“OpenNotes” for Funders: A Radical Idea for More Transparency and Better Relationships

Kevin Bolduc

Transparency — being open, honest, and clear — is a key driver of strong relationships between funders and grantees. It’s valued by foundation and grantee CEOs alike, and grantees think foundations are doing a decent job of being transparent (though more so in sharing about their processes than their learning).

Still, are there more radical ways to improve openness in ways that would benefit both funders and grantees?  As I’ve thought about this question, I’ve been drawn to a transparency movement called OpenNotes, which is changing the relationship between doctors and patients.

(To be clear up front, I admit the doctor-patient/funder-grantee analogy is imperfect. Yes, both involve relationship dynamics with significant levels of information and power asymmetry, punctuated by intermittent high-stakes visits and conversations. But, unlike a patient, an individual grantee doesn’t depend on a foundation for its mortal life. Still, I think the analogy can be instructive. Even the savviest patients I know — like my physician husband — talk about not wanting to bother or anger their doctors.)

In the OpenNotes movement, doctors have taken the radical step of directly sharing their medical notes, lab results, and plans — the entire medical record — with patients. They’ve created systems to make those notes easy to access and discuss. It’s a rapidly growing movement, and now more than 20 million patients have access to their doctors’ perspectives about their health, treatments, and plans.

So how does this relate to foundations? I’d argue that virtually every foundation I’m aware of has similar “notes” in the form of the grant write-ups and recommendations created by program officers for boards and/or senior leadership.

Why not open up those notes to the grantees they’re about? 

If we want to improve funder-grantee relationships — not to mention capacity building and shared learning — what better to share than these summaries about why a grant should be funded and what the risks are in doing so? Even when grant recommendations contain worries about a particular risk — organizational capacity challenges or major external risks, for example — a direct, if difficult, conversation between a grantee and her program officer, prompted by an open note, could yield new ideas, clarifications, or opportunities for assistance.

I’ve seen quite a few examples of funder write-up formats, and most contain explanations about a funder’s perspective on the fit between their program’s strategy and the grantee’s work, assessments of why the organization has the capacity to succeed (and sometimes where that capacity can be strengthened), risks the project faces, and observations about potential impact. This is exactly the kind of substance that program officers and grantees should be discussing as much as possible!

I can imagine reasons why some of you might think this is some combination of silly, impossible, or harmful. Maybe a foundation OpenNotes-style movement would create extra work because grantees would reach out to correct the record or debate a program officers’ assessment of their work. Maybe it would require a different writing style or more editing — or make funders feel pressured to be less honest in their write-ups. Maybe it would create hard feelings.

Well, a lot of that is exactly what doctors once thought, too. I had the chance to sit down with Dr. Tom Delbanco, John F. Keane & Family Professor of Medicine at Harvard Medical School, who was one of the founders of the OpenNotes movement. He told me about how the first doctors to pilot this crazy idea were viewed as “mavericks.” (He also described how the early and long-term funding from foundations, including Commonwealth Fund, Robert Wood Johnson Foundation, and Gordon and Betty Moore Foundation, made the movement possible when health systems were skeptical.)

Doctors initially felt that notes would not be easy to share. Of course they contain the good news of their judgments about what’s going well (e.g., “The patient has had a remarkable response to treatment and is thriving”). But they also contain the unvarnished assessment of what’s not going well (e.g., “Treatment has failed and the patient continues to have unrealistic expectations about the likelihood of cure”).

Doctors worried that patients couldn’t handle the more sensitive information, Dr. Delbanco said. The notes felt like expert doctor-to-doctor talk. And doctors worried they’d be inundated with patient requests and extra work. For a few, “closed” notes reinforced a comfortable hierarchical relationship between doctors and patients.

However, research on doctors’ experiences with OpenNotes has been almost universally positive. Writing OpenNotes hasn’t added time to doctors’ work, nor have doctors been besieged by emails from patients. Some participating doctors do feel they need to change their writing (e.g., less jargon, better documentation). But, overall, doctors seem to think opening their notes provides benefits. In studies of OpenNotes pilots, virtually all doctors chose to continue with OpenNotes even after the pilots ended.

Ultimately, though, this isn’t about the effect on doctors (or funders, in my analogy), right? What we care most about is the effect on patients (or grantees).

This is a question that Dr. Delbanco and others in the OpenNotes movement have been studying since the very beginning. It turns out that OpenNotes seem to strengthen both the quality of care and the patient-doctor relationship — and the specifics of those improvements pretty closely match some of the most important components of the grantee-funder relationship.

As a starting point, research suggests that 99 percent of patients feel the same or better about their doctors after having access to their notes. Research by Dr. Delbanco suggests OpenNotes are associated with patients having a greater sense of control, greater adherence to treatment plans, and greater understanding of their medical situation. The results of a qualitative study of patients’ experiences highlights the ways patients say OpenNotes creates better mutual understanding, a greater sense of trust and partnership with their doctors, greater confidence and comfort in their relationships, and better and clearer communication. Another study describes how patients feel that OpenNotes ensure “that we are on the same page,” “helps me come to my appointments better prepared,” and “provides another opportunity for two-way communication.”

Some of these benefits translate fairly directly to the grantee-funder relationship.  I can picture the grantee who, in reading her grant recommendation note, gains a deeper understanding about a funder’s analysis of the context in which she works, greater clarity about how her organization’s work contributes to the outcomes a funder is seeking, and a stronger sense of alignment, approachability, and trust.

When I’m working with funders on responding to results of a Grantee Perception Report (GPR), it’s often efforts to improve relationships that feel particularly challenging — especially in an environment where program staff don’t feel they have enough time for more interaction with grantees. So why not try opening up notes and improving the quality of the conversations you do have? If the experience of patients and doctors is any indication, I bet that simple act of transparency — sharing both the enthusiasm and worries that grant recommendations contain — would help. I’d love to hear your experience if any of you try.

Kevin Bolduc is vice president, assessment and advisory services, at CEP. Follow him on Twitter at @kmbolduc.

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