The Aligning Forces for Quality Initiative: Background and Evolution From 2005 to 2012

Published Online: September 22, 2012
Dennis P. Scanlon, PhD; Jeff Beich, PhD; Jeffrey A. Alexander, PhD; Jon B. Christianson, PhD; Romana Hasnain-Wynia, PhD; Megan C. McHugh, PhD; and Jessica N. Mittler, PhD
Objectives: The Robert Wood Johnson Foundation’s (RWJF’s) Aligning Forces for Quality (AF4Q) initiative is the largest privately funded community-based quality improvement initiative to date, providing funds and technical assistance (TA) to 16 multi-stakeholder alliances located throughout the United States. The objectives of this article are to describe the AF4Q initiative’s underlying theory of change, its evolution over time, and the key activities undertaken by alliances.
Study Design: This is a descriptive overview of a major multi-site, community-based quality improvement initiative.
Methods: A qualitative approach was used with information obtained from program documents, program meetings, observation of alliance activities, and interviews with RWJF staff, TA providers, and AF4Q alliance stakeholders.
Results: AF4Q is a dynamic initiative, expanding and evolving over time. Participating alliances are addressing 5 main programmatic areas: (1) measurement and public reporting of healthcare quality and efficiency for ambulatory physician practices and hospitals; (2) efforts to engage consumers as partners in their own care (consumer engagement); (3) adoption and spread of effective quality improvement strategies to improve care; (4) ensuring the equitable receipt of healthcare; and (5) integration of alliance activities with payment reform initiatives.
Conclusions: The AF4Q initiative is an ambitious program affecting multiple leverage points in the healthcare system. AF4Q alliances were provided a similar set of expectations and given access to substantial TA. While participating alliances have made progress in addressing the AF4Q programmatic areas, given differences in the alliances’ composition, market structure, and history, there is considerable variation in program implementation.

(Am J Manag Care. 2012;18:S115-S125)

There is considerable interest in using multi-stakeholder alliances and regional coalitions to coordinate quality improvement (QI) efforts across providers and organizations.1,2 Proponents of this approach hypothesize that the coordinated efforts of health plans, purchasers, providers, and consumers will yield better and more sustainable outcomes than activities undertaken independently.3 The Robert Wood Johnson Foundation’s (RWJF’s) Aligning Forces for Quality (AF4Q) initiative is the largest privately funded community-based QI initiative to date, with an expected investment of more than $300 million over the life of the project.4 “The premise of Aligning Forces is that no single person, group or profession can improve health and healthcare throughout a community without the support of others. Aligning Forces for Quality seeks to drive QI by aligning key players in local communities.”5

In 2006, the RWJF began providing grants and technical assistance (TA) to 4 alliances (multi-stakeholder partnerships in each AF4Q community), launching a program that expanded over time and now includes 16 communities across the country. Funding for the alliances is expected to continue through 2015. The AF4Q alliances are not-for-profit community organizations, either preexisting or established specifically for the AF4Q grant, with representatives from the payer, provider, and consumer sectors. While the RWJF plays an active role in strategy development and program oversight, they have delegated the day-to-day program implementation to a National Program Office (NPO). The authors of this article are a team of investigators from Penn State University, the University of Michigan, the University of Minnesota, and Northwestern University contracted by the RWJF to conduct an independent program evaluation.

The AF4Q initiative is a complex and dynamic program, addressing multiple leverage points in the healthcare system. The overarching goal for the program is summarized by the RWJF as follows: “The [AF4Q] program works to improve healthcare by engaging patients in their care, publicly reporting the performance of physicians and hospitals, and improving the quality of care delivered in each community. The Foundation hopes to provide models that will help propel national reform by providing resources, expertise, and training to help providers, payers and consumers all do their part.”4

Rather than being a fully developed program at its inception, the AF4Q initiative has expanded its scope and has made several mid-course adjustments as the program has evolved. In this article, we describe the program’s evolution and the range of AF4Q-related activities undertaken by participating alliances. Information for this article was obtained through program document review, meeting participation, observation of alliance activities, and interviews with RWJF staff, TA providers, and alliance stakeholders. Readers interested in additional information about our research design and data sources may refer to the article by Scanlon et al in this supplement.6

We begin by describing the theory of change underlying the initiative, depicted graphically in a logic model. Subsequently, we describe the evolution of the program from its inception through 3 distinct phases, covering programmatic expectations for the alliances, as well as the guidance and TA provided to support their efforts. Finally, we summarize key activities undertaken by the alliances in each of the programmatic areas that comprise the AF4Q initiative.

Theory of Change: The AF4Q Logic Model

A key step in program evaluation is to articulate the initiative’s theory of change—that is, the underlying assumptions and expectations regarding how program interventions will lead to the expected outcomes, and in what time frame. The Figure depicts a logic model, developed by our evaluation team with input from RWJF staff, the NPO, TA providers, and key alliance stakeholders. “A logic model helps to focus an evaluation by making a program’s assumptions and expectations explicit, and increases stakeholders’ understanding about the program or initiative.”7

As depicted on the right side of the model, the objective of the AF4Q initiative is improvement in key community and population health outcomes such as health status and quality of care received; these outcomes are broad and ambitious, and are envisioned to take time to realize. More proximate outcomes, such as increased transparency about provider quality and price, and improved care coordination, are depicted as intermediate outcomes. The left-hand side of the Figure illustrates how the program is envisioned to achieve these outcomes. Specifically, within the community, the AF4Q initiative starts with a multi-stakeholder community alliance, either new or preexisting. The alliance is responsible for establishing a leadership team and organizational structure to support program activities. Leadership is responsible for formulating the alliance’s vision and QI strategy within their community. In order to achieve this vision, the alliance develops and implements interventions, which are activities targeted at facilitating changes in the programmatic areas germane to the AF4Q initiative. They may sponsor these activities directly, or collaborate with other community organizations.

At a minimum, the alliances must address 5 main programmatic areas: (1) measurement and public reporting of healthcare quality and efficiency for ambulatory physician practices and hospitals; (2) efforts to engage consumers as partners in their care (consumer engagement); (3) the adoption and spread of effective QI strategies to improve care; (4) ensuring the equitable receipt of healthcare; and (5) integration of alliance activities with payment reform initiatives. In addition to aligning stakeholders around a common vision, the AF4Q initiative targets alignment of programmatic areas, depicted by connectors in the interventions box.

Across the top of the Figure, we indicated that the RWJF provides TA through multiple organizations or individuals with expertise in key programmatic areas to assist the alliances in strategy development and implementation. The model also reflects that the alliances vary significantly in terms of history and market structure and are influenced by factors in the external environment not directly related to the AF4Q initiative. Since the RWJF’s objective is to sustain the alliances’ activities beyond the anticipated conclusion of the grants in 2015, an important long-term program goal is to build collaborative capacity within the community. This may be accomplished through continuation of the alliance or through alternative models. Finally, as noted on the bottom of the diagram, the alliances’ activities and the impact of the AF4Q initiative are expected to evolve over a period of time, with necessary adjustments based on feedback from experiences in program implementation.

While the logic model provides a succinct view of the overall program, it is not sufficiently detailed to guide our evaluation. Accordingly, our team also developed individual models for each programmatic area. This has proved to be a challenging task. For example, the literature does not include a consistent definition of consumer engagement, nor do the existing conceptual models address the array of consumer engagement approaches considered in the AF4Q initiative.8 Consequently, we developed a consumer engagement framework targeting 4 categories of behavior: (1) healthy behaviors—the activities individuals perform to maintain health and prevent illness; (2) self-management behaviors—daily activities performed to control or reduce the impact of chronic illness on health status; (3) shopping behaviors—actions targeted at becoming more effective purchasers and consumers of healthcare; and (4) healthcare encounter behaviors—activities undertaken to become more effective self-advocates when interacting with healthcare providers. While not discussed in detail here, our consumer engagement framework illustrates the dynamic nature of behavior change and considers its relationship to individual, group, and community characteristics, including patient activation and the 4 engaged behavior categories. This framework and the other programmatic logic models are available in the online eAppendix. More information about our consumer engagement framework appears in the article by Mittler et al.8

Evolution of the AF4Q Initiative

Under the AF4Q initiative, the RWJF provides funding and TA to participants; in turn, the alliances are expected to meet specified goals and objectives. While the program’s initial scope was substantial, it has expanded through enhancements to existing programmatic areas and the addition of new ones. Since the alliances have been charged with a formidable task, the RWJF has made a significant commitment to the provision of TA: it is estimated that TA for each alliance will exceed several million dollars. In this section, we describe the evolution of the initiative over 3 distinct phases, including the program’s scope, goals, and expectations, and TA offerings.

Phase I

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