Getting the Structure Right for Communitywide Healthcare Improvement
Published Online: September 21, 2012
Gordon Mosser, MD
The United States has no overall structure for the delivery of healthcare. It is difficult to organize improvement of health and healthcare in a way that engages all hospitals, clinical practices, and other health institutions. Moreover, the various regions of the country have different preferences for how care is organized and delivered. To cope with these features of American healthcare, voluntary regional associations or partnerships for health and healthcare improvement have been suggested since the 1960s.1 During the past 20 years, interest in regional collaboratives has grown steadily.2 There are now more than 40 collaboratives across the country.3
Over the past 7 years, the Robert Wood Johnson Foundation (RWJF) has nurtured a regional approach to health and healthcare improvement through its Aligning Forces for Quality (AF4Q) initiative.4 The RWJF’s term for a regional multi-stakeholder partnership is an alliance.
Aims for Alliances
In designing an alliance, the first question to answer is what the alliance will do to improve health and healthcare. Suitable aims include: (1) convening stakeholders to identify the community’s health needs and set goals; (2) promoting healthy behavior in the community, for example, exercise and avoidance of tobacco; (3) public reporting of healthcare providers’ performance; (4) improving the quality of care provided by hospitals and clinical practices; (5) controlling costs; (6) improving health information technology; and (7) reforming payment for healthcare. No alliance has the resources to pursue all of these activities; choices will need to be made. From the beginning of the AF4Q initiative, grantees have been required to pursue public reporting of performance, improve the quality of care, and engage the general public in these activities.
Designing Governance for Quality Improvement
Let us suppose that those forming an alliance have decided that improving healthcare quality will be one of its aims. In order to succeed, the alliance will need to engage hospitals, physicians, and other care providers in systematic quality improvement work. One possibility for the governance of an alliance is a multi-stakeholder board consisting of representatives from hospitals, the medical community, employers, health plans, government, and the community at large—or some subset of these constituencies. But a board with this composition will hinder engagement of hospitals and physicians because an organization governed by employers, health plans, government, and consumers is not friendly territory for providers. For many years, employers, health plans, and government have criticized hospitals and physicians for the high cost and uneven quality of American healthcare. Representatives of hospitals and physicians will be wary as they arrive at this board table. They may take their seats at the table in order to defend themselves, but they are not likely to join in wholeheartedly. Also, it may be difficult to determine whether they are truly engaged, since they will have good reason to appear engaged even if their engagement is only superficial.
It is a management truism that commitment is engendered by giving people authority.5 This insight provides the answer for fashioning governance for quality improvement— put the hospitals and physicians in charge. In other words, design the board so that it is dominated by providers or so that they have control by virtue of the positions they hold. If they control the endeavor, they will trust it. This governance arrangement is seen in highly successful collaborative improvement programs, for example, the California Quality Collaborative, the Institute for Clinical Systems Improvement in Minnesota, Maine Quality Counts, and the Wisconsin Collaborative for Healthcare Quality. At the same time, it is important for employers, health plans, and the general public to be represented in a minority so that the quality improvement program does not become focused solely on issues of high importance to the healthcare professionals, neglecting patients’ perspectives and the costs of care.
Designing Governance for Other Alliance Aims
If the alliance is a single entity and if governance is placed in the hands of the providers to secure their commitment to quality improvement, then, hypothetically, the providers would also control public reporting and any other activities of the alliance. This arrangement would not serve the whole community well. For example, an organization dominated by providers is not likely to be enthusiastic and thorough in publicly reporting the performance of those same providers. Provider-dominated governance will not serve all aims well. We need to consider some arrangement other than a single multi-stakeholder board—which would interfere with quality improvement—or a single provider-dominated board— which would promote quality improvement but hinder vigorous public reporting. The path to a solution begins with setting aside the notion that the alliance must be a unitary, multi-stakeholder entity.
A second line of reasoning leads to the same conclusion. Some alliance aims are not compatible when pursued by a single organization. For example, public reporting and improving quality do not fit well together. An alliance will have difficulty serving as both the public scorekeeper and the coach for healthcare providers. If the alliance serves the public assertively in reporting performance, it will be regarded with caution—perhaps even with suspicion—by the providers. If the alliance has strong working relationships with hospitals and physicians, and is thoroughly supportive of their improvement efforts, it will be hesitant to report performance that might embarrass or discomfort the providers.
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