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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
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
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
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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
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

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
Objective: Our purposes were: (1) to describe how 14 multi-stakeholder alliances participating in the Aligning Forces for Quality (AF4Q) initiative approached the charge of improving healthcare delivery at the community level between 2006 and 2010; and (2) to offer insights to policy makers and program planners seeking to promote or establish communitywide quality improvement (QI).  
Study Design: This was a qualitative study.  
Methods: A total of 84 semi-structured interviews were conducted with AF4Q alliance leaders between 2006 and 2010, and an iterative coding process was used to identify salient themes. Program documents supplemented the interview data and were used to develop an inventory of the alliances’ QI activities using the Leatherman and Sutherland taxonomy of quality-enhancing interventions.  
Results: Alliances spent years planning their QI approaches and activities. Initial selection of QI activities was driven by the availability of local expertise and resources, rather than alignment with a communitywide vision for quality. Alliances were just as likely to rely on local partners to lead QI activities as they were to establish their own activities. The most commonly adopted QI activities were collaboratives aimed at producing organizational-level changes.  
Conclusions: Policy makers and program planners seeking to promote communitywide QI should consider developing clear expectations, offering technical assistance at the start of the program, providing information on the evidence base for QI activities, and highlighting additional funding opportunities that could support QI activities. Alliances may need a stronger push to move beyond coordinated, organizational-level activities to more community-focused, cross-organizational QI activities.  

(Am J Manag Care. 2012;18:S156-S162)   

Over the past decade, there has been much effort devoted to improving healthcare quality in response to compelling evidence that our health system does not perform as well as it could or should.1-3 Healthcare providers are increasingly engaging in a variety of quality improvement (QI) efforts,4 and have been encouraged to do so by the growing number of pay-for-performance programs and QI resources available.5,6 For example, the Institute for Healthcare Improvement, Agency for Healthcare research and Quality, and industry groups have produced guidance on various QI topics, and many public and private organizations have established regional collaboratives to help improve care for specific clinical conditions.7-9  

Although these QI efforts have resulted in many successes, quality problems persist.10-12 some have suggested that in order to stimulate meaningful and sustainable improvement that impacts the population in a given region, QI efforts need to advance from organizational-level initiatives to multi-level (individual, group, organization, and system), communitywide approaches.13-15 there is no single definition of a communitywide approach to QI, but examples include multidisciplinary teams from local hospitals working together through a learning collaborative to reduce infection rates; “horizontal” efforts among providers within a community (eg, hospitals, outpatient clinics, physician practices) to improve care transitions; and payment reforms that encourage local providers to implement patient-centered medical homes (PCMHs). A defining characteristic of communitywide QI is a coordinated, collective effort across organizations. Communitywide QI may be more effective than individual approaches if it eliminates duplication of efforts, improves information sharing across settings, and influences key factors that are out of the control of individual providers (eg, payment reforms).15-17  

The nascent literature on communitywide QI suggests that communitywide QI is possible, but implementation is challenging and requires complex interaction among organizations.15,17 there is currently little information to guide strategy and implementation of communitywide QI. The purpose of this paper is to describe how 14 alliances (multi-stakeholder partnerships in each Aligning Forces for Quality [AF4Q] community/location) participating in the AF4Q initiative approached the charge of improving healthcare delivery within their communities. We review the specific activities undertaken by the 14 AF4Q alliances (data from additional alliances that joined the initiative in 2009-2010 are not included in this analysis) and assess the extent to which they followed a common, communitywide vision for quality. This article will provide policy makers and leaders of QI efforts with an understanding of the activities that alliances can undertake to improve care delivery. It will also provide insight to policy makers and funders about the QI priorities of alliances.  

The AF4Q Initiative

The AF4Q initiative is a $300 million effort created by the Robert Wood Johnson Foundation (RWJF) under the premise that “No single person, group, or profession can improve health and healthcare throughout a community without the support of others.”18 Program funding was directed to alliances charged with improving quality at the community level by focusing on several programmatic areas including public reporting, equity, consumer engagement, and QI (ie, improving care delivery). Given their broad representation, alliances are well suited to facilitate improvement by securing and coordinating resources, promoting collaboration across providers, disseminating information, and prioritizing common goals and initiatives.19 the alliance’s governing body was ultimately responsible for providing vision, strategic direction, and operational oversight for the QI work, as well as linking QI with the other AF4Q programmatic areas. A more thorough description of the AF4Q initiative and characteristics of the alliances may be found in the article by Scanlon et al in this supplement20; here we focus on the AF4Q activities and expectations related to the QI programmatic area (Table 1).  

While guided by the AF4Q National program Office’s (NPO’s) technical assistance (TA), program goals, and measures, alliances had considerable latitude regarding how to pursue their work. For example, alliances could establish their own activities, partner with other organizations, or use a combination of the 2 approaches. They also had the flexibility to focus on any number of outcomes (eg, improving outcomes for diabetes or heart failure, minimizing use of the emergency department for potentially avoidable conditions).


Data Sources  

Key informant interviews were conducted during 2 rounds of site visits and 1 round of follow-up telephone interviews. The first round of site visits was held from November 2006 to September 2007, shortly after the alliances were awarded AF4Q initiative funding. Although in-person interviews were conducted with a number of individuals in each community during the site visit, for this analysis, we limited our focus to the individuals most knowledgeable about the QI activities: alliance directors, who oversee the work of the alliance; and project directors, who are responsible for implementation of the AF4Q initiative. We asked respondents about the alliances’ structure, vision, goals, strategies, and decision-making.  

The second round of site visits was conducted from December 2009 to April 2010. At that time, the alliances identified specific individuals responsible for QI. Therefore, we interviewed the new QI leaders in addition to the alliance and project directors. During the interviews, we asked specific questions about the alliance’s QI activities, including strategies for leading versus partnering to conduct QI.  

Finally, we conducted follow-up telephone interviews with the alliance and project directors in the fall of 2010 to collect data on recent QI activities and why those specific activities were undertaken. Our analysis includes 16 interviews conducted during the first round of site visits, 54 during the second round, and 14 during the follow-up telephone interviews.  

Additionally, we reviewed a number of program documents and materials submitted by the alliances to the RWJF and the NPO between 2006 and 2010, including funding proposals, work plans, and progress reports. A more complete description of the data sources can be accessed in the manuscript by Scanlon et al in this supplement.21


All key informant interviews were recorded, transcribed, and uploaded into Atlas.ti. Our analysis included 4 steps. First, transcripts were reviewed and coded with predefined global codes that aligned with the AF4Q initiative’s initial programmatic areas (eg, QI, public reporting, consumer engagement). Second, following an inductive approach, a more finite set of codes was derived from a review of the transcripts to reflect the emerging QI themes.22,23 these codes reflected (1) alliance QI activities; (2) alliances’ QI strategy, vision, and goals; (3) the QI environment and context; and (4) TA, the NPO, and the RWJF. Third, these finite codes were applied to the transcripts by a researcher and reviewed for consistency by evaluation team investigators. Fourth, 2 investigators reviewed the passages and held weekly discussions to formulate the final themes.  

We also developed an inventory of the alliances’ QI activities. We organized the inventory following Leatherman and Sutherland’s taxonomy of quality-enhancing interventions, which was developed based on structured reviews of evidence and is applicable to organizational and community-level QI activities.14 two investigators independently categorized the alliances’ QI activities, and discrepancies were discussed. to be consistent with the time frame of our interview data, only interventions that were implemented prior to 2011 were included in the analysis. Interventions that were in the planning stages were excluded, and interventions that were implemented in multiple communities (eg, the transforming Care at the bedside collaborative) were counted multiple times. Activities that primarily focused on a different AF4Q programmatic area (eg, public reporting, consumer engagement) were excluded; however, QI activities that had a consumer engagement or public reporting component were retained. Categories were not mutually exclusive; most interventions were counted in more than 1 category. QI interventions that expanded over time were only counted once and their categorization reflects the expanded scope. We calculated the number of activities undertaken by the alliances in each category and the percent of QI activities that were led by the alliances, the NPO, or a local partner.

This research was approved by the institutional review boards of Penn State University and Northwestern University and informed consent was obtained from interviewees.


Evolution of the Alliances’ Communitywide QI Activities

Many alliances were slow to establish plans for QI. From 2006 to 2007, alliances were in the early planning stages of the AF4Q initiative. Alliances commonly engaged in local convening activities to better understand the QI efforts under way in the community and to discuss with partners the activities that might make the biggest impact, given limited resources. Few of the alliances began new QI activities during this stage. even during the 2009 to 2010 site visits, many respondents noted that they continued to be in a planning stage for QI. In some communities, QI committees were just established and trying to identify a clear role; others struggled with how to use public reporting data to guide QI activities, and many respondents commented that their QI activities were just getting under way. According to a respondent, “We are really slow in QI.”

Respondents offered several reasons why they experienced more difficulty developing plans for QI compared with other AF4Q programmatic areas. First, respondents noted an initial lack of QI TA, numerous changes to the QI TA format, and poor communication of TA programs and processes. In the absence of clear guidance or expectations from the RWJF or the NPO, alliances struggled to focus their activities. According to a respondent, “the QI area is the one that I struggle with, and I feel like the Foundation struggles with it, and our TA providers struggle with it.”

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