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PURPOSE: What constitutes effective leadership in a collaborative effort to achieve enduring curricular and student career changes? This question was investigated as part of a larger evaluation of the W. K. Kellogg Foundation's Community Partnership Health Professions Education, a five-year initiative involving projects at seven sites. The goal was to produce more primary care health providers by making enduring curricular change. METHOD: Data were collected from participants with respect to predictors of project success and leaders' use of 16 behaviors via telephone interviews, mailed surveys, and focus groups. Focus groups also gathered project leaders' views of skills and knowledge necessary for effective leadership. RESULTS: Leadership strategies associated with positive outcomes were: consistent leader; use of multiple cognitive frames, especially a human resource frame; use of a broad range of leadership behaviors, particularly participative governance and cultural influence; and a majority of community representatives on the partnership board. The primary leader, compared with a leadership team, is most influential in achieving positive outcomes. CONCLUSION: Effective leaders use a broad array of behaviors, but particularly emphasize the use of participative governance and culture/value-influencing behaviors. In addition, the more frequent use of these behaviors compared with the use of organizational power behaviors is important. It is helpful to perceive the project from a human-relations frame and at least one other frame. Using a leadership team can be helpful, especially in building coalitions, but the importance of the primary leader's behaviors to project outcomes is striking.

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The evaluation literature often debates whether evaluators should be flexible in evaluation design and activities in order to collaborate with program directors and be responsive to programming needs. Two conditions are specified under which evaluation flexibility is not only desirable but essential. Two examples from the cluster evaluation of the W. K. Kellogg Foundation's Community Partnerships for Health Professions Education initiative are provided to illustrate why flexibility under these conditions proved to be essential. One of the examples, related to the "community" involvement in the initiative, illustrates the need for flexibility as programs experience goals clarification. The other example, related to the coincidental national health care reform efforts, illustrates the need for flexibility both to capture programs' efforts to protect their integrity and to ensure against spurious conclusions as a result of external turbulence in policy environments. How the cluster evaluation team addressed these issues is also described.

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The Hill-Burton Hospital Survey and Construction Act has its roots in the social health and welfare programs of the New Deal. This paper traces its development and the positions of three groups-the hospital industry, the U.S. Public Health Service, and the Senate Subcommittee on Wartime Health and Education-on four issues: the nature of federal funding to states, the use of public funds by private hospitals, the oversight powers of a Federal Hospital Council, and health services for the poor. The analysis involves two lines of thought: the political strategy of incrementalism and the roles of the three interest groups in reaching compromises to quickly pass an "unsponsored" bill. Relevance to the current effort to pass a single payer national health insurance is explored.

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Two public opinion polls, in Los Angeles and Michigan, on smoking in public places contradicted findings from other major surveys. Both were commissioned by the tobacco interests during consideration of non-smoking legislation to measure opinion and influence the outcome. Analysis reveals the two polls to be remarkably similar and in violation of basic principles of survey research. Response categories lacked objective or parallel phrasing, response lists were not rotated, and the ordering of items appeared prejudicial. Both polls were effectively countered and the legislation passed.

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This study explores the emerging conflict and cooperation between two types of organizations providing home health care to chronically ill and terminal patients--the hospice and the home health agency. Exploratory results suggest that the variables of size (terminal patient load), and competition (the number of other home health agencies in an area) influence relationships between home health agencies and hospices. It is also suggested that recent Medicare regulations may encourage mergers between agencies and hospices in addition to the existing modes of cooperation and referrals.

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This paper examines volunteer ambulance corps that provide emergency medical care and transportation to their communities. The authors have compared volunteer corps to all ambulance services in Michigan and have focused on the relationship between organizational characteristics, such as membership and community characteristics as indicated by town size, and the support base for the volunteer corps. They conclude that governmental support for voluntary associations such as ambulance corps improves health care delivery in small communities.

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