Decision‐Making Fairness and Consensus Building in Multisector Community Health Alliances: A Mixed‐Methods Analysis

• Author: Jeffrey A. Alexander,Larry R. Hearld,Christopher J. Louis,Jennifer O'Hora,Laura Bodenschatz
• Date: 01 December 2013
• DOI: http://doi.org/10.1002/nml.21086
• Published date: 01 December 2013

RESEARCH ARTICLES

Decision-Making Fairness

and Consensus Building in

Multisector Community

Health Alliances

A Mixed-Methods Analysis

Larry R. Hearld,

1

Jeffrey A. Alexander,

2

Laura Bodenschatz,

3

Christopher J. Louis,

3

Jennifer O’Hora

3

1University of Alabama at Birmingham, 2University of Michigan,

3Pennsylvania State University

Given their inherently diverse composition and potentially com-

peting interests, a foundational activity of community health alli-

ances is establishing consensus on the vision and strategies for

achieving its goals. Using an organizational justice framework,

we examined whether member perceptions of fairness in alli-

ances’ decision-making processes are associated with the per-

ceived level of consensus among members regarding the alliance

vision and strategies. We used a mixed-methods design to exam-

ine the relationship between perceptions of fairness and consen-

sus within fourteen multisector community health alliances.

Quantitative analysis found the perceived level of consensus to be

positively associated with decision-making transparency (proce-

dural fairness), inclusiveness (procedural fairness), and benefits

relative to costs (distributive fairness). Qualitative analysis indi-

cated that the consensus-building process is facilitated by using

formal decision-making frameworks and engaging alliance mem-

Correspondence to: Larry R. Hearld, University of Alabama at Birmingham, School

of Health Professions, Department of Health Services Administration, 1530 3rd

Ave. S, Birmingham, AL 35294. E-mail: lhearld@uab.edu

This research was supported by a grant from the Robert Wood Johnson Foundation.

NONPROFIT MANAGEMENT & LEADERSHIP, vol. 24, no. 2, Winter 2013 © 2013 Wiley Periodicals, Inc 139

Published online in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/nml.21086

140 HEARLD, ALEXANDER, BODENSCHATZ, LOUIS, O’HORA

Nonprofit Management & Leadership DOI: 10.1002/nml

bers in decision-making processes early. Alliance leaders may be

more successful at building consensus when they recognize the

need to appeal to a member’s sense of procedural and distributive

fairness, and, perhaps equally important, recognize when one

rather than the other is called for and draw upon decision-mak-

ing processes that most clearly evoke that sense of fairness. Our

findings reinforce the importance of fairness in building and sus-

taining capacity for improving community health.

Keywords: decision making, management, mixed methods,

consensus building, community health alliances

ONE OF THE PRINCIPAL barriers to creating a more efficient, ef-

fective, and equitable health care system is a fragmented

delivery system that undermines coordination and mis-

aligns incentives among stakeholders such as providers, payers,

and consumers (Davis 2007; Institute of Medicine 2009). This bar-

rier, along with a growing awareness of its systemic nature and

wide-ranging consequences, has led policy makers and practition-

ers to search for alternative ways to coordinate activities among

stakeholders to improve health care delivery, and by extension, the

health of local communities (Gamm, Rogers, and Work 1998; In-

stitute of Medicine 2001). Community health alliances have been

proposed as one possible solution (Hasnain-Wynia et al. 2003;

Shortell et al. 2002). Alliances, often separately incorporated as

501(c)3 entities, are voluntary organizations that bring together a

diverse array of stakeholders (including physicians, hospitals,

health insurers, employers, government agencies, and consumers)

to work collaboratively on health-related issues in a community.

Such a diverse membership, however, can pose significant chal-

lenges, such as different goal orientations and competing interests

that can impede efforts to coordinate efforts in an effective manner

(Tsasis 2009). Therefore, a foundational activity of alliances is estab-

lishing consensus regarding their vision, goals, and strategies for

achieving these goals (Sofaer et al. 2003). In this study, we defined

consensus as the perceived level of agreement among alliance mem-

bers about a particular issue or course of action (Sager and Gastil

2006). In the developmental stages of an alliance, getting members

to agree on issues is critical for establishing a basis for action, par-

ticularly in voluntary organizations like alliances in which barriers

to exit are low (Judge and Ryman 2001; Shortell et al. 2002). Beyond

the developmental stages, consensus can increase member participa-

tion (Metzger, Alexander, and Weiner 2005) and enhance percep-

tions of alliance effectiveness (Hasnain-Wynia et al. 2003). In short,

consensus on key issues provides a platform for mobilizing members

and sustaining momentum on alliance activities. Despite this impor-

tance, building consensus is a significant challenge in alliances in