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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
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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,
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
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
Evaluating a Complex, Multi-Site, Community-Based Program to Improve Healthcare Quality: The Summative Research Design for the Aligning Forces for Quality Initiative
Dennis P. Scanlon, PhD; Laura J. Wolf, MSW; Jeffrey A. Alexander, PhD; Jon B. Christianson, PhD; Jessica Greene, PhD; Muriel Jean-Jacques, MD, MAPP; Megan McHugh, PhD; Yunfeng Shi, PhD; Brigitt Leitze
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

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,
Objective: The Robert Wood Johnson Foundation’s (RWJF’s) Aligning Forces for Quality (AF4Q) program was the largest privately funded, community-based quality improvement initiative to date, providing funds and technical assistance (TA) to 16 multi-stakeholder alliances located throughout the United States. This article describes the AF4Q initiative’s underlying theory of change, its evolution over time, and the key activities undertaken by alliances.

Study Design: Descriptive overview of a multi-site, community-based quality improvement initiative.

Methods: We summarized information from program documents, program meetings, observation of alliance activities, and interviews with RWJF staff, TA providers, and AF4Q alliance stakeholders.

Results: The AF4Q program was a dynamic initiative, expanding and evolving over time. The underlying theory of change was based on the notion that an aligned, multi-stakeholder approach is superior to independent siloed efforts by stakeholders. Participating alliances developed or strengthened programming to varying degrees in 5 main programmatic areas: (1) measurement and public reporting of healthcare quality, patient experience, cost, and efficiency for ambulatory physician practices and hospitals; (2) efforts to engage consumers in health, healthcare, and alliance governance (consumer
engagement); (3) adoption and spread of effective strategies to improve care delivery; (4) advancing healthcare equity; and (5) integration of alliance activities with payment reform initiatives.

Conclusion: The AF4Q initiative was an ambitious program affecting multiple leverage points in the healthcare system. AF4Q alliances were provided a similar set of expectations, and given financial support and access to substantial TA. There was considerable variation in how alliances addressed the AF4Q programmatic areas, given differences in their composition, market structure, and history.

Am J Manag Care. 2016;22:S346-S359
Proponents of using multi-stakeholder alliances and regional coalitions to coordinate efforts to improve the quality of healthcare hypothesize that the coordinated efforts of health plans, purchasers, providers, and consumers will yield better and more sustainable outcomes than activities undertaken independently.1-3 The Robert Wood Johnson Foundation’s (RWJF’s) Aligning Forces for Quality (AF4Q) initiative was based on the premise that “no single person, group, or profession can improve health and healthcare throughout a community without the support of others. AF4Q asks these critical stakeholders to work toward common, fundamental objectives that…will lead to better care.”4 AF4Q was the largest privately funded, community-based quality improvement (QI) initiative to date, with an investment of more than $300 million over the life of the project.5

In 2006, RWJF began providing grants and technical assistance (TA) to 4 alliances (multi-stakeholder partnerships in each AF4Q community), launching a program that expanded over time, and ultimately included 16 communities across the country. Funding for the alliances ended in the middle of 2015. The AF4Q alliances were either preexisting not-for-profits or established specifically for the AF4Q grant, with payer, provider, and consumer representatives. While RWJF played an active role in program strategy development and oversight (ie, site selection, development of requests for proposals [RFPs], and funding decisions), it delegated the day-to-day program implementation to a national program office (NPO).

The authors of this article (an update of a previously published article describing the background and evolution of the program through 2012)6 are a team of investigators from Penn State University, the University of Michigan, the University of Minnesota, Northwestern University, and George Washington University, contracted by RWJF to conduct an independent program evaluation. This article describes the program’s evolution and the range of AF4Q-related activities undertaken by participating alliances. Information was obtained through program document review, meeting participation (eg, AF4Q national meetings, NPO-hosted teleconferences with project directors, and alliance-hosted meetings), observation of alliance activities, and interviews with RWJF staff, TA providers, and alliance stakeholders. Readers interested in additional description about our research design and data sources may refer to an article previously published by Scanlon et al that describes the design of the formative phase of the evaluation7 and an article by Scanlon et al in this supplement which focuses on the design of the summative phase.8

We begin by describing the theory of change underlying the initiative, which we summarized graphically in a logic model. Subsequently, we discuss the evolution of the program from its inception through conclusion, covering programmatic expectations for the alliances, and the guidance and TA provided.

Theory of Change: the AF4Q Logic Model

A key step in program evaluation is to articulate the initiative’s theory of change—that is, the underlying assumptions and expectations regarding how program interventions will lead to the expected outcomes, and in what timeframe. This theory of change is often graphically depicted through a logic model, which “helps to focus an evaluation by making a program’s assumptions and expectations explicit, and increases stakeholders’ understanding about the program or initiative.”9 The Figure depicts the logic model developed by our evaluation team early in the program’s implementation with input from RWJF staff, the NPO, TA providers, and key alliance stakeholders.

As depicted on the right-hand side of the model, the objective of the AF4Q initiative was improvement in key community and population health outcomes, such as health status and quality of care received. The outcomes were broad and ambitious, and were envisioned to take time to realize. More proximate outcomes, such as increased transparency about provider quality and cost, and improved care coordination, are depicted as intermediate outcomes. The left-hand side of the Figure illustrates how the program was envisioned to achieve these outcomes. Specifically, within the community, the AF4Q initiative started with a multi-stakeholder community alliance. The alliance was responsible for establishing a leadership team and organizational structure to support program activities. Leadership was responsible for formulating the alliance’s vision and strategy within their community. To achieve this vision, the alliance developed and implemented interventions, which were activities targeted at facilitating changes in the programmatic areas germane to the AF4Q initiative. Alliances may have sponsored these activities directly, or in collaboration with other community organizations.

At a minimum, the alliances had to develop or advance efforts in 5 main programmatic areas: (1) measurement and public reporting of healthcare quality, patient experience, cost, and efficiency for ambulatory physician practices and hospitals; (2) efforts to engage consumers in their health, healthcare, and alliance governance (consumer engagement); (3) the adoption and spread of strategies to improve care delivery; (4) advancing healthcare equity; and (5) integration of alliance activities with payment reform initiatives. In addition to aligning stakeholders around a common vision, the AF4Q initiative targeted alignment of programmatic areas, depicted by connectors in the interventions box.

Across the top of the Figure, we indicated that RWJF provided TA through multiple organizations or individuals with expertise in key programmatic areas to assist the alliances in strategy development and implementation. The model also reflects that the alliances varied significantly in terms of history and market structure and were influenced by factors in the external environment not directly related to the AF4Q initiative. Because RWJF’s objective was to sustain the alliances’ activities beyond the conclusion of the grants in 2015, an important long-term program goal was to build collaborative capacity within the community. This could be accomplished through continuation of the alliance or through alternative models, such as continuation of programmatic activities by others in the community. Finally, as noted on the bottom of the Figure, the alliances’ activities and the impact of the AF4Q initiative were expected to evolve over a period of time, with necessary adjustments based on feedback from experiences in program implementation.

While the logic model provides a succinct view of the overall program, it was not sufficiently detailed to guide our evaluation. Accordingly, our team also developed individual models for 4 of the programmatic areas. These programmatic logic models are available in a previously published online eAppendix.10

Evolution of the AF4Q Initiative

Under the AF4Q initiative, RWJF provided funding and TA to participants; in turn, the alliances were expected to meet specified goals and objectives. While the program’s initial scope was substantial, it expanded through enhancements to existing programmatic areas and the addition of new ones. RWJF made a significant commitment to the provision of TA, investing more than $25 million in TA over the course of the program (see the Table for a list of select TA providers contracted by the NPO).11 In this section, we describe the evolution of the initiative, including the scope, goals, expectations, and TA offerings.

Phase I (July 2006-April 2008)

The overarching goal of the initiative’s first phase was to help communities substantially improve the quality of healthcare provided in ambulatory care settings for persons with chronic diseases. Phase I targeted 3 programmatic areas believed to be key drivers of quality (depicted in the interventions box of the logic model): (1) performance measurement and public reporting of performance data; (2) QI in primary care physician practices; and (3) consumer engagement. RWJF chose to invite 4 communities with a history of stakeholder collaboration on healthcare quality—Detroit, Michigan; Memphis, Tennessee; Minnesota; and Puget Sound, Washington (which expanded to the state of Washington)—to serve as the initial communities for the program. Funding began in July 2006, and the Center for Health Improvement (Sacramento, California) was selected as the NPO. An additional 10 communities (Cincinnati, Ohio; Cleveland, Ohio; Humboldt County, California; Kansas City, Missouri/Kansas; Maine; south central Pennsylvania; West Michigan; Western New York; Willamette Valley, Oregon [which expanded to the state of Oregon]; and Wisconsin) were added in February 2007 through a competitive grant process. Short overviews of each alliance, which include information on their founding organizational structure, date of entry into the AF4Q program, descriptions of their focus as of spring 2016, and geographic scope, can be found in eAppendix A.

Alliances were to publicly report ambulatory care performance information for the community’s primary care providers within 3 years, using local multi-payer data and nationally endorsed quality measures. They were given a broad goal for consumer engagement, which was to get consumers to “create an overall demand for high-quality care, in their choice of provider and health plan, in their choice of treatment options, as advocates for change, and in managing their own health conditions.” Rather than offering a specific model for consumer engagement, RWJF chose to encourage the alliances to innovate and “let a thousand flowers bloom.” In addition, the alliances were required to have “substantial and credible consumer representation” on their leadership teams.12 While RWJF identified QI as a core component of the initiative, no formal requirements were established in this phase. However, alliances were encouraged to engage in activities associated with patient-centered medical homes (PCMHs) and other ambulatory QI programs.

 
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