Conversations with Experienced Backbone Leaders: Community Health Improvement Partners


This is the last of our blog series Conversations with Experienced Backbone Leaders. We sincerely hope you’ve enjoyed the series. If you have any feedback on the series, we’d love to hear it; please email me at

Cheryl Moder is the Vice President of Collective Impact at San Diego’s Community Health Improvement Partners (CHIP), a 20-year old nonprofit whose mission is to advance long-term solutions to priority health needs through collaboration. Among other responsibilities, CHIP has served as the backbone for the San Diego County Childhood Obesity Initiative for the past 10 years.

My conversation with Cheryl was wide-ranging, from skills needed to lead a backbone organization to tips on sustaining a CI initiative. I particularly liked her thoughts on how to create trusting relationships. We even discussed many “nuts and bolts” of the Childhood Obesity Initiative, such as their workgroup structure and strategic planning cycle.

Both experienced and new backbone leaders can learn a lot from Cheryl’s experience. Enjoy!

Here are a few highlights from our conversation:

  • Even though collecting data regarding community-level obesity is quite challenging, Cheryl’s team spent the past 1.5 years working with partners (in different sectors) to determine indicators of progress and collect outcome data.
  • The Childhood Obesity Initiative works hard to ensure healthy partnerships. For example, they formed an ad-hoc committee to recommend process improvements that would lead to better partnership. One recommendation was to create a Partnership Guidelines document, which outlines expectations and benefits for partners. Cheryl says that “these clear guidelines help build mutual respect and achieve operational excellence”
  • The initiative’s structure has remained fairly constant over time (Leadership Council, Executive Leadership Team, 7 “domain” workgroups, and a Domain Council), but policies have evolved. For example, to increase trust, a policy was created requiring the backbone to bring funding opportunities, including those that may lead to competition with partners, to the Leadership Council for discussion and approval before applying. This approach assures transparency and unity
  • From 2005 to 2015, the childhood overweight/obesity rate in San Diego County decreased 1.6 percentage points from 35.8% to 34.2%, or a 4.5% reduction. Despite this overall decline, there are stark disparities in rates of childhood overweight and obesity among different racial/ethnic and socioeconomic populations that need to be addressed
  • The initiative has also seen “system-level” changes such as re-directed funding, and changes in professional practices, cultural norms, and public policy
  • Cheryl highlights a number of challenges in sustaining their initiative:
    • Building trust
    • Recognizing the work of partners
    • Flexibility to change the initiative’s activities
    • Volunteer management
    • Continued backbone support
    • Documenting successes
  • Cheryl’s advice for sustaining initiatives is to:
    • ­ Demonstrate your effectiveness
    • ­ Diversify your funding
    • ­ Focus on the benefits of partnership
    • ­ Build deep and meaningful relationships with your partners
  • Cheryl had some really interesting thoughts on building trust, such as the need to genuinely care about one’s partners
  • Equity is embedded into the initiative’s activities, as their work is focused on populations and communities that need it most

David: What are you most excited about today regarding your collective impact work?

Cheryl: One of most exciting things we’re working on is identifying, tracking, and measuring key indicators of policy and environmental changes we’ve seen. Some people might say “you’re celebrating your 10-year anniversary but only doing this now?’” Well, if you look at field of community obesity prevention, measuring impact has been a challenge. The primary reason is a lack of local data regarding community-level policy and environmental changes.

How have you gathered outcome data?

For over a year, we’ve conducted an inclusive and participatory process to collect data across many sectors. Our evaluation plan outlines 3 different levels of evaluation:

  • At the highest level, we need to move needle on childhood obesity, and BMI is typically what’s used to measure obesity
  • Next, we look at community-level policy and environmental changes that we feel have the potential to move the needle on the ultimate childhood obesity outcome
  • Third, we look specifically at the work of partners within work groups toward implementation of specific strategies

For the middle tier, we initially worked with partners to develop criteria (e.g., data need to be available, tie back to the goals and mission, and reflect our partners’ activities), then we obtained the data. It was truly a community-based project where partners have been helpful every step of the way. Findings will be shared with the entire community in a first ever “State of Childhood Obesity” report, to be published every three years.

In the report, we’re looking at 12 indicators across multiple sectors (several of which are tied to schools), examining school policies around healthy beverages and physical activity and the presence of active school wellness councils. Partners created a rubric to measure the strength of school wellness policies across the 42 public K-12 districts in San Diego County. We also used data collected by our county’s health department using the WellSAT tool to examine strength of after-school policies. Those are just some examples.

How do you ensure the cross-sector partnerships are alive and well?

We want to achieve operational excellence of our private-public partnership because the Childhood Obesity Initiative IS the partners! So, based on input from our partners and funders, we formed an ad-hoc task force looking at process improvement issues around partnership, and it has generated many great recommendations. For example, the task force created a Partnerships Guidelines document (click here to view the document), which outlines things such as defining what it means to be a partner in the initiative, what benefits partners can expect to derive from participation, partner roles and responsibilities, backbone roles, and categories of partnership. The document helps us to clarify expectations and build trust.

Outlining the value that partners get from participation is important, because if they’re not deriving value, they’re not going to participate. Conversely, the better we define expectations, the more partners understand why the partnership needs their involvement. These clear guidelines are necessary to build mutual respect and achieve operational excellence.

CHIP serves as the backbone for initiatives besides the Childhood Obesity Initiative. How do the three initiatives relate to one another?

CHIP is the backbone for place-based initiatives in two underserved communities, each with a different funding source. As our efforts have evolved over time, we’ve improved our ability to take our countywide CI model and apply it to a concentrated geographic area with an enhanced focus on community engagement. This allows us to take approaches we know work best at the county level and apply them within distinct communities and, conversely, to expand promising practices tested at the local level more broadly.

CHIP has a robust food systems initiative where we’ve brought together food system directors with food distributors and local growers in an effort to bring more locally-grown products to schools. Those partnerships have really paid off, as we’ve seen tremendous growth in farm-to-school activities. We also have a similar project going on in healthcare around healthy food in hospitals. That work has taken on a life of its own, and we’ve seen a tremendous reduction in meats processed with antibiotics. The role of the backbone in bringing partners together is essential.

CHIP also works in the area of mental/behavioral health and serves as the backbone for a successful initiative focused on reducing and preventing suicide in San Diego County.
While technically separate initiatives, all of these collaboratives serve our broader mission of improving community health; they’re all examples of our embracing emergence.

Sustaining an initiative for 10 years is quite an accomplishment. How have you kept your strategies relevant?

Our Childhood Obesity Action Plan serves as our guiding document and outlines everything we do (history, goals, strategies, etc.). We revise the Action Plan every 4-5 years to make sure it’s state of the art and that we’re keeping up with the ever-changing landscape. The most recent update process in 2015 took 1.5 years. With a dedicated committee to shepherd the update, we got input from over 100 partners, worked closely with each domain workgroup, and even went outside our sphere of influence to make sure the plan included the right strategies.

What is your current organizational structure?

For the Childhood Obesity Initiative we have a Leadership Council that meets 9-10 times a year. The Council serves to guide and direct our efforts. That group has been meeting since before the initiative was formed, and many of the original partners are still on the Council.

We also have a subset of the Council called the Executive Leadership Team. This group includes the Leadership Council co-chairs and a couple other key partners and meets on an ad-hoc basis to address issues as they arise. They don’t make decisions per se, but they make recommendations to bring back to the Leadership Council.

We have 7 “domain” workgroups, otherwise known as sector workgroups (Government, Healthcare, Schools and After-School, Early Childhood, Community, Media, and Business). These workgroups serve as mini “think and do tanks” and develop workplans to track and measure progress toward implementation of specific domain strategies. The co-chairs for each workgroup work with CHIP (the backbone) to set agendas and facilitate meetings. The co-chairs are the thought leaders within their sectors and engage their peers and colleagues to join them in this work.

There is also a “Domain Council,” which includes all the co-chairs of the domains. We bring them together bi-annually so we can talk about cross-domain collaborative opportunities. All of the workgroups have more than one co-chair, and they divide responsibilities based on their strengths and availability.

Has your structure evolved over time?

The structure has remained pretty constant. What’s changed over time are the policies and procedures, to get us all on the same page. For example, we found early on that there could be a lack of trust around funding because occasionally the backbone is actually in competition with partners for the same funding source.

To address this issue, we created a policy that says anytime CHIP (the backbone) wants to apply for funding, we bring those funding opportunities to the Leadership Council for discussion and a vote to proceed with a funding proposal. That has helped us to create a great deal of transparency. There are occasions where we compete for funding sources, but when you put it on the table and everyone agrees we should pursue the funding, it improves trust.

We have also created policies on advocacy, guidelines about accepting donations, standards for use of our initiative’s logo, and policies about how we manage media relations (e.g., who speaks on behalf of the initiative).

What population-level changes have you seen as a result of your initiative?

Unlike other CI initiatives where you have clear data sources, childhood obesity is a tough nut to crack. The California Department of Education requires public school districts to measure, track, and report body composition in grades 5, 7, and 9 as part of physical fitness testing. However, the department has changed the way they report data over the years, which makes year-to-year comparisons impossible. So, the good news is that there’s data, but the bad news is that you can’t do year-to-year comparisons over time.

From 2005 to 2015, the childhood overweight/obesity rate in San Diego County decreased 1.6 percentage points from 35.8% to 34.2%, or a 4.5% reduction. This is good news overall, but when we delve deeper and disaggregate the data, we find that disparities exist, with higher overweight/obesity rates for children from certain racial/ethnic groups and those who are economically disadvantaged. These findings challenge us to ensure that health improvements are equitably shared among all children, especially those with the highest childhood obesity rates and the greatest barriers to good health.

We also look at BMI among specialized populations. For example, the five local agencies that administer WIC in San Diego County have reported to us BMIs for children ages two to five. In addition, our county public health department has added BMI to its immunization registry and is conducting analysis to determine how representative the data are. The data we’ve compiled thus far is very promising, and over time we hope to find a single surveillance mechanism that works. None of these data sets is perfect, however. There should be an easy answer to the question, “What is the rate of childhood obesity in San Diego County?” but there isn’t one.

What system-level changes (e.g., funding flows, policy changes) have you seen as a result of the Childhood Obesity Initiative?

The foundation created by the Childhood Obesity Initiative has resulted in millions of dollars of investment in San Diego County to both public and private partners from many funding sources.

One great story: one of our partners said that her funding source to improve healthy food and physical activity for young children in childcare was being cut, and I suggested she bring this up at a Leadership Council meeting. She did, and the public health department was excited about some of the things this partner was doing. They found an appropriate funding source and within a month or two the partner had a signed contract and was back in business. This was a community-based organization that otherwise would NEVER have had that relationship.

Other system-level changes include:

  • The Childhood Obesity Initiative’s work in developing and tracking shared measurement systems has involved partners across all domains. Community stakeholders participated in every step of the process, from design to data collection to analysis. One example of a systems change is that San Diego County’s five WIC agencies agreed for the first time to share data related to BMI and breastfeeding for our recent report. Partner involvement is important because stakeholders are much more likely to support and act on evaluation results and recommendations if they are involved in the process.
  • We’ve also seen public policy changes and some cities are now taking a “health in all policies” approach. For example, the city of Chula Vista recently adopted an action plan that addresses health-related policy changes across city departments to be implemented over the next five years. In addition, the city established a formal health commission that is tasked with making recommendations to the city council about health policy.
  • Partners’ priorities are also changing. I mentioned robust work in food systems, where bringing together these partners to address the barriers to healthy food procurement has led to significant changes in San Diego County’s food systems landscape. There is growing recognition that these changes have a positive impact on health, the environment, and our local economy.

What are the main evolutions your initiative has gone through?

We’ve increased the number of people on workgroups. For example, in the Early Childhood group we mapped who needs to be at the table then assigned responsibility to current partners to contact and invite additional workgroup members.

The workgroups also have more focus and refinement and have begun to document progress in a better way. Instead of brainstorming and “doing whatever” based on who is at the table, there’s now a more structured process utilizing workplans to make sure activities are very closely tied to overarching goals.

One mistake that new CI initiatives make is to “say yes” to everything in the beginning. You get caught up in the excitement and want to bring new people in and follow up on every opportunity. But, you eventually you become overloaded.

What have been the biggest challenges you’ve faced when sustaining the initiative?

Building trust takes time, but trust is fundamental to any successful partnership. Trust is built in part by reasonable and understood expectations. I’m going go old school and say the best way to build trust is to create meaningful relationships with people. And that takes time, attention, and intention.

Another challenge is recognizing the work of the partners, and getting partners comfortable talking about their work in context of the larger collective efforts. The more successful you are, more people want to be a part of the effort, and more you need to bend over backwards to give credit to your partners. It’s very easy to make mistakes regarding partner recognition, especially early on before trust has been fully developed.

Other challenges we’ve come across are:

  • The ability to be flexible. Political will and resources can shift your focus, which may be difficult because you may have existing funding tied specific deliverables, which doesn’t allow for much flexibility
  • Being acutely aware of people’s motivations and what keeps them at the table over time
  • Volunteer management. Volunteers don’t always do what you want them to do. So, managing people who aren’t paid to be at the table (although I know some CI initiatives pay their partners), can be a challenge
  • Funding is an ongoing source of frustration, and there are so few organizations that understand the value of a backbone organization. It’s frustrating and an ongoing source of stress
  • Finally, documentation of success is difficult. We need to not only document outcomes, but also the intangibles: the benefits of connecting the dots and other things the backbone does. I think documenting those things are equally important, but we don’t always tell that story well

What advice do you have for collective impact initiatives concerned about the sustainability of their initiative?

First, demonstrate your effectiveness to the degree you can, based on the data you have. This is important for both partners and funders.

Second, diversify your funding portfolio as much as possible. If you have limited funding and a primary funding source goes away, it puts the entire initiative at risk.

Third, focus on the benefits of partnership. Your partners will be your best supporters if they understand what they’re getting out of the partnership.

Finally, build deep and meaningful relationships with your partners. That’s the key to the entire thing.

How do you build trusting relationships with partners?

I think fundamentally you have to care about people. You have to care about why they’re there. You have to care about their motivations, who they are as people, partners, and individuals. You don’t have to like everyone, but you do have to care about them. And it can’t be superficial.

I’ve done this job for 10 years, and I don’t always agree with partners, but there’s always mutual respect. You’ll have difficult times, but at end of the day, they’re people just like you. Learn about their jobs. Ask about their families. Celebrate their successes. Know enough about them and their lives to know them as real people.

How do you think about equity with regards to the initiative?

Certainly we have a tremendous focus on health equity. Data show us rates of chronic diseases are higher in neighborhoods that lack of healthy food access, lack of transportation, have lower levels of education attainment, etc. – these are all social determinants of health. And we’ve seen higher rates of childhood overweight and obesity among populations that are economically disadvantaged. So, equity is always top of mind.

For example, we work to improve access to healthy food and beverages, and to improve the built environment (bike paths, parks) where there’s limited infrastructure. Obesity crosses all boundaries, but much of our work is focused on communities that need it most.

To date, how have you engaged the community?

One of CHIP’s most successful programs is the Resident Leadership Academy, which provides local leaders in under-resourced neighborhoods with training and tools to take action to increase healthy behavior, improve safety, and create thriving neighborhoods. The program guides community residents in taking a policy, systems, and environmental change approach to reduce health-related disparities by addressing the social determinants of health. Upon completion of the program, participants initiate projects and advocate for policies to improve the conditions in their communities using the skills and tools acquired through the training.

The Childhood Obesity Initiative also has an active community domain workgroup that works to enhance community-led activities and policy advocacy focused on healthy eating and active living throughout the county. One example is creation of an online mapping tool that enables community leaders to learn about and connect with others who are conducting similar neighborhood improvement activities.

What structures or processes do you have to incorporate learning and reflection throughout your work, and to ensure decisions are data-informed?
Cheryl: First, we have an annual full-day retreat that allows us to do a deeper dive into one specific area. In past years we’ve discussed our strategic plan, evaluation, shared measurement, operational excellence, and developing effective partnerships.

Second, we incorporate qualitative and quantitative data in our Leadership Council and domain workgroup meetings. Findings and recommendations from our soon-to-be-released “State of Childhood Obesity” report will be discussed at the Leadership and Domain Councils and will drive future direction.

Lastly, domain partners participate in data collection and analysis, and Leadership Council members participate in an annual survey regarding items such as meeting efficiency.

What are the most important capacities to develop when working collaboratively with others on a collective impact initiative? How have you developed these leadership capacities?

A few things stand out:

  • Having a great deal of credibility within the community
  • Being a skilled convener and facilitator
  • Oftentimes the backbone is responsible for overseeing evaluation activities, and having some experience in that area is important
  • Being politically savvy, understanding people’s intentions and motivations, building relationships
  • A backbone leader should be skilled at seeing the big picture, as the backbone is the only one that’s in that role! I call it being an “air traffic controller.” At the same time, you have to be detail-oriented and good at follow-up and follow-through

What are you most proud of regarding your initiative?

I’m most proud of the policy and environmental changes we’ve seen at all levels (i.e., systems change). I’m also really proud of the longevity of our initiative.

But, at end of the day, it’s the relationships and partnerships I’m most proud of. Many of them are over a decade old. When you can count on partners and they can count on you, it creates a sense of trust that enables you to do the work well.

What do you think? Share your questions and comments below.

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