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Supplements The Aligning Forces for Quality Initiative: Early Lessons From Efforts to Improve Healthcare Quality
Creating and Sustaining Change: Early Insights From Aligning Forces
Claire B. Gibbons, PhD, MPH; and Anne F. Weiss, MPP
Getting the Structure Right for Communitywide Healthcare Improvement
Gordon Mosser, MD
Lessons for Reducing Disparities in Regional Quality Improvement Efforts
Scott C. Cook, PhD; Anna P. Goddu, MSc; Amanda R. Clarke, MPH; Robert S. Nocon, MHS; Kevin W. McCullough, MJ; and Marshall H. Chin, MD, MPH
The Imperative to Promote Collaborative Consumer Engagement: Lessons From the Aligning Forces for Quality Initiative
Debra L. Ness, MS
That Was Then, This Is Now
Lisa A. Simpson, MB, BCh, MPH, FAAP
Regional Health Improvement Collaboratives Needed Now More Than Ever: Program Directors' Perspectives
Randall D. Cebul, MD; Susanne E. Dade, MPA; Lisa M. Letourneau, MD, MPH; and Alan Glaseroff, MD, ABFM
The Aligning Forces for Quality Initiative: Background and Evolution From 2005 to 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
Barriers and Strategies to Align Stakeholders in Healthcare Alliances
Larry R. Hearld, PhD; Jeffrey A. Alexander, PhD; Jeff Beich, PhD; Jessica N. Mittler, PhD; and Jennifer L. O’Hora, BA
The Aligning Forces for Quality Initiative: Background and Evolution From 2005 to 2012 - eAppendix
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Midterm Observations and Recommendations From the Evaluation of the AF4Q Initiative
Jeffrey A. Alexander, PhD; Dennis P. Scanlon, PhD; Megan C. McHugh, PhD; Jon B. Christianson, PhD; Jessica N. Mittler, PhD; Romana Hasnain-Wynia, PhD; and Jeff Beich, PhD
Community-Level Interventions to Collect Race/Ethnicity and Language Data to Reduce Disparities
Romana Hasnain-Wynia, PhD; Deidre M. Weber, BA; Julie C. Yonek, MPH; Javiera Pumarino, BA; and Jessica N. Mittler, PhD
Approaches to Improving Healthcare Delivery by Multi-stakeholder Alliances
Megan C. McHugh, PhD; Jillian B. Harvey, MPH; Dasha Aseyev, BS; Jeffrey A. Alexander, PhD; Jeff Beich, PhD; and Dennis P. Scanlon, PhD
Evaluating a Community-Based Program to Improve Healthcare Quality: Research Design for the Aligning Forces for Quality Initiative
Dennis P. Scanlon, PhD; Jeffrey A. Alexander, PhD; Jeff Beich, PhD; Jon B. Christianson, PhD; Romana Hasnain-Wynia, PhD; Megan C. McHugh, PhD; Jessica N. Mittler, PhD; Yunfeng Shi, PhD; and Laura J. B
Using Websites to Engage Consumers in Managing Their Health and Healthcare
Jessica N. Mittler, PhD; Karen M. Volmar, JD, MPH; Bethany W. Shaw, MHA; Jon B. Christianson, PhD; and Dennis P. Scanlon, PhD
Participating Faculty: The Aligning Forces for Quality Initiative: Early Lessons From Efforts to Improve Healthcare Quality at the Community Level
Letter From the Guest Editor
David Blumenthal, MD, MPP
Samuel O. Thier Professor of Medicine and Professor of Health Care Policy Massachusetts General Hospital/Partners HealthCare System and Harvard Medical School, Boston

Midterm Observations and Recommendations From the Evaluation of the AF4Q Initiative

Jeffrey A. Alexander, PhD; Dennis P. Scanlon, PhD; Megan C. McHugh, PhD; Jon B. Christianson, PhD; Jessica N. Mittler, PhD; Romana Hasnain-Wynia, PhD; and Jeff Beich, PhD
Objective: To offer midterm observations and recommendations based on how Aligning Forces for Quality (AF4Q) alliances are faring in their journey toward improving healthcare quality at the community level.
Study Design: This study used a mixed method design.
Methods: Longitudinal evaluation data to date were analyzed, including results from multiple surveys, qualitative analysis of key informant interviews, review of secondary documents and analysis of secondary data, and ongoing tracking of the activities of the 16 participating alliances. The observations and recommendations are based on consensus achieved by the AF4Q evaluation team investigators after in-depth iterative discussions.
Results: Six formative observations are identified and discussed: (1) stakeholder support and participation has been maintained despite changes in economic and political environments; (2) progress on program goals has been slow; (3) the “alignment” in the AF4Q initiative has been slow to materialize; (4) the AF4Q initiative has established a productive network of peer communities; (5) the impact of the AF4Q initiative, and the time to observe impact, vary by community, based on history and context; and (6) sustainability is the major future challenge for the AF4Q initiative.
Conclusions: Multi-stakeholder alliances’ efforts to improve quality should be viewed as “pieces of the health reform puzzle” rather than stand-alone solutions. As healthcare reform is challenged politically, alliances can practice the bipartisanship that focuses conversation on what is good for the community and how best to achieve community goals amid a potential sea of change in both federal and state policy and funding.

(Am J Manag Care. 2012;18:S126-S132)
The Robert Wood Johnson Foundation’s (RWJF’s) Aligning Forces for Quality (AF4Q) initiative is arguably the most ambitious attempt in American history to improve the quality of healthcare in communities using a collaborative, multi-stakeholder approach. Details about the history and evolution of the AF4Q initiative are provided in the article by Scanlon et al in this supplement.1 In general, membership in the AF4Q initiative provides the 16 participating alliances (ie, the generic term used for the multi-stakeholder partnership in each community) with 3 complementary components: (1) a set of program expectations and interventions to achieve those goals; (2) technical assistance (TA) to help  alliances develop meaningful population-based interventions; and (3) grant funds to support the staffing and infrastructure required to start and maintain the work of the alliance over a protracted period until the alliance and/or its activities become self-sustainable. While each alliance customizes its work to fit the local context and needs of its community, the program requires that all alliances be actively involved in 5 main programmatic areas: (1) public reporting of quality measures; (2) efforts to engage healthcare consumers and patients in their health and the care received in communities (ie, consumer engagement); (3) systems-level quality improvement; (4) healthcare equity and disparities reduction; and (5) payment reform. Additionally, alliances must focus on the sustainability of these activities.

The AF4Q initiative evolved from the RWJF’s observation that documented quality problems persisted across communities despite isolated examples of successfully addressing those problems with existing tools. The RWJF hypothesized that the missing link was local implementation and the support of a diverse set of committed stakeholders to address subpar quality in communities. Acknowledging that much of the work of the 16 AF4Q alliances would be groundbreaking, the RWJF intended for these alliances to serve as “learning laboratories” for other communities, policy makers, and others interested in local solutions to the nation’s most pressing healthcare quality and value problems. Thus, the RWJF funded a long-term independent formative and summative evaluation of the AF4Q initiative.

The summative component of the evaluation is designed to measure and report on the AF4Q initiative’s effect at the conclusion of the RWJF’s formal support in 2015. The formative component of the evaluation is ongoing, and it is designed to document the initiative’s evolution and highlight important lessons and observations along the way, including examples of barriers, facilitators, and progress on intermediate outcomes. At this intermediate juncture, we can issue important formative observations to assess how these alliances are faring on their journeys toward improving healthcare quality at the community level.

As described in this supplement, the AF4Q initiative evaluation employs qualitative, quantitative, and mixed research methods. More details about the AF4Q initiative evaluation design and associated data collection and analysis can be found in the article by Scanlon et al in this supplement.2 The formative observations we present in this article, and the associated recommendations, are based on analysis of longitudinal evaluation data to date, including results from multiple surveys, qualitative analysis of key informant interviews, review of secondary documents and analysis of secondary data, and ongoing tracking of the activities of the 16 participating alliances. The observations and recommendations presented in this paper are based on consensus achieved by the evaluation team investigators after iterative in-depth discussions.

The formative observations and recommendations that we present should be of interest to those involved in multi-stakeholder quality improvement work in communities, regardless of AF4Q affiliation, those funding this type of community-level work, policy makers, and others interested in seeing these efforts expanded to other communities. Our research is particularly relevant, as community-based approaches to improving healthcare have become a prominent component of national and local health reform efforts.3

Formative Observations From the AF4Q Evaluation to Date

1. Stakeholder support and participation has been maintained despite changes in economic and political environments

Healthcare plans, provider organizations, purchasers, and consumers are not always natural allies in healthcare improvement, and some would argue that the historical separation of interests among these stakeholders is the source of our fragmented healthcare delivery system and a major reason for documented poor quality.4 While communities were selected for the AF4Q initiative based on their perceived ability and willingness to collaborate, the ability to establish and maintain the legitimacy and neutrality of the alliance is something that should not be taken for granted. Our tracking of alliance efforts since the launch of the AF4Q initiative suggests that alliances have been able to maintain the interest, support, and commitment of a diverse set of stakeholders in their respective communities. Importantly, this commitment has been maintained over approximately 5 years, and during a time in which the nation has experienced a deep recession and the passage and implementation of major healthcare reform. Evidence of this sustained participation and commitment comes from our key informant interview data and results from 3 waves of a survey given to those who participated in the alliances’ activities. This alliance survey, which asks participants about the value of the alliance for the community, individual, or organization the respondent represents, is one way we measure if support for the alliance wanes over time.5 For example, results pooled from all alliances, for all participating stakeholders, suggest that: (1) respondents view the alliances’ participants as having a clear and shared vision of health in their communities (89%); (2) alliances are taking meaningful actions (83%); and (3) the benefits of participating in the alliance outweigh the costs of participation for individuals and organizations (88%). Importantly, the level of agreement on these questions has remained steady or increased across the 3 waves of the survey, for both the recurring panel respondents and the entire sample of respondents.

It is no small feat that the AF4Q alliances have been able to keep a diverse set of stakeholders at the table, as prior research has shown that mistrust, competing interests, cultural differences, and personal and organizational histories often conspire to make collaboration a challenge.6 Further, the personal ties and informal networks found in alliances often increase the vulnerability of these organizations when turnover, burnout, and attrition among key participants disrupt momentum and cohesion. A key factor that has kept AF4Q alliance members working toward a common goal of improved quality of care is the perception that the alliances were neutral players with no hidden agendas or implicit arrangements with particular stakeholders. As a credible, neutral entity, most alliances have been able to offer a level playing field for the discussion of hard issues and provide a context for leaders to work with different stakeholders without raising questions about credibility or ulterior motives. As one informant observed: “[The] AF4Q [initiative]…really…built the credibility of [the alliance] because what that project did was to say ‘Yes we can work together, yes we can agree on these common measurements’… Because of the AF4Q program…it’s built capacity, credibility, and I think with the medical groups, the health plans, and the state. And I don’t think they could have done it without that grant.”

Our ongoing research has found that there are 2 factors, in particular, that have helped to build the trust and neutrality that we have observed: the leadership of the alliances and the decision-making processes employed by the alliances. Alliance leadership plays a critical role in establishing and sustaining neutrality and legitimacy and, by extension, member participation and commitment, because these organizations cannot rely on the formal structure and authority, such as ownership, that facilitate action in other organizations. Credible leadership has been established through interpersonal skills and effective communication, and it is closely tied to whether the alliance itself is viewed by participants as a body where various stakeholders can “let their defenses down” and where critical, open discussions can occur without the threat of negative consequences.

Similarly, alliances that utilize open and inclusive decision-making processes (eg, all issues and options are identified before making a decision and members feel like they have a voice in the direction eventually taken) appear to be more successful at building consensus around vision, mission, and strategy. Open decision-making processes promote trust among members and cultivate a climate in which members can freely and safely exchange ideas.

These efforts require time, leadership, and patience. We have observed that progress on AF4Q programmatic efforts is often built on the time-consuming and ongoing processes of trust building and managing cultural differences among stakeholders—critical but often underestimated areas in community-based efforts to improve healthcare quality.

2. Progress on broad program goals has been slower

While support for the alliances and their broad vision of improving community health remains strong, progress toward measurable population-level change, such as improved quality, efficiency, and reductions in health disparities, has been slow for 2 reasons. First, as suggested above, it took longer to establish the governance structures and processes than originally anticipated. Second, the evidence base surrounding the key programmatic areas in the AF4Q initiative was not as well established as originally assumed, requiring alliances to engage in defining and developing the evidence base before developing and implementing their strategies.

The underdeveloped evidence base meant that many early conversations in AF4Q communities were centered on defining these major program areas (eg, consumer engagement, quality infrastructure) and discussing the merits of potential interventions. The work of the alliances in the early stages of the AF4Q initiative focused primarily on developing pilot programs or local evidence to determine what works, rather than on achieving broad, community-level changes in quality of care. For example, Hurley et al determined that the alliances spent a significant amount of time trying to define what consumer engagement meant to various stakeholders in order to broker agreement about which aspects of consumer engagement should be prioritized and pursued.7 The overall dearth of evidence about effective interventions to improve consumer engagement, especially at a communitywide level, contributed to initial strategies that emphasized smaller pilot initiatives.

 
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