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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
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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
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
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

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
Objective: To identify barriers to stakeholder alignment and strategies used by 14 multi-stakeholder alliances participating in the Aligning Forces for Quality initiative to overcome these barriers.
Study Design: The study used a mixed method, comparative case study design.
Methods: Alliances were categorized as more or less highly aligned based on an alignment index constructed from survey responses. Six alliances (top and bottom quartile) were selected for more in-depth qualitative analysis. Semi-structured interviews of key informants were used to identify factors that distinguished more highly aligned alliances from less highly aligned alliances.
Results: Market context was one of the most important factors differentiating alliances. More highly aligned alliances had more extensive histories of collaboration, established more credibility in the local community, and were more effective at balancing collaborative initiatives against competitive interests. More highly aligned alliances also took more active approaches to build consensus among stakeholders regarding alliance initiatives, and were able to successfully utilize small decision-making bodies to foster this consensus. In contrast, leadership credibility, leadership stability, and trust were important facilitators of alignment for all alliances, regardless of the level of alignment. These factors intersect and overlap in a multitude of ways to influence stakeholder alignment.
Conclusions: Alignment in an alliance context is critical for leveraging the unique knowledge, skills, and abilities of stakeholders in ways that can build capacity to improve the health of the community in ways that cannot be achieved independently by stakeholders. The findings highlight the need for multifaceted approaches to promote stakeholder alignment.

(Am J Manag Care. 2012;18:S148-S155)

Healthcare alliances (ie, multi-stakeholder community partnerships) may be defined as voluntary organizations that bring together a diverse array of stakeholders (eg, physicians, hospitals, insurers, employers and other purchasers, consumers) to work collaboratively on a variety of health-related issues in a community. Healthcare alliances are increasingly being examined as a potential solution for problems of fragmentation that undermine coordination across the continuum of care and contribute to poor-quality care.1,2 However, because alliances are by definition composed of stakeholders from different industry sectors, balancing the diverse and sometimes divergent goals of stakeholders with the goals of the alliance can be a challenging endeavor. Weiner and Alexander suggest that reconciling “turf issues” is a critical governance activity that requires alliance-governing bodies to engage in 2 key tasks: (1) aligning the interests of partner organizations with the interests of the partnership; and (2) resolving conflict arising from diverging interests or role ambiguity.3 Alignment is defined in this study as a shared understanding about the alliance’s vision, strategic goals, and sense of commitment, collaboration, and cooperation among stakeholders. In practical terms, stakeholder alignment facilitates more efficient and effective coordination of activity and serves as an important precursor to action.4,5 Despite the importance assigned to alignment in multi-stakeholder alliances, less attention has been devoted to identifying environmental and organizational conditions and activities that may facilitate or impede alignment.

The purpose of this study of 14 alliances participating in the Aligning Forces for Quality (AF4Q) initiative, a national program of the Robert Wood Johnson Foundation (RWJF) designed to help targeted communities improve the overall quality of healthcare, reduce racial and ethnic health disparities, and provide models for national reform, was to identify barriers to stakeholder alignment as well as strategies used by alliances to overcome these barriers. We use a mixed method analysis to compare and contrast alliances that have achieved different levels of stakeholder alignment. The findings of this study are likely to be of interest to alliance leaders and participants interested in identifying ways to promote alignment among diverse stakeholder groups. The findings are also likely to be of importance to policy makers and program designers (eg, funding agencies) interested in developing or supporting collaborative efforts to improve healthcare in local communities.

Background and Conceptual Framework

In an alliance context, the combination of knowledge, skills, and resources of a diverse membership is believed to stimulate the alliance to think in different ways about how to achieve its goals, plan more comprehensive and integrated programs, and strengthen its relationship with the broader community.6 Analysts have proposed several important determinants of an alliance’s ability to combine these unique skills and knowledge bases in ways that can stimulate different ways of thinking about and achieving its goals. These determinants include stakeholder characteristics (eg, heterogeneity, level of involvement), relationships among stakeholders (eg, trust, respect, conflict), alliance characteristics (eg, leadership, governance), and the external environment of the alliance (eg, community characteristics, policy/political environment).6,7 Others have emphasized the contextual nature of alliances, particularly the temporal, emergent aspects of an alliance’s structure and management processes that influence how the component parts of the alliance are brought together.8-12

Based on the literature, we propose that there are 4 primary domains of activity that form the building blocks for stakeholder alignment in multi-sector alliances. Market context refers to factors outside the alliance that shape an alliance’s activities and programs. Alliance structure and governance refers to characteristics of the alliance that reflect and affect how an alliance is designed to function (eg, committee structure) and the processes used to manage alliance activities. Leadership relates to activities, attributes, or style of leaders. Alliance climate is the recurring patterns of behavior, attitudes, and feelings among stakeholders that characterize life in the alliance and shape interactions with other alliance participants. An overview of these domains and how they relate to one another is provided in the Figure.

Design and Methods

Quantitative Data Used to Determine the Level of Alignment

Quantitative data were drawn from an Internet-based survey of individuals and organizational representatives who were formal members (ie, leaders, staff, members-at-large) of 14 AF4Q alliances (data from additional alliances that joined the initiative in 2009-2010 are not included in this analysis). The survey was fielded over a 4-week period in each alliance between October 2008 and October 2009. The response rate was 48.6% (623 of 1283 possible respondents).

Alliances were categorized as more or less highly aligned based on an alignment index constructed from questions regarding alliance governance, leadership, and their participation in the alliance (eg, level, costs, and benefits). Based on our definition of alignment, 6 items were selected to assess the level of alignment achieved by alliances: (1) alliance vision (“The members of the alliance have a clear and shared vision of health in our community.”); (2) alliance purpose/ mission (“The purpose for which the alliance was formed is clear to me.”); (3) alliance strategy (“The alliance members are in agreement on the best strategies to achieve our priorities.”); (4) collaboration and cooperation among alliance members (“The alliance decision makers willingly collaborate and cooperate with each other.”); (5) commitment (“Based on my observations, the alliance members appear to be strongly committed to its success.”); and (6) differences of opinion (“Serious differences of opinion among the alliance members are rare.”). All 6 items were measured on a 5-point scale ranging from “strongly disagree” (1) to “strongly agree” (5). “Do not know” responses were coded as missing and dropped from the analysis.

To construct the alignment index, we first conducted an exploratory factor analysis (varimax rotation) on a half sample of survey respondents using the 6 survey items. The results of this analysis indicated a 2-factor structure, with the vision, mission, and strategy items loaded on 1 factor and the collaboration, commitment, and difference of opinion items loaded on the second factor. To confirm the factors identified in the exploratory factor analysis, we conducted a confirmatory factor analysis on the other half sample of respondents, which again indicated support for a 2-factor structure for the alignment construct (root mean squared error of approximation = 0.04; comparative fit index = 0.99). However, both analyses (factor loadings and modification indices) suggested that the purpose/mission item should not be incorporated in the alignment index; thus, this item was dropped from subsequent analysis.

Next, we used reliability (intraclass correlation coefficient 1; intraclass correlation coefficient 2) and inter-rater agreement (rwg; average deviation) statistics to assess whether individual-level responses could be reliably aggregated to the alliance level. Both sets of statistics supported aggregating the individual responses to the alliance level. Therefore, individual-level responses within an alliance were averaged separately for each alignment factor, with all items given equal weight. The alliances were then rank-ordered using the 2 scales. Because the 2 scales were highly correlated (r = 0.56), alliances that ranked highly on 1 scale also ranked highly on the second scale. Therefore, the final rank ordering was based on a composite alignment score that averaged the scores for the 2 factors, with both factors given equal weight.

Six of the 14 AF4Q alliances—the 3 alliances in the top quartile and the 3 alliances in the bottom quartile of the composite alignment score—were selected for more in-depth analysis with qualitative data. The average composite score for the 3 alliances in the bottom quartile was 3.4 compared with an average of 4.1 for the 3 alliances in the top quartile (range = 3.3-4.2). Composite scores for 2 of the 3 alliances in the top quartile were significantly greater than the composite scores for the alliances in the bottom quartile. Because we view alignment as a process that is measured on a continuum, rather than a discrete event measured in absolute terms, we describe these 2 groups of alliances as “more highly aligned alliances” (top quartile) and “less highly aligned alliances” (bottom quartile) in the remaining sections of this article.

Qualitative Data Collection and Comparative Case Analysis

The purpose of our qualitative analysis was to compare the more highly aligned alliances with the less highly aligned alliances to assess whether these 2 groups differed with respect to barriers to alignment or used different strategies to facilitate alignment. Qualitative data were collected via semi-structured, face-to-face interviews in each of the AF4Q alliance communities from July 2006 through February 2007. Interviews covered a range of topics, including alliance history, governance, and management; staffing; membership; vision and goals; and activities designed to achieve alliance objectives. A total of 275 individuals were interviewed (average = 20 per alliance; range = 15-26), representing a broad cross-section of stakeholders in each alliance, including insurance company executives, hospital executives and practicing physicians, representatives from consumer organizations, government representatives, local employers and other purchasers, consumers, and alliance staff. Each interview lasted approximately 1 hour and was tape-recorded and transcribed in full.

First, all transcripts were coded with predefined, macro-level themes (eg, goals/vision; consensus). In the second step, we used alignment-related terms to conduct text searches within the interviews, which were then collated into a separate report for each alliance. Investigators reviewed these reports independently to examine what informants said about barriers to alignment or strategies used by alliances to foster alignment. This process yielded a consolidated set of emergent themes that could be organized into the 4 broader domains of factors associated with alignment (ie, market context, structure and governance, leadership, and climate).13 In the third step, the team used the set of themes in a further round of coding and generated a subsequent set of reports that linked all coded text with one of the broader categories of themes. Each team member then examined these reports, identified key challenges and strategies for each domain, and wrote a short memo that more fully described these themes.  In the fourth and final step, we used the memos to compare and contrast challenges and strategies within and across the 2 groups of alliances.

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