Megan C. McHugh, PhD; Jillian B. Harvey, MPH; Dasha Aseyev, BS; Jeffrey A. Alexander, PhD; Jeff Beich, PhD; and Dennis P. Scanlon, PhD
Over the past decade, there has been much effort devoted to improving healthcare quality in response to compelling evidence that our health system does not perform as well as it could or should.1-3
Healthcare providers are increasingly engaging in a variety of quality improvement (QI) efforts,4
and have been encouraged to do so by the growing number of pay-for-performance programs and QI resources available.5,6
For example, the Institute for Healthcare Improvement, Agency for Healthcare research and Quality, and industry groups have produced guidance on various QI topics, and many public and private organizations have established regional collaboratives to help improve care for specific clinical conditions.7-9
Although these QI efforts have resulted in many successes, quality problems persist.10-12
some have suggested that in order to stimulate meaningful and sustainable improvement that impacts the population in a given region, QI efforts need to advance from organizational-level initiatives to multi-level (individual, group, organization, and system), communitywide approaches.13-15
there is no single definition of a communitywide approach to QI, but examples include multidisciplinary teams from local hospitals working together through a learning collaborative to reduce infection rates; “horizontal” efforts among providers within a community (eg, hospitals, outpatient clinics, physician practices) to improve care transitions; and payment reforms that encourage local providers to implement patient-centered medical homes (PCMHs). A defining characteristic of communitywide QI is a coordinated, collective effort across organizations. Communitywide QI may be more effective than individual approaches if it eliminates duplication of efforts, improves information sharing across settings, and influences key factors that are out of the control of individual providers (eg, payment reforms).15-17
The nascent literature on communitywide QI suggests that communitywide QI is possible, but implementation is challenging and requires complex interaction among organizations.15,17
there is currently little information to guide strategy and implementation of communitywide QI. The purpose of this paper is to describe how 14 alliances (multi-stakeholder partnerships in each Aligning Forces for Quality [AF4Q] community/location) participating in the AF4Q initiative approached the charge of improving healthcare delivery within their communities. We review the specific activities undertaken by the 14 AF4Q alliances (data from additional alliances that joined the initiative in 2009-2010 are not included in this analysis) and assess the extent to which they followed a common, communitywide vision for quality. This article will provide policy makers and leaders of QI efforts with an understanding of the activities that alliances can undertake to improve care delivery. It will also provide insight to policy makers and funders about the QI priorities of alliances. The AF4Q Initiative
The AF4Q initiative is a $300 million effort created by the Robert Wood Johnson Foundation (RWJF) under the premise that “No single person, group, or profession can improve health and healthcare throughout a community without the support of others.”18
Program funding was directed to alliances charged with improving quality at the community level by focusing on several programmatic areas including public reporting, equity, consumer engagement, and QI (ie, improving care delivery). Given their broad representation, alliances are well suited to facilitate improvement by securing and coordinating resources, promoting collaboration across providers, disseminating information, and prioritizing common goals and initiatives.19
the alliance’s governing body was ultimately responsible for providing vision, strategic direction, and operational oversight for the QI work, as well as linking QI with the other AF4Q programmatic areas. A more thorough description of the AF4Q initiative and characteristics of the alliances may be found in the article by Scanlon et al in this supplement20
; here we focus on the AF4Q activities and expectations related to the QI programmatic area (Table 1
While guided by the AF4Q National program Office’s (NPO’s) technical assistance (TA), program goals, and measures, alliances had considerable latitude regarding how to pursue their work. For example, alliances could establish their own activities, partner with other organizations, or use a combination of the 2 approaches. They also had the flexibility to focus on any number of outcomes (eg, improving outcomes for diabetes or heart failure, minimizing use of the emergency department for potentially avoidable conditions).Methods Data Sources
Key informant interviews were conducted during 2 rounds of site visits and 1 round of follow-up telephone interviews. The first round of site visits was held from November 2006 to September 2007, shortly after the alliances were awarded AF4Q initiative funding. Although in-person interviews were conducted with a number of individuals in each community during the site visit, for this analysis, we limited our focus to the individuals most knowledgeable about the QI activities: alliance directors, who oversee the work of the alliance; and project directors, who are responsible for implementation of the AF4Q initiative. We asked respondents about the alliances’ structure, vision, goals, strategies, and decision-making.
The second round of site visits was conducted from December 2009 to April 2010. At that time, the alliances identified specific individuals responsible for QI. Therefore, we interviewed the new QI leaders in addition to the alliance and project directors. During the interviews, we asked specific questions about the alliance’s QI activities, including strategies for leading versus partnering to conduct QI.
Finally, we conducted follow-up telephone interviews with the alliance and project directors in the fall of 2010 to collect data on recent QI activities and why those specific activities were undertaken. Our analysis includes 16 interviews conducted during the first round of site visits, 54 during the second round, and 14 during the follow-up telephone interviews.
Additionally, we reviewed a number of program documents and materials submitted by the alliances to the RWJF and the NPO between 2006 and 2010, including funding proposals, work plans, and progress reports. A more complete description of the data sources can be accessed in the manuscript by Scanlon et al in this supplement.21Analysis
All key informant interviews were recorded, transcribed, and uploaded into Atlas.ti. Our analysis included 4 steps. First, transcripts were reviewed and coded with predefined global codes that aligned with the AF4Q initiative’s initial programmatic areas (eg, QI, public reporting, consumer engagement). Second, following an inductive approach, a more finite set of codes was derived from a review of the transcripts to reflect the emerging QI themes.22,23 these codes reflected (1) alliance QI activities; (2) alliances’ QI strategy, vision, and goals; (3) the QI environment and context; and (4) TA, the NPO, and the RWJF. Third, these finite codes were applied to the transcripts by a researcher and reviewed for consistency by evaluation team investigators. Fourth, 2 investigators reviewed the passages and held weekly discussions to formulate the final themes.
We also developed an inventory of the alliances’ QI activities. We organized the inventory following Leatherman and Sutherland’s taxonomy of quality-enhancing interventions, which was developed based on structured reviews of evidence and is applicable to organizational and community-level QI activities.14 two investigators independently categorized the alliances’ QI activities, and discrepancies were discussed. to be consistent with the time frame of our interview data, only interventions that were implemented prior to 2011 were included in the analysis. Interventions that were in the planning stages were excluded, and interventions that were implemented in multiple communities (eg, the transforming Care at the bedside collaborative) were counted multiple times. Activities that primarily focused on a different AF4Q programmatic area (eg, public reporting, consumer engagement) were excluded; however, QI activities that had a consumer engagement or public reporting component were retained. Categories were not mutually exclusive; most interventions were counted in more than 1 category. QI interventions that expanded over time were only counted once and their categorization reflects the expanded scope. We calculated the number of activities undertaken by the alliances in each category and the percent of QI activities that were led by the alliances, the NPO, or a local partner.
This research was approved by the institutional review boards of Penn State University and Northwestern University and informed consent was obtained from interviewees.Results Evolution of the Alliances’ Communitywide QI Activities
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