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Supplements The Aligning Forces for Quality Initiative: Early Lessons From Efforts to Improve Healthcare Quality
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The Aligning Forces for Quality Initiative: Background and Evolution From 2005 to 2012 - eAppendix
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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
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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
Second, several alliances conducted surveys or led regional needs assessments to identify priority areas for QI, and those activities were time consuming. Finally, external factors, such as the passage of healthcare reform and new grant opportunities through regional extension centers (RECs), the beacon Community program, and others made it difficult for alliances to commit to a QI strategy and scope early on. “The overall picture isn’t quite clear. There are reasons for that. We just got the REC and we’re waiting [to hear about] the beacon [Community program]. There’s a lot of unknown and uncertainty.”  

Early QI activities built upon existing resources in the community; over time, alliances were more strategic in the selection of QI activities. Few alliances developed a clearly defined, communitywide vision for quality that was used to guide the selection of QI activities. Instead, early activities built upon ongoing interventions or took advantage of resources or expertise within the community. For example, respondents in Cleveland said that they had local experts who had previously led PCMH initiatives and improving performance in practice efforts, so they decided to build upon those activities. Other alliances delegated AF4Q’s QI programmatic area to partner organizations with a long history of QI. A respondent noted, “We already had a strong QI infrastructure [in the community], so we let others…continue to take the lead. They fulfilled the QI requirements of the [AF4Q] grant.”  

From 2009 to 2010, respondents were more strategic about their selection of QI activities; for example, they pursued activities that aligned with other large grant opportunities such as the beacon Community program and the REC. The additional funding allowed alliances to expand the reach of their QI activities. Selection of activities was also motivated by federal payment reform efforts. Respondents viewed the pilot and demonstration projects created under the Affordable Care Act (ACA) as key opportunities to support the creation of PCMHs and enter into discussion with local providers about the creation of accountable care organizations. Many of the alliances also focused on readmissions. According to a respondent, “these are the things that everyone is interested in—from the most meager federally qualified health centers to the most well resourced institutions. Everyone needs to reduce readmissions because we’re going to get hammered on payment. So those are things we are trying to help out with.”  

Despite the slow start in the QI programmatic area, by 2010, QI plans became more sophisticated. By 2010, many alliances expanded activities beyond learning collaboratives and focused on more sophisticated QI activities, such as those involving healthcare across different settings. They also began to consider strategies for spread and sustainability. For many alliances, large grants and payment reform efforts were central to the sustainability plans. Additionally, some alliances began to consider how to target hard-to-reach providers, such as smaller hospitals and independent physician practices.  

Classification of QI Activities  

The majority of QI activities focused on individual, organizational-level interventions. Using the Leatherman and Sutherland taxonomy to classify alliances’ QI activities, we found that alliances most commonly implemented activities aimed at changing organizational culture and behaviors (Table 2). Often, these activities were implemented through learning collaboratives facilitated locally and by the NPO. Some alliances also offered targeted coaching for individual practices.  

A common form of organizational change was the adoption of PCMHs. There were several reasons why this strategy was attractive to the alliances: the respondents believed there was an evidence base for PCMHs; there was a relatively high level of interest in PCMH models from providers; and development of PCMH activities positioned the alliances and their partners to take advantage of ACA programs and other large grants, such as the beacon Community Program.  

A majority of QI activities were data-driven. Almost all alliance leaders reported that QI activities incorporated performance data (Table 2). For example, practice-coaching activities for ambulatory care providers typically included a focused look at the practice’s data to direct the specific interventions. Additionally, alliances targeted low-performing practices to receive additional assistance, and high-performing practices were encouraged to share best practices. Similarly, many of the learning collaboratives sponsored by the NPO included requirements for the participants to submit data. The NPO analyzed the data and provided the participating organizations with feedback.  

Although the AF4Q initiative was initially designed for public reporting and QI activities to be aligned and carried out simultaneously, the alliances were offered more tA and guidance in the area of public reporting at the outset of the program, and many respondents described a sequential relationship between public reporting and QI, which also may explain delays in QI planning. For example, “QI is dependent upon first having good public reporting and health information technology” and “the collaborative learning group felt that they had to wait until the performance measurement people were further along.”  

Alliances infrequently pursued regulation or incentives. Across the 14 AF4Q communities, there were 13 efforts aimed at implementing financial incentives. These efforts typically involved projects to persuade local payers to provide financial incentives for establishing PCMHs. Regulatory interventions took the form of coaching to prepare practices for PCMH accreditation by the National Committee for Quality Assurance. Although regulation and incentives are powerful and wide-reaching motivators for community-level QI, alliances’ representation from payers and state agencies was rather limited, largely prohibiting these activities.

Alliances were just as likely to support the QI activities of local partners as they were to initiate their own QI activities. Many alliances noted that they did not want to duplicate the QI work already taking place within the community. Collectively, alliances supported a variety of local organizations (providers, health systems, state and local associations, government agencies, other QI organizations, and health plans) engaged in QI activities. The roles of the alliance in these activities varied from serving on an advisory board to providing data so that that the lead organization could monitor progress.

Notably, by 2010, several respondents suggested that their ability to partner with other organizations had improved due to greater local awareness of the alliance and/or an enhanced reputation as a QI leader. A respondent from Maine noted that they were approached by the recipient of the REC grant and asked to participate because of their increased credibility. A respondent from Cleveland said that the alliance was now viewed not only as a resource for QI, but also as a skilled convener in the community.

There was considerable variation in QI activities across communities. the number of QI activities adopted by alliances ranged from 5 to 21, reflecting differences in alliances’ histories, relationships with community partners, and QI planning times. there was also considerable variation across alliances regarding the decision to lead QI activities versus supporting the QI efforts of local partners. However, the alliances that were more likely to support partners’ QI efforts (rather than lead their own efforts) had well-established relationships with QI organizations, hospital associations, or others with a strong QI reputation. Still, all alliances led at least 1 QI activity.


Our investigation examined alliances’ approaches to their QI task and the specific activities undertaken. Alliances could not consistently provide information on the scope of their activities and we caution readers against making assumptions about alliances’ success based on the number of activities initiated. Further, our analysis excluded activities that were primarily focused on a different programmatic area (eg, public reporting, consumer engagement), even though alliance and program directors may have considered those to be QI activities. Finally, our results are not necessarily generalizable, due to the funding and TA provided to the alliances by the RWJF and the NPO.  


Our analysis of the AF4Q alliances’ approaches to addressing QI offers several insights that may be beneficial to policy makers and program planners seeking to promote or establish communitywide QI. First, the protracted planning period for QI, in comparison with other programmatic areas, suggests that program planners should give careful thought to implementation timelines. Given the complexity of improving care delivery within a community, and the inherent difficulties of working within a multi-stakeholder alliance, it may not be realistic to have a clear plan within the first year. Communitywide QI efforts are likely to require multi-year tracking to identify significant implementation progress, and even longer to assess impact. Based on feedback from the alliance leaders, we also suggest that program planners develop clear expectations for alliances and offer TA that begins at the start of the program. We might have seen earlier progress in QI if the RWJF and the NPO had provided alliances with as much up-front TA for QI as they did for public reporting.  

Second, absent strong direction from program sponsors, our findings provide some information on the types of activities that are likely to be attractive to alliances. Initially, alliances may be inclined to build upon the resources and strengths that exist within a community. If program planners wish to direct efforts to new areas, possible strategies could include providing the groups with the evidence base for the activity, offering targeted TA, and highlighting additional funding sources. Based on our findings, these more practical and strategic factors may provide stronger motivation for selecting particular interventions than an abstract vision for QI within a community. Although it is sensible to build on the local strengths and resources, communities should be cautious that without a communitywide vision, their work might not meet the needs of the community.  

Third, alliances overwhelmingly chose to pursue strategies that focused on organizational-level change. Collectively, these changes may produce meaningful and coordinated improvements that impact the population within a community. However, one concern is that by focusing on institutions, participants may continue to narrowly focus on their own organizations, rather than attempt more complex interventions that require greater collaboration across providers, such as addressing care transitions. Program planners should consider pushing alliances to pursue more cross-organizational activities.

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