file creating currents of influence (1)

8/6/2019 File Creating Currents of Influence (1)

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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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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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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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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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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.

5


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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

7


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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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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.

9


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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.

1


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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.


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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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.


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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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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 [email protected].

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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