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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
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
Currently Reading
Producing Public Reports of Physician Quality at the Community Level: The Aligning Forces for Quality Initiative Experience
Jon B. Christianson, PhD; Karen M. Volmar, JD, MPH; Bethany W. Shaw, MHA; and Dennis P. Scanlon, 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

Producing Public Reports of Physician Quality at the Community Level: The Aligning Forces for Quality Initiative Experience

Jon B. Christianson, PhD; Karen M. Volmar, JD, MPH; Bethany W. Shaw, MHA; and Dennis P. Scanlon, PhD
The AF4Q initiative experience suggests public reporting of physician performance can be established successfully at the community level in a relatively short time by healthcare coalitions that receive financial support and technical assistance and are held to performance benchmarks. Communities that did not have such reports prior to the AF4Q initiative now have additional physician performance information available to local consumers. Community coalitions that were reporting physician performance prior to joining the AF4Q initiative extended the scope of their reports consistent with the AF4Q initiative guidance. Interview respondents credited participation in the AF4Q initiative, supported by other factors, as critical to their progress in reporting physician performance. It should be noted, however, that most AF4Q alliances were chosen in part because healthcare stakeholders in their communities had some experience in collaborative efforts; it is not clear whether communities with no such history could have achieved the same results.

The success of alliances in accomplishing their public reporting goals contrasts with the decidedly mixed results of some past attempts to influence local healthcare systems through voluntary collective actions.15 Among the many factors that likely contribute to this success, 3 seem especially important. First, prior reporting of physician performance by 3 of the 14 original AF4Q grantees proved that it could be done. Second, the likely winners and losers from physician performance reporting were not clear at the onset, reducing the potential for organized resistance to form early in the process. Third, most physicians had experience with health plan efforts to measure and report their performance. While this experience was not always satisfactory, it led many physicians in alliance communities to believe that performance reporting was inevitable. According to some respondents, participation in community-based reporting efforts was welcomed by physicians as an opportunity to shape the content of reports and influence decisions regarding the data used for performance measurement.

At present, and consistent with Young,8 interview respondents noted 2 potential obstacles to the expansion of community-based public reporting of physician performance. The first is lack of ongoing financial support. One alliance leader observed that, “If Robert Wood Johnson money went away, it would be extremely challenging for this community to pick up a half a million dollars a year to do public reporting.” Yet, this obstacle clearly has been surmounted in some communities where alliances have instituted dues for stakeholder participation, while other alliances have received funding from health plans or state governments.

A second potential obstacle is that a credible national public reporting effort could emerge, particularly in light of federal funding for the adoption of electronic medical records (EMRs) in physician practices. Properly configured EMRs can facilitate the collection of data from all patients irrespective of insurance status, and reporting of clinical measures can allay physician concerns about use of claims-based measures. EMRs could also create efficiencies in data collection and measure construction, lowering the costs for nationally produced reports. If a credible national effort emerges, community stakeholders might be less inclined to devote their time and resources to the development of locally produced physician performance reports.

Limitations of Analysis

The criteria employed by the RWJF to select community coalitions to participate in the AF4Q initiative suggest caution in extrapolating from the experience of AF4Q alliances. First, it is possible that the findings reflect primarily the selection of experienced and highly motivated community coalitions.10 However, not all community organizations chosen to be AF4Q alliances had experience with, or enthusiasm for, public reporting of physician performance. As noted, many were initially skeptical of the value of such reports relative to the required resource investment, and only 3 were reporting measurements prior to the AF4Q initiative. Also, some newly formed AF4Q alliances had limited histories of stakeholder collaboration.

Second, because several alliances have only recently begun to report physician performance, we have limited ability to conclude whether reporting has stimulated the long-term responses on the part of providers, purchasers, and consumers that the AF4Q initiative anticipates (see eAppendix A, AF4Q Initiative: Public Reporting Logic Model). However, a number of interview respondents cited specific quality improvement activities implemented by local physician groups that they believed were in response to alliance quality reports. A recently published study relating the experience of 1 alliance supports these observations.16 As part of the overall AF4Q initiative evaluation, data are being collected from longitudinal consumer and provider surveys, ongoing interviewing, and secondary sources that will be used to assess the long-term impact of public reporting initiatives in AF4Q communities.10

Author affiliations: Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, MN (JBC); Center for Health Care and Policy Research, Penn State University, University Park, PA (DPS, BWS); Department of Health Policy and Administration, Penn State University, University Park, PA (DPS, KMV).
Funding source: This supplement was supported by the Robert Wood Johnson Foundation (RWJF). The Aligning Forces for Quality evaluation is funded by a grant from the RWJF.
Author disclosures: Dr Christianson, Dr Scanlon, Ms Shaw, and Ms Volmar report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.
Authorship information: Concept and design (JBC, DPS); acquisition of data (JBC, DPS, BWS, KMV); analysis and interpretation of data (JBC, DPS, BWS, KMV); drafting of the manuscript (JBC, DPS, BWS, KMV); critical revision of the manuscript for important intellectual content (JBC, DPS); obtaining funding (DPS); and administrative, technical, or logistic support (BWS, KMV).
Address correspondence to: Jon B. Christianson, PhD, University of Minnesota School of Public Health, 420 Delaware St SE, MMC 729, Minneapolis, MN 55455. E-mail: chris001@umn.edu.
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