Government sponsored pay-for-performance systems (P4P) have emerged in many contexts, including those featuring third-party federalism such as Medicaid. In this vein, voluntary networks called Medicaid accountable care organizations (ACOs) seek to achieve health care savings while boosting the quality of care. Drawing on evidence from four states, this study probes how collaborative governance strategies that downplay formal democratic controls and enhance administrative flexibility shaped the response to two implementation problems. We find that administrative flexibility, combined with signals of support from political principals, helped galvanize ACO formation but undermined efforts to tailor performance metrics to the needs of Medicaid enrollees.

The Hook-up and Commissioning program for the BP operated Clair Ridge facility was conducted over a period of three years, starting with the accommodation platform in 2015/16, and then the Production and drilling platform over 2017 and 2018. The total topsides weight is 53,000 tonnes, and the field is located in the harsh waters of the Atlantic West of Shetland. Typically 750 persons were based offshore, but over the life of the program some 7000 individuals worked offshore at some point on the project. Recognizing the safety leadership challenges with such a major hook-up and changing workforce a huge amount of effort went into preparation and working with our contractors to onboard the workforce. Over the first months of the campaign the safety metrics were healthy and there was a good reporting culture, however an increase in incidents was seen, including one late in 2015 where a medical evacuation was required from the platform. The individual made a full recovery and returned to work however it caused the Operator and Contractor project leaders to reflect on their safety leadership and how they were working with and engaging with the workforce. It was a catalyst for change as the team was determined that no other serious incidents would happen during the project delivery. In this paper we will share the Clair Ridge safety leadership journey and the steps taken by the operator, with the support and collaboration of the main contractors, to set a new approach to safety through the development of a genuine Culture of Care. This included: Building of trust and credibility between leadership and the workforceLeadership openness and transparency in communicationEmpowering front-line supervision to be safety leaders and giving them the skills and tools to do this well As a result of the approach the Clair Ridge team is proud that, in the three years since the incident in 2015, over 9 million offshore workhours have been completed without any other Lost Time Incident, and a safe start-up was achieved with no process safety related incidents. Clair Ridge realised some of the highest participation in safety observations and near miss reporting across the Operator's global projects portfolio, a continual and significant reduction in all injuries and benefited from an excellent reporting culture. A Culture of Care has been owned by all, and been recognised and commended by the contractor workforce and visitors to Clair Ridge.