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Bringing together a wide range of partners to support primary care quality improvement (QI) can help increase capacity and expertise, reduce duplicative efforts, reach a broader and more diverse set of practices, and help sustain QI efforts over time. Additionally, the inclusion of trusted organizations increases the credibility of the effort—for the practices you are aiming to recruit, for potential funders, and for outside observers. 

This chapter describes key steps for effectively establishing a state-based healthcare extension program to support QI in primary care, drawing on the experiences of ������Ƶinitiatives and lessons learned from them. 

Conduct Landscape Review and Needs Assessment

Before developing a healthcare extension program, it is useful to conduct a thorough landscape review and needs assessment to understand existing capacity and needs in the state. A landscape review will help you to assess the state’s current QI activities, identify related ongoing QI efforts and opportunities to coordinate with these efforts, and identify potential partners for your work. A needs assessment will help ensure the program fills an existing gap and that its services and offerings address the specific needs of primary care practices in your state (or sub-state region of focus). An effective landscape review and needs assessment will include web-based searches and review of relevant publications, as well as meetings with interested parties within your state (e.g., state Medicaid agency, the state department of health, primary care clinicians, and primary care professional organizations) for on-the-ground insights. 

Understand Your State’s QI Experience and Existing Capacity

A good first step for your landscape review is to collect information about past and current state and regional QI projects and other health-specific initiatives and the groups responsible for those efforts. It is helpful to identify successful programs, existing barriers to implementation, any clear gaps that need to be addressed, and any already developed infrastructure (e.g., trained practice facilitators) or primary care QI capacity, before determining what you need to develop. 

For example, consider the extent to which practices in your state have participated in the following (go to Table 7 in chapter 5, for additional examples): 

• Alternative payment models and value-based care models that support QI:
  • The and its Innovation Center’s , such as the , , , and .
• State Medicaid programs and Medicaid managed care plan value-based care models:
• Federal QI grant initiatives:
  • ������’s&�Բ�����;IMPaCT and EvidenceNOW.
  • The Health Resources and Services Administration’s  and  for rural health.
• Health topic–specific QI initiatives such as , , , , and .
• QI initiatives through the state department of health, the state Medicaid agency, and Medicaid managed care plans.
• QI initiatives led by private health plans, health systems, primary care associations, and primary care professional associations.
• (QIN-QIOs) improvement interventions.
• Health information technology efforts that support QI through  and .

To help states evaluate their alignment with federal primary care initiatives, the Virginia Center for Health Innovation and Milbank Memorial Fund have developed a Primary Care State-Federal Alignment Tool, which can be found .

Once you have the full picture of the current QI- and primary care–focused efforts in your state, you can determine the areas of greatest need for new or more coordinated efforts. It might also be helpful at this stage to consider whether it makes more sense to start a new program or expand an existing program. 

Understand the Needs and Interests of Primary Care Practices 

A needs assessment can be helpful to understand the QI capacity of practices in your state and to understand the needs, interests, and priorities of practices to help determine the focus of your QI projects. Such an assessment could result in focusing your efforts, at least initially, on a particular disease or other content area (e.g., improving heart health or equity), on certain types of practices (e.g., rural, or small independent practices), or on specific areas of practice improvement (e.g., using electronic health records for QI). 

To gather these types of insights at the outset, it can be helpful to consult with leaders from the state primary care association and state and local chapters of primary care professional associations (e.g., the American Academy of Pediatrics, the American Academy of Family Physicians, the American College of Physicians, the American Academy of Physician Associates, and the American Association of Nurse Practitioners). In addition, practice-based research networks (PBRNs) work directly with primary care practices and likely have a good sense of their needs and priorities. It can be helpful to reach out to the PBRN(s) in your state or sub-state region to gather its perspective. Attending conferences or other meetings where primary care clinicians in your state gather is also a good way to learn about current concerns from the clinician perspective. You might also want to review other resources such as the for your state developed by the Robert Graham Center, to review trends in key primary care indicators to identify areas of strength and those in need of improvement. 

Once practices have been recruited to participate in your extension program, you can conduct needs assessment surveys to better understand how to tailor your QI services to best meet their interests and needs. Read more about needs assessment surveys in Select and Tailor QI Services in chapter 4.

Develop a Mission Statement 

Drafting a mission statement/statement of purpose and a vision statement is a key step in strategic development. The program’s mission statement is likely to evolve over time and with the inclusion of the various perspectives of partners. The revised version can become part of your project charter or bylaws (refer to the Project Charter and Bylaws section below). However, drafting an initial mission statement at the outset can help clarify and communicate your program’s key goals and objectives. As an example, the Tennessee Population Health Consortium (a broad group of statewide QI initiatives of which Tennessee Heart Health Network is a part) developed the tagline, mission statement, and vision statement shown in the box below.¹¹ 

Invite Partners to Participate 

Including a diverse set of organizations in your extension program helps to bring in the varied expertise, skills, and perspectives—as well as the credibility, capacity, and connections—necessary to carry out an effective statewide QI support effort. For the success of the program, it is also important to identify and invite partners with values that align with your mission/purpose for the extension program. It can also be useful to consider whether there are any organizations or people in the state who might be opposed to your program’s goals or (perhaps more likely) might see your program as competition for limited resources and the attention of primary care practices. Inviting these groups to partner with your extension program can be an effective strategy to reduce opposition, as long as you are able to align the mission and objectives of the two organizations.¹⁰

Identify Needed Expertise

Depending on the expertise and skills of the lead organization and initial partners, you might need to identify additional organizations and people to help meet the specific goals of your extension program. Relying on organizations based within your state to fill these roles is ideal, but it could be necessary to seek out regional (or even national) partners to fully cover one or more of these needs—at least while you work to build expertise and capacity inside your state. 

The EvidenceNOW cooperatives included partners with the necessary knowledge, expertise, or skills in the following areas:^b

• Clinical evidence. EvidenceNOW: Building State Capacity cooperatives included organizations with knowledge and resources on the latest clinical evidence related to heart health in primary care. For example, the cooperatives included the following types of organizations:
  • Universities and university systems including schools of medicine, recipients, academic health systems (e.g., MetroHealth), and a college of pharmacy (Auburn University School of Pharmacy in Alabama Cardiovascular Cooperative).
  • Professional associations including state-based associations for physicians such as family physicians and internists; professional associations of nurses, nurse practitioners, physician assistants, pharmacists, and dieticians; and primary care associations.
  • Disease-specific associations such as the American Heart Association.
• QI support. The EvidenceNOW: Advancing Heart Health cooperatives found that partnering with multiple organizations to supply practice facilitators in their region of focus provided access to a workforce that was larger and better distributed than what they would have gotten by hiring their own practice facilitators or partnering with one organization.¹² In addition, relying on more than one organization for practice facilitators protects your program if one of those organizations closes. Organizations that might employ practice facilitators include QIN-QIOs, PBRNs, Regional Extension Centers, university-based clinical and translational science centers, (AHECs), and state offices of rural health. 
• Practice recruitment. It can be helpful to partner with organizations that have credibility and established relationships with the types of practices you want to recruit to participate in your program. The partners that helped the EvidenceNOW cooperatives with recruitment included organizations with expertise in QI, healthcare organizations (including health systems), PBRNs, professional associations, and universities.
• Geographic reach. Partnerships are critical to reaching and providing support to practices across an entire state. Land-grant universities have agricultural extension programs that are already engaged in health-related activities and can help with geographic reach across a state. The EvidenceNOW: Building State Capacity cooperatives engaged a wide variety of partners to ensure broad geographic reach. For example:
  • The University of Alabama at Birmingham developed a new partnership with the Auburn University School of Pharmacy to expand the reach of its cooperative. 
  • The Heart Healthy Ohio Initiative worked with three regional health improvement collaboratives to ensure broad practice recruitment.
  • The University of Tennessee Health Science Center, which led the Tennessee Heart Health Network, has four campuses spanning the state and is part of a larger land-grant university system that has a robust regional extension service. By partnering with the extension service, the Tennessee Heart Health Network expanded support for primary care delivery of population health services to every rural county in Tennessee.
• Equity. To be more equitable, the EvidenceNOW: Building State Capacity cooperatives partnered with organizations serving traditionally excluded and underserved groups, such as people who are uninsured or underinsured, people who live in rural areas, and people from racial or ethnic minorities such as African American and Native American populations. For example:
  • Alabama Cardiovascular Cooperative partnered with the Alabama Primary Health Care Association to recruit federally qualified health centers throughout the state. Community health centers provide low-cost care to people who are underserved. 
  • Healthy Hearts for Michigan focused on reaching rural practices and brought in the Michigan Center for Rural Health to help adapt the QI project and services for a rural setting. Michigan also targeted recruitment activities to practices that serve Native American communities. 
  • The Tennessee Heart Health Network focused on practices serving African American communities in the western region and rural Appalachian communities in the eastern region of the state. 
• Patient perspective. When patients and other people with lived experience are included in the planning and growth of an extension program, their experiences and needs can best be reflected in the program’s approach and activities. For example:
  • The Tennessee Heart Health Network created patient advisory councils to help inform its work. Members of these councils served as patient experts, adding the patient’s voice and perspective at every stage of the practice improvement process. 
• Data collection and reporting. EvidenceNOW: Building State Capacity cooperatives engaged partners such as state health information exchanges to help collect practice data and create data dashboards to inform practices’ QI activities. For example:
  • Alabama Cardiovascular Cooperative worked with the state health information exchange and a vendor that collected data and provided dashboards for practices. 
  • Healthy Hearts for Michigan partnered with the Health Information Technology Regional Extension Center for Michigan. 
  • The Tennessee Heart Health Network was closely aligned with the Tennessee Population Health Data Network in its collection and reporting of QI data. 
• Program evaluation and research capacity. Academic partners provide expertise in both qualitative and quantitative methods to assess the implementation and impact of the QI projects. For example:
  • Healthy Hearts for Michigan relied on its academic partners, Northwestern University and the University of Michigan, to share knowledge with community-based partners (e.g., Quality Improvement Organizations, professional associations) on topics such as human subjects research, institutional review boards, obtaining informed consent, research fidelity, and dissemination.
• Coordination and sustainability. State government (including state departments of health, social services, aging, and mental health) and payers (e.g., Medicaid, commercial health plans) can help establish statewide QI goals, eliminate duplicative efforts, and align QI efforts with payment and policy (e.g., harmonizing formulary access for QI projects with a focus on blood pressure medications). These partners can help sustain efforts after initial grant funding ends by maintaining the network of practices and providing ongoing funding for external QI support.

Engage Partners

Once you have identified which partners you want to include, you can begin reaching out to pitch your extension program. These meetings can be used to share your vision, why you believe the organization or person would be a good partner, and what participation might entail (roles, time commitments, etc.). In addition to sharing your mission statement, consider also developing a value proposition to make your case to potential partners about how involvement in your healthcare extension program could benefit them (find more information in Develop a Value Proposition in chapter 3). 

Through discussion, you will be able to gain a more complete understanding of the specific skills and assets the partner would bring to your program and assess their interest level and their willingness to participate. Fully understanding the interests and strengths of each partner will help you assign roles within the program that will best capitalize on the varied skills, knowledge, credibility, energy, and dedication that each partner brings. For example, the Heart Healthy Ohio Initiative team developed a survey for potential payer partners (PDF, 62 KB) to assess their willingness to participate in program activities and collect additional information about the heart health–related coverage the payers provided their members. 

In addition to figuring out which organizations to invite to participate to fill the needs of your extension program, you will also want to consider what type of role each partner organization will play. For example:

• Some key organizations will have a role in leadership and decision making (e.g., sitting on an executive council).
• Some will be involved in the day-to-day activities of running the extension program and carrying out the QI work, even sharing staff or funding.
• Other organizations will play a more advisory, ad hoc, or peripheral role. 

Your extension program might want to designate terms, such as “member” or “key partner,” to differentiate the organizations with a more significant or integral role from the other organizations playing a less central or more informal role. The EvidenceNOW: Building State Capacity cooperatives each included a large group of partners that came together to support and advise the overall effort, as well as a smaller core group that participated in the regular activities of the cooperative (such as in working groups).

Once a partner has agreed to participate in your program, it can be helpful to develop and have both parties sign a Scope of Work, Letter of Agreement, or Memorandum of Understanding. Having such an agreement in place can help prevent misunderstandings related to roles and levels of involvement and ensure continuity even if there is staff turnover and the original members leave the organization. For partners that share funding, Subcontracting Agreements might be required.

Develop an Organizational and Governance Structure

Organizing Framework

Using a framework to guide the development of your extension program can provide an organizing principle to help achieve your goals. As an example, Teresa Hogue’s Community Based Collaboration: Community Wellness Multiplied¹³ (Table 2) provides a framework for community-based initiatives showing the range of linkages, from loosely organized networks to collaborations with a shared vision. 

Table 2. The Range of Linkages for Community-Based Initiatives

EvidenceNOW: Building State Capacity grantees used frameworks to guide the development of their cooperatives. 

• Alabama Cardiovascular Cooperative used the Community-Academic Partnerships framework,¹⁴ which aims to promote and advance equal partnership between academic researchers and interested community organizations in creating and executing implementation research. This framework offers guidance on “(a) building a coalition, (b) conducting local consensus discussions, (c) identifying barriers and facilitators to implementation, (d) facilitating interactive problem solving, (e) using an advisory board or workgroup, (f) tailoring strategies, (g) promoting adaptability, and (h) auditing and providing feedback.”¹⁴
• Healthy Hearts for Michigan used the EPIS framework to assess the facilitators of and barriers at each of four stages of cooperative development (Exploration, Preparation, Implementation, and Sustainment).¹⁵ 
• Heart Healthy Ohio Initiative used the Collective Impact Model. The model posits that “complex problems require collaborative and synchronized approaches involving leaders from community partners representing diverse backgrounds and perspectives.”¹⁶ The Initiative applied this model in a co-design process to engage a diverse set of partners in collaborative development of an external QI infrastructure (find more about the Collective Impact Forum’s model on its  and in ).

Lead Organization 

The organization that leads an extension program generally assumes significant responsibility for the administrative operations of the group, including securing funding and overseeing finances, convening meetings, and organizing communications across partners. However, depending on the organizational and governance structures that are set up, the lead organization might or might not share decision-making authority with other partners (go to the section on Leadership and Governance Structure below for additional discussion of decision-making authority in an extension program). 

Different types of organizations can effectively lead a healthcare extension program. For example, a healthcare extension program could be led by a QI organization, a payer (including Medicaid), a university, or even a state government agency. What organization is best suited to lead the extension program depends on historical leadership roles in the state and trust in the convening organization across partners.⁷ Academic institutions have commonly served as the lead organization for AHRQ-funded cooperatives in large part because they were funded as research grants or cooperative agreements, and academic institutions have the infrastructure to apply for and manage large federal research grants. For example, universities led three of the four EvidenceNOW: Building State Capacity cooperatives. Universities also have expertise on clinical health topics and on the latest evidence for clinical practice. However, other types of lead organizations have different potential benefits. For example, an effort led by state government might be able to mandate support from payers in the state or provide dedicated funding over time. 

Leadership and Governance Structure

As described in  (PDF), the complexity and formality that are required for a group’s governance framework increase in proportion to the size of the group and the nature of the relationships in the group. “For example, large groups with unfamiliar participants, significant conflict, or great differences in participants’ power may require a more structured governance framework. By contrast, groups with strong prior relationships, low conflict, and group members with balanced power may have less need for structure.”¹⁷ 

Primary care extension programs typically have a governing group or committee with responsibility for guiding overall activities and direction. Among the EvidenceNOW: Building State Capacity cooperatives, this group was variously known as a Steering Committee, Executive Committee, or Executive Council and typically included a chair, who might or might not have come from the lead organization. In some cases, this group was large and included representatives from across partner organizations; in other cases, the group was very small and included only representatives from the lead organization and members from one or two other primary partner organizations. 

The EvidenceNOW: Building State Capacity cooperatives each employed a “hub-and-spoke” model, with a central group or committee (e.g., an Executive Committee) that provided leadership (the “hub”) and working groups dedicated to implementing the various components of the project (the “spokes”). 

• Alabama Cardiovascular Cooperative was governed by an Executive Committee that included representatives from the lead organization and three core partners. The Executive Committee had decision-making authority and used consensus to ensure members retained equal influence over group direction and activities. An advisory board, with representatives from diverse sectors throughout the state, provided guidance and recommendations to the Executive Committee.
• Healthy Hearts for Michigan had a Steering Committee that met twice a year and was responsible for broad oversight of the cooperative’s activities. The Steering Committee included the two project principal investigators (PIs), representatives from member partners, and the leads from each working group. The PI from the lead organization headed the Steering Committee and maintained decision-making authority. A Physician Advisory Committee included physicians from across partner organizations and provided clinical guidance. A project management team made up of a small group from the two lead organizations managed day-to-day operations. 
• Heart Healthy Ohio Initiative had an Executive Team with 10 members representing the lead organization and five other key partner organizations. An informal voting and feedback structure was in place to share input from partners to help inform the Executive Team’s decisions.
• Tennessee Heart Health Network had an Executive Council with representatives from all key partners. The Executive Council had an elected chair and 12 members that the partners selected. Other representatives of member organizations attended and participated in an ex-officio role. The Council met three or four times per year; provided strategic oversight, guidance, and support to the cooperative; and had ultimate decision-making authority. An Operations Team oversaw daily activities and made most day-to-day programmatic decisions.

Working Groups

Extension programs typically form working groups to carry out specific activities. Because the working groups often meet independently to accomplish their key activities, it can be helpful to also hold regular meetings of the working group leads to promote cross-team engagement and alignment. 

Partners are likely to commit to differing levels of effort on the working groups, based on their role in the program and their other commitments. Generally, partner representatives will be expected to spend only limited time on program activities, unless they receive funding for their involvement or the program’s efforts closely align with the partner organization’s mission. The Collective Impact Forum has an to help working groups get started, including an Action Planning Template. 

Though the specific names, activities, and staffing of the working groups varied across the EvidenceNOW: Building State Capacity cooperatives, each included groups focused on QI implementation and evaluation. Some of the cooperatives also used working groups to cover administrative activities, partner engagement, practice recruitment and retention, dissemination, marketing and communications, and sustainability. Table 3 describes selected working groups from across the EvidenceNOW: Building State Capacity cooperatives.

Table 3. Selected Working Group Names and Functions Across Cooperatives

QI = quality improvement.

Staffing

Staffing structures vary across extension programs, but generally include one or more project leaders, a project coordinator or program manager to oversee administrative and other project activities, several staff to lead the working groups (as described above), and practice facilitators to support QI in the field. Sometimes the program manager position is full-time. 

Different possible staffing models exist for practice facilitators, as described in chapter 5 of AHRQ’s Developing and Running a Primary Care Practice Facilitation Program: A How-To Guide. Models include hiring facilitators as program employees, contracting with other organizations to provide facilitators, or relying on volunteers or practice staff to serve as facilitators. Primary Care Extension programs have often used a mixed approach for staffing, and then adjusted over time as the program matures and staffing needs change.¹⁸ Among the EvidenceNOW: Building State Capacity cooperatives, the number of practice facilitators ranged from 4 full-time facilitators working with Alabama Cardiovascular Cooperative to 10 part-time practice facilitators engaged by Healthy Hearts for Michigan. Two of the cooperatives appointed lead practice facilitators to coordinate and oversee the work of the practice facilitators.

Career advancements and funding changes often mean that staff cannot continue to contribute to the project at the same level for multiple years—particularly staff working for academic partners. To minimize the loss of project knowledge and momentum when staff change, the program can develop staffing plans and conduct regular succession planning and cross-training. 

Form the Extension Program 

A systematic review found that facilitative factors for establishing multiorganization partnerships include trust and respect between partners; a shared vision, goals, and/or mission; effective communication; and well-structured meetings.¹⁹ Challenges include excessive time commitments; funding pressures or control struggles; and unclear roles or functions of partners.¹⁹ In their progress reports, annual reports, and other interactions with AHRQ, the EvidenceNOW: Building State Capacity cooperatives agreed that developing a cohesive group of partners working toward shared goals from a common understanding typically took more than 12 months. 

In this section we describe steps you can take to bring together your partners and help establish and maintain a cohesive and well-aligned extension program. 

Meetings and Other Activities 

Engaging in early (and ongoing) relationship building and communication efforts can help build trust and collaboration among partners. Meetings, both in-person and virtual, are a primary way to bring partners together, develop relationships, and build common understanding and group identity. 

Initial Launch Meeting(s)

The initial launch meeting (also known as a kickoff meeting) is an opportunity for representatives from partner organizations to meet one another, discuss and clarify roles, coalesce on the goals of the program, and strategize about future activities and next steps. During the initial launch meeting the lead organization reviews the primary purpose and goals of the extension program, describes any structures that are already in place or are nonnegotiable, and has a plan or clear proposal for how any remaining big decisions will be made (e.g., by majority or consensus). 

Having a successful and productive first meeting can help set the tone for the rest of the work and generate excitement and forward momentum. Aiming to have a productive first meeting, Alabama Cardiovascular Cooperative planned to start its project with a day-long kickoff retreat, conducted by a facilitator experienced in coalition building. Because of COVID-19 precautions, the in-person retreat was replaced with a series of virtual meetings with the same goals; it resulted in the development of program procedures and governing documents. 

Co-creating an agenda with the meeting participants, or at least sharing it in advance and asking for input, is a good way to build team investment in a successful meeting. It is important to plan for adequate time during the meeting for in-depth discussions and to allow participants to get to know one another. Often, the most valuable results of these meetings are the relationships and ideas generated from discussion among the participants. It is also useful to have a notetaker who can share key takeaways and action items after the meeting with all participants.

In addition to an initial program-wide launch meeting, each working group can hold a launch meeting to build rapport, establish specific goals, clarify participants’ roles and responsibilities, and determine action items.

Standing Meetings 

After the initial launch meeting, the extension program can collectively decide how frequently to come together for program-wide meetings (e.g., quarterly or biannually) and who will participate (e.g., some meetings include all partners and others include only key partners). For example, Alabama Cardiovascular Cooperative maintained two monthly all-member meetings for program-wide status updates and decision making and hosted an annual all-member, in-person retreat. Healthy Hearts for Michigan held all-hands meetings twice a year for partners to share updates. 

Other Communication Activities

In addition to holding regular program-wide and working group meetings, it can be useful to develop newsletters, listservs, websites (particularly with member-only sections), and dedicated social media groups to support information sharing. For example, Healthy Hearts for Michigan developed a monthly e-newsletter for partners (select for an example here [PDF, 156]), held regular Lunch & Learn meetings to share information with partners on relevant topics of interest (listen to a recorded example here), and emailed a weekly update to a core group of partners to relay noteworthy items (such as practice recruitment progress) and list upcoming meetings and events. 

Develop a Project Charter and Bylaws

Once key partners have been engaged and the organizational and governance structures for the program established, it can be useful to develop a project charter and bylaws. 

A charter sets a common understanding of the program, what it intends to do, who is involved, and how it intends to work. For the charter to be effective, partners will review and agree on the initial charter, and then revise it periodically. As an example, the Heart Healthy Ohio Initiative leadership developed its charter (PDF, 1 MB) by building on the charter of the Ohio Cardiovascular and Diabetes Health Collaborative (another QI initiative in the state with some of the same leadership and a similar mission), and then sharing it with partners for review, feedback, and approval. 

Extension programs might want to develop charters both for the overall group and for working groups, to help achieve explicit alignment and agreement across members. For example, each of the working groups in Healthy Hearts for Michigan established a charter, to be updated as needed throughout the project. (Access the charter for its Outreach and Engagement Workgroup (PDF, 174 KB), as well as a template (Word, 158 KB) the cooperative developed to help create workgroup charters.) 

Bylaws are akin to a detailed operating manual for your program: 

“Bylaws are the written rules that control the internal affairs of an organization. Bylaws generally define things like the group's official name, purpose, requirements for membership, officers' titles and responsibilities, how offices are to be assigned, how meetings will be conducted, and how often meetings will be held. Bylaws also govern the way the group agrees to function, as well as the roles and responsibilities of its officers. They are essential in helping an organization map out its purpose and the practical day-to-day details of how it will go about its business.”²⁰

Refer to the bylaws of the Tennessee Population Health Consortium (PDF, 370 KB) for an example.

Assess Partner Engagement

Developing strong partnerships is key to an effective extension program, so it is a good idea to regularly ask partners for feedback and solicit suggestions for improvement. Each of the EvidenceNOW: Building State Capacity cooperatives conducted regular surveys with its members (as an example, refer to Alabama Cardiovascular Cooperative’s Heart Health Improvement Project survey [Word, 23 KB]). 

In addition to conducting a partner survey, Healthy Hearts for Michigan conducted interviews with a subset of partners as part of its first assessment (read the interview protocol [PDF, 138 KB]). Alabama Cardiovascular Cooperative gained insights from a survey it conducted with partners in the first year that provided valuable direction for future improvements. For example, these initial insights included that partners did “not feel [their] roles are fully articulated or understood; that power is shared equally among members; nor that Cooperative meetings are as productive as they could be.”²¹ (Refer to Alabama Cardiovascular Cooperative’s Members’ Survey report [PDF, 220 KB] for more details.) 

b. The EvidenceNOW: Building State Capacity cooperatives also considered the primary care practices involved in their QI projects and networks to be cooperative partners. However, because practices had a unique role in this work, as well as a unique set of needs for recruitment and retention in the cooperative, we discuss engaging practices in the next chapter (3. Building and Maintaining a Network of Primary Care Practices) rather than here.