That Was Then, This Is Now

Published Online: September 21, 2012
Lisa A. Simpson, MB, BCh, MPH, FAAP
For 20 years, in report after report, researchers have been pointing out wide gaps between high quality care and the care that individuals actually

receive.1 After the landmark 1991 Institute of Medicine (IOM) report, Crossing the Quality Chasm, shined a bright light on the problem, a second IOM report described the many policy actions that the federal government could take to “lead by example;” however, few were acted on in the initial years.2 A coherent national policy response took many years to emerge. If the difference in quality was a chasm, then the federal policy response was more of a desert—with only a few notable oases of innovation and experimentation. In contrast, private sector action on quality increased, spurred on by the actions of accreditors, purchasers, and a thriving

improvement community inspired by leaders such as Don Berwick.3 The conditions were ripe to launch an experiment like the Aligning Forces for Quality (AF4Q) initiative, founded on the belief that, as in politics, all healthcare is local. The initiative drew on the best findings from health services research, emerging experience from other community collaborative efforts, and an understanding of how to drive sustainable change. From these roots, the AF4Q initiative launched with the foundational principle that improving quality requires action by multiple stakeholders working toward a single and clear aim, and united by a shared sense of place (ie, their community). The AF4Q initiative launched into this environment in 2006. Looking back, this was truly a bold step!

In the intervening years, the policy and innovation landscape shifted dramatically, and new federal authorities provided vital levers for advancing quality.4 These levers can support and accelerate the efforts of AF4Q communities in many ways; however, their greatest impact in a time of continuing cost concerns may be in creating an environment in which the status quo is no longer a feasible alternative. This provides an opportunity for the AF4Q communities and their partners (eg, the National Program Office, other communities, the Robert Wood Johnson Foundation [RWJF]) to pause, consider their strategy, and align their efforts with this new policy landscape. Some ideas for the AF4Q communities to capitalize on the current policy environment are explored here, organized by the AF4Q initiative core strategies, namely multi-stakeholder coalitions, public reporting of quality information, consumer engagement, and quality improvement.

Multi-Stakeholder Community Coalitions

A focus on multi-stakeholder coalitions as a platform for change is not a new concept5,6; however, it has rarely been supported, tested, and refined to the extent that the AF4Q communities have done. This is a singular achievement, creating a set of prototypes for how the different components of the healthcare delivery system in a given community might collaborate for the express purpose of health improvement. This approach has since been embraced by federal initiatives,

including the Beacon Communities Program7 and the Innovation Challenge grants of the Center for Medicare & Medicaid Innovation. More recently, a call was issued for a national health improvement communities program, to improve the care of patients with multiple chronic conditions

associated with high costs.8 Thus, the AF4Q initiative helped to shape the framing and implementation of federal investments, and AF4Q communities are now well positioned to compete for these funds.

Multi-stakeholder coalitions, however, face challenges. Coalitions are, by their nature, fragile; even in the best circumstances, they may affect change slowly. Sustaining interest and investment by disparate partners, particularly in more competitive markets, requires demonstrating impact in ways that are tangible and provide a clear return on investment for the various players, particularly the payer and business communities where the dominant concern is cost. Similarly, market relationships are changing as hospitals and physician practices position themselves to respond to new payment models, such as accountable care organizations, and states move ahead in the implementation of healthcare reform. These changes could undermine the trust established by coalitions. Finally, the reality of responding to so many new federal directives and the speed at which they are expected to demonstrate impact (often in less than 3 years) may require governance and management changes that could fragment the unified vision that coalitions have worked so hard to attain.9,10

Public Reporting of Quality Information

Public reporting to drive accountability and improvement in the healthcare system is now a well-enshrined strategy in the public and private sectors.9-11 The Affordable Care Act builds on the many existing federal public reporting programs and calls for additional performance reports, a physicianspecific public website, core measure sets across populations, release of Medicare claims data, and an expanded scope of reporting to include the quality improvement activities of health plans (not just their actual performance).12 (For example, Section 3015 calls for public reporting on provider- and condition-specific quality data, a new Physician Compare website [Section 10331], new priorities, and for funding provider-level quality measures to be set by the Agency for Healthcare Research and Quality [Section 3013]. The new Medicaid Quality Measurement Program will develop and select a core set of quality measures for adult healthcare under Medicaid [Section 2701], and Medicare claims data will be released, for the purpose of evaluating provider and supplier performance [Section 10332].) Meanwhile, the number of states with at least some providers needing to publicly report performance grew to 28 in 2011, and the number of websites providing comparative performance information to consumers grew to 116 in 201111; multi-stakeholder regional collaboratives have assumed a prominent role in producing such reports.9

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