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Supplements The Aligning Forces for Quality Initiative: Summative Findings and Lessons Learned From Efforts to Improve Healthcare Quality at the Community Level
The Aligning Forces for Quality Initiative: Background and Evolution From 2005 to 2015
Dennis P. Scanlon, PhD; Jeff Beich, PhD; Brigitt Leitzell, MS; Bethany W. Shaw, MHA; Jeffrey A. Alexander, PhD; Jon B. Christianson, PhD; Diane C. Farley, BA; Jessica Greene, PhD; Muriel Jean-Jacques,
Summative Evaluation Results and Lessons Learned From the Aligning Forces for Quality Program
Dennis P. Scanlon, PhD; Jeffrey A. Alexander, PhD; Megan McHugh, PhD; Jeff Beich, PhD; Jon B. Christianson, PhD; Jessica Greene, PhD; Muriel Jean-Jacques, MD, MAPP; Brigitt Leitzell, MS; Yunfeng Shi,
The Longitudinal Impact of Aligning Forces for Quality on Measures of Population Health, Quality and Experience of Care, and Cost of Care
Yunfeng Shi, PhD; Dennis P. Scanlon, PhD; Raymond Kang, MA; Megan McHugh, PhD; Jessica Greene, PhD; Jon B. Christianson, PhD; Muriel Jean-Jacques, MD, MAPP; Yasmin Mahmud, MPH; and Jeffrey A. Alexande
Reporting Provider Performance: What Can Be Learned From the Experience of Multi-Stakeholder Community Coalitions?
Jon B. Christianson, PhD; Bethany W. Shaw, MHA; Jessica Greene, PhD; and Dennis P. Scanlon, PhD
Improving Care Delivery at the Community Level: An Examination of the AF4Q Legacy
Megan McHugh, PhD; Jillian B. Harvey, MPH, PhD; Jaime Hamil, MPH; and Dennis P. Scanlon, PhD
From Rhetoric to Reality: Consumer Engagement in 16 Multi-Stakeholder Alliances
Jessica Greene, PhD; Diane C. Farley, BA; Jon B. Christianson, PhD; Dennis P. Scanlon, PhD; and Yunfeng Shi, PhD
Lessons Learned About Advancing Healthcare Equity From the Aligning Forces for Quality Initiative
Muriel Jean-Jacques, MD, MAPP; Yasmin Mahmud, MPH; Jaime Hamil, MPH; Raymond Kang, MA; Philethea Duckett, MPA; and Juliet C. Yonek, MPH, PhD
Currently Reading
Aligning Forces for Quality Multi-Stakeholder Healthcare Alliances: Do They Have a Sustainable Future
Jeffrey A. Alexander, PhD; Larry R. Hearld, PhD; Laura J. Wolf, MSW; and Jocelyn M. Vanderbrink, MHA
Participating Faculty
eAppendix
Letter From Donald M. Berwick, MD, MPP, Guest Editor
Donald M. Berwick, MD, MPP
The View From Aligning Forces to a Culture of Health
Carolyn E. Miller, MSHP, MA, and Anne F. Weiss, MPP
Leading Multi-sector Collaboration: Lessons From the Aligning Forces for Quality National Program Office
Katherine O. Browne, MBA, MHA; Robert Graham, MD; and Bruce Siegel, MD, MPH
Healthcare Reform Post AF4Q: A National Network of Regional Collaboratives Continues Healthcare Reform From the Ground Up
Elizabeth Mitchell and Dianne Hasselman, MSPH

Aligning Forces for Quality Multi-Stakeholder Healthcare Alliances: Do They Have a Sustainable Future

Jeffrey A. Alexander, PhD; Larry R. Hearld, PhD; Laura J. Wolf, MSW; and Jocelyn M. Vanderbrink, MHA
Objectives: Multi-stakeholder healthcare alliances in the Robert Wood Johnson Foundation’s Aligning Forces for Quality (AF4Q) program brought together diverse stakeholders to work collaboratively to improve healthcare in their local communities. This article evaluates how well the AF4Q alliances were collectively positioned to sustain themselves as AF4Q program support ended.

Methods: This analysis relied on a mixed-methods design using data from a survey of more than 700 participants in 15 of the 16 AF4Q alliances (1 alliance was unable to participate because it was in the process of closing down operations at the time of survey implementation), qualitative interviews with leaders in all 16 of the alliances, and secondary sources. Qualitative analysis of interview data and secondary sources were used to develop a classification of alliance strategic directions after the AF4Q program relative to their strategies during the AF4Q initiative. Descriptive analyses of survey data
were conducted in the following areas: (1) alliance priorities for sustainability, (2) alliance positioning for sustainability, and (3) alliance challenges to sustainability.

Results: The likelihood of sustainability and the strategic direction of the former AF4Q alliances are both decidedly mixed. A substantial number of alliances are at risk because of an unclear strategic direction following the AF4Q program, poor financial support, and a lack of relevant community leadership. Some have a clear plan to continue on the path they set during the program. Others appear likely to continue to operate, but they plan to do so in a form that differs from the neutral convener multi-stakeholder model emphasized during the AF4Q program as they specialize, make a major shift in focus, develop fee-for-service products, or focus on particular stakeholder groups (ie, employers and providers). In most cases, preserving the organization itself, rather than its programmatic activities from the AF4Q program era, appeared to receive the greatest emphasis in sustainability efforts.

Conclusion: As their core strategy, most alliances will not perpetuate the original AF4Q program vision of diverse local stakeholders coming together to implement a prescribed set of aligned interventions centered on healthcare improvement.

Am J Manag Care. 2016;22:S423-S436
Multi-stakeholder healthcare alliances—also known as collaboratives, partnerships, or coalitions—are organizations that bring together diverse stakeholders to work collaboratively to improve healthcare in local communities.1,2 Many of these organizations have been created in response to misaligned incentives and persistent poor quality of care, and are intended to promote local collaboration among stakeholders that have traditionally operated independently and sometimes in a conflicting fashion on health-related issues.3,4 An alliance’s ability to accomplish its goal of improving the value of healthcare is predicated on sustaining the interest and participation of community stakeholders over extended periods.2,5

The Aligning Forces for Quality (AF4Q) program was the signature effort of the Robert Wood Johnson Foundation (RWJF) to improve the overall quality of healthcare in targeted communities, reduce racial and ethnic disparities, and provide models for national reform through activities rooted in the efforts of local multi-stakeholder alliances.6 An article by Scanlon et al in this supplement provides a detailed description of the specific components and development of the AF4Q program.7 As the program entered its final years, AF4Q alliances were asked by RWJF to consider their respective futures and how to build on the progress made during the program. Alliances were provided with technical support for that effort. Questions of sustainability were particularly germane because RWJF’s vision was not to permanently support these alliances but to “prime the pump” by giving alliances a chance to establish themselves and get new programs off the ground, or to strengthen existing multi-stakeholder approaches to launch or enhance programs.

The goal of this article is to provide an initial examination of how the AF4Q alliances were collectively positioned for the future as the AF4Q program ended. Using data gathered through an online survey, key informant interviews, and alliance documentation, the following were examined: (1) the strategic directions of the alliances after the AF4Q program, (2) priorities for sustainability for the alliances after the AF4Q initiative, (3) how well the alliances were positioned to accomplish their goals at the conclusion of the AF4Q program, and (4) perspectives on the likely challenges the alliances will face in pursing their goals. This article ends with a general conclusion about the state of AF4Q alliances and their collective future. Our assessment is intended to provide a window into how community-based, multi-stakeholder alliances transition from participating in a long-term program—characterized by direct funding, ample technical assistance, and prescriptive programmatic requirements—to a more uncertain, but open, future.

Conceptual Framework: the Central Importance of Value

A recent review of the literature on collaborative sustainability concluded that most studies emphasized operational and management aspects of collaboratives thought to promote sustainability but largely neglected first-order issues, such as the value provided by the collaborative.8 Research in this area typically assumes that collaboratives and their activities should be sustained, even in the absence of evidence that they provide value. Such assumptions are problematic because the absence of a clear value proposition that stakeholders agree on is likely to be a deterrent to stakeholders joining or maintaining membership in a collaborative, regardless of how well the alliance is managed. Conversely, if participants see value or have a hand in shaping the priorities and direction of the alliance, the chances of commitment and ongoing support by stakeholders increase.

Given these issues, the future of the AF4Q alliances was by no means clear or certain at the conclusion of the AF4Q program. Alliances faced the challenge of maintaining commitment and investment from diverse, sometimes disparate, partners while attempting to identify priorities and a strategic direction that create value for their stakeholders. To gauge how well AF4Q alliances were positioned to sustain themselves and their activities after the AF4Q program, we evaluated how alliance leaders and participants viewed their alliance and its likely future direction. We focused specifically on issues related to creating value for stakeholders and the community, notably the strategic direction of the alliance, opinions on necessary alliance priorities, assessments of current alliance positioning to sustain itself or its activities, and likely future challenges to alliance sustainability. Collectively, these areas provide insights into the potential value that may (or may not) accrue to the alliance as a result of different ways of using its resources in pursuit of a particular goal. In contrast to previous research that emphasized the specific actions of the alliance as an independent agent, we emphasize how alliance participants perceive value through their priorities and concerns about their alliance’s direction and likelihood of success.

Methods

Data

This mixed-methods study utilized both qualitative and quantitative data collected from the AF4Q alliances. A brief description of each AF4Q alliance is located in the eAppendix of the article by Scanlon et al in this supplement (eAppendix available at www.ajmc.com).7 Qualitative data focused on the strategic direction of the 16 alliances after the AF4Q program relative to their strategic direction during the program. Strategic direction is defined as the alliance’s stated goals and the major course(s) of action the alliance has chosen to pursue them. Data on the strategic direction of the alliances following the AF4Q program were collected via a multi-stage process over the 6 months following the April 2015 end of the program. Specific qualitative data sources included key informant interviews with alliance staff and board leaders, alliance strategic plans and related process documents, and alliance website captures. Data on alliance strategies during the AF4Q program were collected through key informant interviews with alliance leaders and alliance documentation, including periodic progress reports that were submitted to the AF4Q National Program Office.

Quantitative data were drawn from an internet-based survey (alliance survey) of alliance participants in 15 of the 16 AF4Q alliances administered at the end of the AF4Q program (1 alliance was unable to

participate because it was in the process of closing down operations at the time of survey implementation). Survey content was based largely on the results of a systematic critical review of the literature on healthcare alliance sustainability.8 The survey sampling frame was developed from a comprehensive list of alliance participants provided by each alliance (ie, staff and consultants, board and leadership team members, committee and work group members, advisory group members, and members-at-large). The survey was conducted from June 2015 to September 2015.

The alliance leadership first sent a recruitment e-mail to all alliance participants. This e-mail alerted potential respondents to the survey request and served as an introduction to the purpose and administration of the survey. After the leadership’s introductory e-mail, the Penn State Survey Research Center sent a second e-mail containing the survey link to targeted respondents and subsequently followed up with 3 e-mail reminders, sent approximately 1 week apart. A total number of 638 individuals (38.6%) completed the whole survey (range across alliances, 21.8%-92.9%). In addition, 77 (4.7%) provided responses for a portion of the survey. Survey respondents included representatives from a broad range of stakeholder groups including insurers (9.9%), providers such as physicians and hospitals (26.1%), government agencies (11.2%), employers (5.1%), consumers (4.5%), alliance staff (17.5%), and unaffiliated participants (2.1%).

Analysis

A classification of alliance strategic directions was developed to group alliances into distinct categories based on a comparison of their strategies and focal activities during the AF4Q program against their anticipated strategic direction after the program ended. A primary research associate developed a table for each alliance that summarized its programmatic focus during the AF4Q program and its plans following the AF4Q initiative. A second research associate and the lead investigator reviewed each table. When information gaps were identified, additional existing data were consulted (ie, past key informant interview transcripts and alliance documents on file) to verify or clarify the table. Using a predefined set of mutually exclusive categories developed by the authors and the summary tables, the lead investigator and the primary research associate independently assigned each alliance to 1 of the 3 classification system categories and then compared their assignments. While there was agreement across the classification for nearly all of the alliances, any classification decisions that differed for the 2 team members were discussed by the full set of authors before final assignment to a category.

The quantitative analysis utilized 2 univariate statistics for 12 survey items grouped into 3 categories: (1) alliance priorities for sustainability, (2) alliance positioning for sustainability, and (3) alliance challenges to sustainability. The first univariate statistic was the top-box score,9,10 which reflected the percentage of respondents who chose either of the 2 highest scale responses for each of the items (ie, “high priority” or “essential”; “agree” or strongly agree”; and “very likely” or “completely likely”). The second univariate statistic was the coefficient of variation (CV), a standardized measure of dispersion calculated as the standard deviation divided by the mean. A larger CV indicates less agreement or consensus regarding an item. Both statistics were constructed as an overall mean across respondents from all alliances and separately for respondents from each alliance.

 
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