Hamos, James E. PhD
Why partnerships? The Association of American Medical Colleges, with support from the Robert Wood Johnson Foundation, initiated the Health Professions Partnership Initiative (HPPI) in the 1990s as “the linchpin in a long-term strategy to greatly enlarge the applicant pool of minority students ready and eager to pursue a career in medicine.”1 In the definitive literature review for the HPPI evaluation, Patterson and Carline2 note that
stand-alone or independent programs sponsored entirely by health-professions schools, without the involvement of other institutions, are usually less effective than true partnerships. Partnerships, on the other hand, require a much higher level of institutional commitment and involvement by both health-professions schools and public schools. They usually put in place a more comprehensive package of interventions, planned in collaboration with the target school or school district.
In spite of these strong statements about partnerships, both in the original framing of the HPPI as a strategy and in the study of its impact, the notion of what is a partnership has not been fully defined. This is not unusual in the many contexts in which partnerships exist, but in this article I suggest that, while offering some degree of flexibility to the many who become partners, the ambiguity should serve as a basis for growth of educational partnerships.
The term partnership is used in numerous contexts and has varied meanings. In the private sector, partnerships often are business entities in which multiple individuals (i.e., the general partners) manage the business and have equal liability for its debts; other individuals (i.e., limited partners) may invest but not be directly involved in managing the business, and their sole liability is their investments. In the public sector, however, partnerships—such as those developed in the HPPI projects—often involve relationships between individuals or groups in which the participants work together in an effort to achieve a specified goal.
In looking at dictionary definitions for aspects of how public sector partnerships operate, one might come across the “C” words that encompass quite a range of possible relationships. For example, partnerships may involve coordination, where partners largely try to maintain prior work but with the awareness of each others’ contributions to a common goal. Partnerships can involve cooperation in activities, when there is some level of joint planning to minimize waste and increase the benefit. In a full-blown collaboration, partners work together in a jointly designed and unique intellectual effort. Collaborators identify that they are in the endeavor together, with an understanding that reaching the goal involves strategy and full use of everyone’s talents. From observations of the HPPI partnerships as well as others, one finds that they operate in one or more of these definitional modes at varying times. As the HPPI partnerships continue their work and as new partnerships develop, however, the need is great not only for continuing the work but also for deepening collaborations among partners to increase the matriculation into medical school (and other health professions schools) of students from minority or other underrepresented groups.
In a study on partnership in the context of international development, Brinkerhoff offers a rich portrayal of two dimensions of partnership:
Partnership is a dynamic relationship among diverse actors, based on mutually agreed objectives, pursued through a shared understanding of the most rational division of labor based on the respective comparative advantages of each partner. This relationship results in mutual influence, with a careful balance between synergy and respective autonomy, which incorporates mutual respect, equal participation in decisionmaking, mutual accountability, and transparency.
Two concepts are vital in this description: mutuality and organizational identity. “Mutuality refers to mutual dependence and entails respective rights and responsibilities of each actor to the others,” while organizational identity is the “extent to which an organization, [even when involved in a partnership], remains consistent and committed to its mission, core values, and constituencies.”3 Too often, partners emphasize the unique culture of separate organizations—highlighting the maintenance of organizational identity—and fail to reach a depth that may have some costs but also the potential for tremendous mutual gain toward the goals.
In order to propel their constituent partnerships to some deeper level where mutuality is a core tenet, some programs have codified beliefs on the many components of partnerships. An excellent example of this is the Community-Campus Partnerships for Health (CCPH), a nonprofit organization that promotes partnerships between communities and higher educational institutions as a means of improving health professional education, civic engagement, and the overall health of communities. The CCPH established a group of exemplary principles that, if taken to full power, should direct CCPH partnerships and are applicable to others, such as those of HPPI. Significant among the CCPH’s principles are:
(a) partners have agreed upon [the] mission, values, goals, and measurable outcomes for the partnership;
(b) the relationship between partners is characterized by mutual trust, respect, genuineness, and commitment;
(c) the partnership builds upon identified strengths and assets, but also addresses areas that need improvement;
(d) the partnership balances power among partners and enables resources among partners to be shared;
(e) there is clear, open, and accessible communication between partners; and
(f) roles, norms, and processes for the partnership are established with the input and agreement of all partners.4
In defining one’s own involvement in a partnership, values such as these are worthy of extensive discussion and commitment.
Partnerships within K–12 Educational Contexts
One wonders why the notion of partnerships has entered the domain of schools and school districts that encompass the K–12 (kindergarten through grade 12) sector. For the most part, K–12 entities throughout the United States function quite independently. At the classroom level, teachers are charged with providing instruction through the curriculum so that students may develop knowledge and skills. At an organizational level, schools of an individual school district most typically are managed by administrators, such as principals and superintendents, as well as overseen by a local school board that is accountable to the community. There are no requirements to partner with other institutions, such as colleges and universities or local businesses and industries.
What, then, is the perceived need such that classrooms, schools, and/or school districts would enter into partnerships? Schools have always been evaluated by a variety of measures. Traditionally, this has included class grades, attendance, graduation rates, participation in advanced courses (e.g., algebra in middle school, advanced placement in high school), and college acceptances. More recently, in the current era of state and federal accountability, schools have been forced to respond to students’ outcomes on large-scale, criterion-referenced assessments, disaggregated among varied student populations (e.g., race, ethnicity, special education, free and/or reduced-cost lunch). Schools look to outside partners for support in their efforts to have students achieve only when they realize that they cannot accomplish, by themselves, the difficult task of educating all students and with the realization that outside partners bring human and fiscal resources that can enrich the teaching and learning enterprise. Several lessons learned from the Annenberg Challenge, which invested several millions of dollars in urban schools during the 1990s, drive the message home: while “every child benefits from high expectations and standards,” “schools are too isolated,” and thus should reach out to other schools as well as recruit “lots of allies to do this work,” such as parents and businesses that include institutions of higher education.5 Schools and school districts have begun to accept that additional resources through partnerships can improve their own desired outcomes, offering a variety of opportunities for external partners to contribute. Indeed, many of these were embedded as strong practices in the HPPI projects.
In the K–12 educational system, partners can directly offer academic enrichment to students so that they might succeed with traditional benchmarks, such as grades, SAT scores, and advanced placement scores. Further, partners can contribute to success with new benchmarks framed by state standards and assessments. This enrichment—often focused on enhancing communication (verbal and written) and/or mathematical skills that are central to so much of learning—can occur directly in classrooms (where partners couple strategies with curricular goals) or outside the school environment through structures such as Saturday academies or summer programs that include an academic track. Partners can also offer one-on-one enrichment to individual students through tutoring or mentoring initiatives. Support for students can, and should, occur beyond academics because there are other means to enrich the learning experience for young people. Increasing students’ motivation to learn and succeed often is just as important as is a specific emphasis on academic knowledge and skills. By interacting with young people, many individuals from partner organizations can serve as role models who have succeeded in or persisted through the world of education in order to gain employment. Additionally, encouraging young people to visit the workplace (e.g., by shadowing individuals or participating in internships) offers students an opportunity to broaden their experience and observe how academic learning contributes to future success.
Partners also can bolster the efforts of adults in the K–12 system. For teachers, partners can provide professional development that enhances content knowledge, either shoring up knowledge or offering new ways of thinking about the academic disciplines. Teachers, then, bring increased expertise to their instructional practice with students. Partners can work with teachers to provide direct support of their curricula, seeking the best methods to enrich classroom teaching and learning. Lastly, partners can act as mentors to teachers and, more broadly, their schools and school districts. There is particular value in mentoring teachers new to the teaching profession as many new teachers—especially those in at-risk settings—leave the profession early in their careers.6
Stakeholders in K–12 Partnerships
There are a number of groups of individuals who are obvious stakeholders in the K–12 setting. In the previous section, the emphasis has been on students and teachers as prime targets for potential partnership work. However, there are others to consider—administrators, who bear the overall responsibility for managing schools and school districts; guidance counselors, who help students make decisions about their personal and educational needs; and parents, who often do not or cannot fully participate in the educational process. All of these individuals are heavily invested in the success of students as individuals and schools as educational institutions, so depending on the local situation and leadership, they may participate in and contribute to partnership activities. Indeed, bold partnership initiatives work with school personnel and reach out to parents with the realization that parents “are the biggest influencers as to how well [students] do in school.”7
People who are not directly in the K–12 sector have not, automatically, considered themselves stakeholders in K–12 outcomes. Therefore, their work in partnerships often has been done for altruistic purposes rather than a belief that they are dependent on the successes of the K–12 educational system or, perhaps, even that that they have been drivers of some of the issues that bedevil this system. This is especially true of higher education, the next stop for the vast majority of students who complete high school. Society has always asked high schools to graduate students that are prepared for the world of work or higher education. Most typically, colleges and universities accept students based on their grades and standardized test scores. These “coins of the realm” are key determinants of acceptance into highly selective versus less selective institutions, even as the postsecondary world realizes the grades and test scores are not fully accurate indicators of knowledge, motivation, or ability to persevere (which are other significant factors in an individual’s ultimate success). Higher education must appreciate that the products of a successful K–12 system ensure the vitality of colleges and universities, and that higher education should fully consider how it admits students and then frames teaching and learning on its campuses. Moreover, colleges and universities should feel a deep responsibility to K–12 since new teachers are one of the major products of higher education and must enter K–12 classrooms fully prepared to teach young students.
In the context of the HPPI, one wonders if academic health centers consider themselves as altruistic players in partnerships or as stakeholders in K–12 education. Almost always, academic health centers develop a commitment of providing service to the communities in which they reside and see support for K–12 education as a community benefit. Nevertheless, academic health centers act both as institutions of higher education and as large businesses since they are actively engaged in health professions education, biomedical and health-related research, and patient care. Therefore, self-interest dictates they look to their surroundings to consider whom they will educate and who will serve the research and patient care enterprise. In years past, the affluent and patient-centered nature of the health care professions has produced a steady influx of individuals who succeeded in educational settings, both K–12 and postsecondary, and identified the specific pathway to fill available slots in the workforce of the academic health centers. However, as the 21st century offers individuals equal success in other directions and as disparities in health care continue among racial and ethnic minority groups, academic health centers should realize that empowerment of more students from the K–12 sector, especially from groups that are severely underrepresented in health care and research, is vital to the future of the centers. In sum, academic health centers must accept a responsibility as stakeholders in K–12 education. This point is emphasized in the Sullivan Commission’s report:
Health professions schools, hospitals, and other organizations should partner with businesses, communities, and public school systems to: a) provide students with classroom and other learning opportunities for academic enrichment in the sciences; and b) promote opportunities for parents and families to increase their participation in the education and learning experiences of their children.8
Expectations and Opportunities for Partnerships
This article has, thus far, contended (1) that partnerships exist in varying degrees of depth, with deep partnerships being those based in a notion of mutuality while maintaining institutional identity; (2) that K–12 students, teachers, and administrators can benefit from partnerships; and (3) that higher education—including academic health centers—should enter partnerships as stakeholders in the outcomes. Within this supplement to Academic Medicine, readers will find numerous examples where aspects of these three elements congealed in partnerships formed through the HPPI. That being said, ample opportunities continue for the HPPI partnerships, and for other academic health center partnerships with K–12, to clearly demonstrate the fruits of their efforts, to assure that partnerships are worth the time and money, and to further and deepen partnership work.
Perhaps the singular expectation that should be addressed by partnerships is for clear measurements of outcomes. Almost always, the evaluation of partnership work involving the K–12 sector, if done at all, predominantly emphasizes students’ performance outcomes as the indicators of impact. For example, in the near term, were there gains on project-specific assessments given to students both prior to and after an activity, or did students’ grades or test scores improve in subsequent semesters? In the long term, if appropriate systems to follow students are in place, it is possible to learn if more students of diverse backgrounds have gone on to college or entered the health care or research professions. Linking such measures together and trying to attribute them to partnership-specific interventions is a laudable endeavor.
However, while succeeding in any of these outcomes might be significant partnership goals, they are difficult to change and they do not include other measures of partnership processes that might be especially informative to decision-makers or to others who wish to accurately follow a partnership model. For example, partnerships often do not study themselves, especially along the many complicated dimensions embedded in principles, such as those noted above by the CCPH, or others, such as ENLACE (Engaging Latino Communities for Education).9 At the school level, partnership projects often fail to measure outcomes related to nonstudent stakeholders, including such dimensions as changes in teachers’ content knowledge or instructional practice in classrooms or modifications in attitude and practice among administrators, such as principals and guidance counselors. For the nonschool partners, there are potential outcomes for their stakeholders, as well. For academic health centers, this might include changes among faculty, administrators, and staff in ways of thinking and practice relative to K–12 students and teachers, as well as changes in overall institutional policies and procedures.
Measuring many incremental steps and producing clear outcomes across multiple domains in a partnership, then, might lead to important new possibilities in how a partnership’s work is regarded by the partners’ members, especially by the faculty of academic health centers. As noted in a CCPH’s Commission report,
a significant gap exists between the promise of health professional schools as engaged institutions and the reality of how faculty members are typically judged and rewarded…. Recognizing and rewarding community-engaged scholarship in the health professions will require changes not only in the wording of policies and procedures but, even more importantly, in the culture of institutions and professions. Leadership is needed from both academic institutions and the many external stakeholders that influence their values and priorities.10
If the evidence, captured through a myriad of measures, indicates that these efforts are producing the intended outcomes and, especially, are leading to increased participation of individuals from underrepresented groups in the health professions, it is incumbent upon the academic health centers to adapt the mission, vision, values, and policies of their professions, schools, and universities to encourage members of their institutions to participate in partnerships.
Taken even further, academic health centers might begin to consider themselves not only as partners with K–12, but also as part of a continuous educational system in which a belief in mutuality of purposes and outcomes is a common behavior. In many settings around the country, the term “K–16” has begun to define a movement by educators to work together in more complementary, partnership-driven ways to strengthen educational achievement from early childhood through completion of the college degree (see Haycock11 for an early articulation of K–16). Most often, K–16 partnerships have worked in the domain of policies and activities aimed at academic success in the early years, in students’ preparation for college, and in improvement of teacher quality. A few areas of the country have elaborated the concept of K–16 still further to “K–20,” which would include graduate education as well as professional schools (such as those of the academic health centers). For example, the Florida legislative mandate for K–20 aspires to develop beyond partnerships among the multiple education sectors such that “the mission of the K-20 education system shall be to increase the proficiency of all students within one seamless, efficient system, by allowing them the opportunity to expand their knowledge and skills through learning opportunities and research valued by students, parents, and communities.”12 Such a movement towards a shared ownership and accountability for the success of all students, and the adults who work around them, is a worthy consideration for all current partnerships, including those who participated in the HPPI.