS INITIaTIVEa Jint Prject Ties n The Clirni EnwmentP.o. Bx 29907Sn Frncisc, Ca 94710(415) 561-6356
Strong Clinics,Healthy Communities
February 2008
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