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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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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,
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Letter From Donald M. Berwick, MD, MPP, Guest Editor
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Letter From Donald M. Berwick, MD, MPP, Guest Editor

Donald M. Berwick, MD, MPP
Donald M. Berwick, MD, MPP

President Emeritus and Senior Fellow
Institute for Healthcare Improvement
Cambridge, MA

 
Dear Colleague:

The healthcare philanthropy of the Robert Wood Johnson Foundation (RWJF) has a distinguished history of disrupting conventional thinking. Its Clinical Scholars program added whole new disciplines to healthcare leadership, at first unfamiliar and even unwelcome. Its longstanding investments in highlighting and reducing healthcare disparities, advancing prevention, and encouraging bold quality improvements have prodded the nation’s conscience. Following up on the Institute of Medicine’s (IOM’s) seminal report, Crossing the Quality Chasm: A New Health System for the 21st Century,1 RWJF supported a stunningly ambitious attempt to foster real models of systemic healthcare improvement—a program called “Pursuing Perfection,” which I was privileged to help direct and had an aim nothing short of its title.

The Aligning Forces for Quality (AF4Q) initiative was entirely in that tradition of disruption. From the moment I first heard the notion, I thought that it represented the best of social investment and the wisest of risks. The title clearly pointed a finger at what I had come to believe, and still believe, to be the most important barrier in America—and, frankly, most of the developed world—to the pursuit of truly effective total systems of healthcare: misalignment.

It would not be hard for any thoughtful observer to describe the attributes of an ideal healthcare system. For example, sick or well, we hope for care that is coordinated, seamless, responsive to each individual on his or her own terms, enriched by relevant community resources, continually improving, scientifically reliable, and transparent. We might even suspect (as I do) that care of such high quality would be far less costly than uncoordinated, sluggishly responsive, isolated, self-satisfied care.

Let me say a word more about the idea of “alignment,” and why I think it is so important. Around 2001, in the context of my membership on the IOM committee that wrote Crossing the Quality Chasm, I created the diagram shown in the Figure,2 which I labeled “The Chain of Effect in Improving Healthcare.” I intended it to be a systems diagram, showing 4 layers (or tiers) of systems, which interact and affect each other. They include: (1) a system of “Aims,” comprising the experiences wanted by and for the people served (in effect, the “Triple Aim”); (2) the “microsystems,” or small units of production that attempt to meet those needs (eg, an emergency department, surgery suite, or doctor’s office); (3) the organizations that house collections of such microsystems; and (4) the environment that sets the context in which those organizations and microsystems operate (eg, payment, regulation, professional education, and licensure).

Conceptually, these 4 tiers, or systems, ought to—need to—be cognizant of, and coordinated with, each other for the purpose of meeting needs. The microsystem helps the patient; the organization helps the microsystem; the environment helps the organization. That, to me, is “alignment,” and it is crucial to notice the direction of “flow” of service and support. The duty of the environment is to meet the needs of the organization, and not the other way around.

Healthcare today has this wrong, in 2 ways. First, for the most part, those 4 nested systems tick away as if they are independent of each other, accountable only to themselves, perfecting themselves and not their interdependency. For example, policy makers often do not seem to understand the actual circumstances of clinical encounters, and physicians often seem naïve about organizations. Further, when these systems are not cognizant of each other, the “flow” of influence is backward from the viewpoint of improvement: organizations spend their time complying with the environment, and microsystems spend their time complying with their parent organizations. The patient—the need—gets less attention; indeed, patients are sometimes left out entirely. The result is “misalignment,” in which energies get squandered in managing upward, or in separate islands of effort.



 
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