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Barriers and Strategies to Align Stakeholders in Healthcare Alliances

Supplements and Featured PublicationsThe Aligning Forces for Quality Initiative: Early Lessons From Efforts to Improve Healthcare Quality
Volume 18
Issue 6 Suppl

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) Introduction

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.

Presented next are the key findings of this analysis, organized by the 4 domains. Our primary interest was the factors that distinguished more highly aligned alliances from less highly aligned alliances; however, we also describe factors that more generally facilitated or impeded alignment.


Market Context

Credibility. Alliance credibility was an important factor differentiating more highly aligned alliances from less highly aligned alliances. In more highly aligned alliances, credibility helped alliances more easily establish themselves as neutral forums where stakeholder self-interest could be held (more) in check, which was important for recruiting and sustaining participation from stakeholders who were often competitors outside the alliance. For the more highly aligned alliances, this credibility originated from 2 primary sources: (1) the credibility of the constituent organizations and (2) the credibility of the alliance leaders. Informants often noted how the sponsoring organizations were respected in the community, which helped bring attention to the alliance and garner support for its goals. In one case, for example, the alliance was grafted onto an existing organization with a positive reputation and track record in the community; thus, the alliance was endowed with a certain level of credibility just by association. As described by one informant, “…I would say that they’re [the existing organization] as well positioned as anyone to do it…it’s a fairly new effort within the last 3 years, but has done very well in getting itself stabilized, becoming a part of the community and a well-accepted part of it. That, and I think, given that track record of being able to quickly establish us as a reputable organization, they’re as well positioned as anyone is to sort of pull off this collaborative, alliance type of effort.” Informants from more highly aligned alliances also frequently noted the importance of leadership credibility. In particular, a nucleus of long-tenured, well-respected leaders in a community was important for establishing alliance credibility because these individuals often brought to the table longstanding, productive working relationships that could imbue the alliance with a sense of credibility. In contrast, less highly aligned alliances experienced threats to established credibility, such as significant changes in programmatic needs issues that were raising important governance and strategic challenges, or had yet to establish credibility in the community, as described by one informant commenting on the availability and use of public reports: “Well, I think to make the biggest impact, the audience has to have the confidence in the organization that is releasing that information. So I think, as I said before, there’s been discounting of information that’s released [and that] leaves the consumer confused. Is there a role for [the alliance] to be that organization that releases that information?…I think that could happen…I said to [the alliance executive director], ‘We need at some point, when we’re ready and when we have the clout behind us and the credibility behind us, to have a meeting with the media and say, if you want some definitive review of information that’s coming out over your wire services or locally, that you could use the [alliance] as a clearing house to either support what’s being presented to you or discounted or debated.’”

Walking the Competition-Collaboration Tightrope. A fundamental challenge for alliances, and one that seems to differentiate more highly aligned alliances from less highly aligned alliances, is finding a balance between collaboration and competition. In particular, informants from less highly aligned alliances noted that a significant barrier to alignment was a concern among stakeholders that the goals of the alliance were not aligned with the goals of their own organizations, and that the work of the alliance could hurt their competitive position vis-à-vis their competitors or significantly threaten how they were currently structured to do business. For example, a healthcare insurer representative from a less highly aligned alliance expressed concerns about how the alliance might provide a venue for providers, employers and other purchasers, and consumers to work together directly and thereby threaten the health plan’s intermediary role between these different stakeholders. As a result, stakeholders were more reluctant to commit to alliance programs, summed up by an informant describing the ambivalent participation of one group of stakeholders: “Then it’s can we [the stakeholder organization] support them [the alliance] and do what they want and not cross all these other projects that we’ve engaged in? Where are we going to be in conflict and where are we not going to be in conflict?” By way of contrast, an informant from a more highly aligned alliance noted that “…organizations have generally had some willingness to be able to think about not just their more parochial type of mission, but also how does their mission fit into a broader mission. So I guess my sense that the organizations themselves, while they have their own agendas and are generally organized to do one thing, I think that traditionally they’ve shown some willingness to also think beyond what their specific charter is,…giving up pieces for a greater good.”

History/experience with collaboration. Another factor that differentiated more highly aligned alliances from less highly aligned alliances was a history of collaboration between stakeholder groups (eg, insurers, employers and other purchasers). More highly aligned alliances tended to have a more extensive history of collaboration, especially across stakeholder groups, within and outside the formal boundaries of the alliance. This history was important for providing a precedent or template for how stakeholders could work together. Leveraging these historical experiences was particularly important for moving beyond typical start-up issues such as the structure of the organization or who should participate, to more goal-oriented issues such as the most appropriate goals for the organization and work processes needed to achieve those goals. As noted by one informant from a more highly aligned alliance when discussing the value of the alliance: “…I think it’s aligning those organizations and because we have a history of all these things—we also have a history of working together here so some of the bumps and bruises and turf, I think, have already been worked out…I think there’s a willingness and an interest to align, and I think what alignment means here for us is just really trying to figure out what that common agenda is, what are those objectives, and what are we going to work on in common and getting agreement on that.”

In contrast, less highly aligned alliances either lacked a strong history of collaboration or these historical collaborations were predominantly within stakeholder groups. As noted by some informants, previous collaborative efforts that were more stakeholder group—centric sometimes resulted in these stakeholders bringing well-established norms and assumptions to the alliance, which could slow the engagement and participation of other stakeholder types. Likewise, stakeholder group–centric relationships and activities often reinforced the siloed nature of stakeholders in a community, resulting in overlapping healthcare activities and a failure to understand the opportunities that existed to work together, summed up by an informant from a less highly aligned alliance: “So the people were not connecting the dots. And I don’t think they do it naturally because that’s not their day job. They’re really overwhelmed. So I think you need someone that can kind of step back and kind of listen and look and see what the opportunities are in the community.”

Similarly, a lack of cohesion within stakeholder groups was another alignment challenge confronted by less highly aligned alliances. The physician community, in particular, was highly fragmented, with a large number of practices of different sizes and in a diverse range of settings. Furthermore, in the less highly aligned alliances, the physician constituency often lacked the organization and leadership that was critical for communicating with this stakeholder group and fostering their commitment to the alliance. As described by an informant from a less highly aligned alliance: “You have to understand that [the alliance market] historically is a very balkanized place for the physician community. Compared with the rest of the nation, you have relatively few clusters of physician groups and so it’s largely a divided, cottage-type industry…if you want to talk to the health systems you talk to 7 people. If you want to talk to the physicians, you might have to talk to 2000 or 3000.” As frontline providers of care, an inability to effectively and efficiently reach this group of stakeholders was seen as a significant barrier to moving forward with alliance activities.

Alliance Structure and Governance

Decision-making structure. Nearly all of the alliances relied upon a small, core group of members as a primary decision-making body. What differentiated more highly aligned alliances from less highly aligned alliances, however, was whether the use of such a small group was a facilitator or barrier to aligning stakeholder efforts. In the case of more highly aligned alliances, the use of a small, core group of members was perceived as helpful in more easily reaching consensus on decisions and moving programs forward. For these alliances, smaller groups fostered more frequent, richer interactions with one another and enabled them to develop a familiarity with, and trust in, one another that allowed decisions and commitments to be made.

In contrast, in the case of less highly aligned alliances, smaller groups were often perceived as unrepresentative and in some cases created the perception of a 2-tier status among stakeholders, as summed up by one informant: “Well, I think there were 6 or 7 of the larger groups that initially started the project, and I think that they’ve had a little higher status. And, in part because they had the vision to move this agenda forward and others have come on board. I mean from a membership perspective, there’s sort of a dues structure there. Sort of everyone’s equal, but even in the bylaws, there were some issues about who could participate on the executive committee and who can move up into leadership. They’re being discussed. They’re not being swept under the table. But there are issues.” The perception of such status differences represented a significant challenge to an alliance’s ability to reach consensus on decisions and foster commitment from all stakeholders once these decisions were made.

Approaches for building consensus on and commitment to alliance goals and strategies. Nearly all alliances were facing similar challenges of transitioning from a broad-based vision of what the alliance should be to more focused, concrete strategies of how to realize that vision. Most alliances engaged in considerable debate and experienced some degree of disagreement regarding the most appropriate strategies needed to accomplish the alliance’s goals, who should implement those strategies, and how they should be implemented. Where more highly aligned alliances tended to differ from less highly aligned alliances was in their approach to bringing about agreement on these strategies. In particular, less highly aligned alliances tended to adopt a more passive, wait-and-see approach to fostering consensus among stakeholders. In these alliances, stakeholders tended to believe that, over time, increased interaction and greater familiarity would result in improvements in cooperation among stakeholders and collaborative work toward alliance goals and strategies. Also, time was viewed as the antidote for counteracting the mistrust and skepticism that often clouded relationships between traditionally competitive stakeholders. In contrast, more highly aligned alliances took a more active approach, actively communicating with stakeholders to educate them about the alliance, its goals, strategies, and how these activities would (or would not) affect the stakeholders.


In contrast to the market context and alliance structure domains, the interviews did not indicate differences between more highly aligned and less highly aligned alliances with respect to leadership and its relationship with alignment. However, 2 leadership themes emerged as important, consistent facilitators of alignment: credibility and stability.

Leadership credibility. The credibility of alliance leaders was a factor commonly associated with stakeholder alignment. Leadership credibility and reputation were especially important early on in the life of the alliance because they helped provide alliances more generally with credibility and helped generate participation among stakeholders. Another common theme, and one closely tied to an alliance leader’s credibility, was his/her style of leadership. Most informants believed that fair and balanced leadership was essential for cultivating commitment from stakeholders, building consensus on important decisions, and sustaining participation during difficult times. This belief was summed up by a respondent who stated “…it is amazing what the right person in the right position can do and [the alliance director] is not only just so highly respected from all his work and he has always been involved on the purchasers’ side but has always tried to work with the hospital systems…Also, his style is very thoughtful and non-threatening and…in something that can be so contentious such as this kind of collaboration, I think having the right person in a leadership role can just be huge to what you can accomplish.”

Leadership stability. Another factor commonly associated with stakeholder alignment was leadership stability. Informants generally believed that stable, consistent leadership was important for building trust and commitment from members and maintaining momentum on alliance initiatives. An interesting caveat to leadership stability was a sense that transitions in leadership within stakeholder organizations could present an opportunity for alliances. For example, informants from one alliance where several major stakeholder organizations were undergoing leadership changes believed that these changes might help unfreeze traditional organizational mind-sets that have impeded collaborative efforts among different stakeholders in the past. This opportunity was summed up by one informant who stated: “So we had 3 major organizations with new leadership…organizations who are trying to think differently about how they are trying to approach this, so on the one hand, I don’t think we have really entrenched organizations that won’t do anything… And so we have an opportunity, I think there is interest in doing things differently and these organizations can change.”

Alliance Climate

Similar to the leadership domain, no themes emerged as salient differentiators between more highly aligned and less highly aligned alliances. Instead, informants commonly identified trust as an important aspect of an alliance’s climate for promoting alignment. Trust was especially important in bridging governance and structural gaps that were present in the early stages of the alliance. More precisely, trust between individuals helped stakeholders look beyond unequal contributions, influence, and participation that may have made the alliance seem less than neutral, as summed up by one informant: “You know, it’s [the alliance] probably not perceived as neutral—we try to be, but I think what makes some of these alliances work best is when everybody knows what the others’ interests are. So we clearly have a bias toward making information public, and that’s what it’s about. Other people sit at the table and that’s not their thing, there are other things that we align with. So it’s probably, I think, more important—it’s the trust level. We have a certain level of trust right now in the market and sort of momentum that people can get behind.”

Although trust was described as an essential ingredient for aligning stakeholders, the factors that contribute to trust (described above) were not equally distributed across alliances. In particular, informants noted that trust is often facilitated by previous collaborative work and long-standing personal relationships, which were more prevalent in more highly aligned alliances. Likewise, informants also noted that the residue of historically competitive or contentious relationships still lingered in the markets served by the less highly aligned alliances, tempering the positive effects of trust.


The findings of this study highlight several different approaches to fostering alignment, with varying levels of success, which have a number of implications for alliance leaders and advocates who view alliances as a means of overcoming many of the shortcomings in the existing healthcare delivery system. First, market context emerged as one of the most important general factors distinguishing more highly aligned alliances from less highly aligned alliances. This finding and the market context themes more generally (credibility, collaboration-competition balance, market composition) highlight the permeability that exists between an alliance and its surroundings, and the reality that alliances seldom begin as a clean slate but rather build upon the historical relationships between stakeholders and their respective leaders. These relationships typically have both positive and negative qualities and one important differentiator of alliances seems to be an ability to leverage the positive qualities while limiting the impact of negative qualities.

While this finding calls attention to the broader market context that often extends beyond formal boundaries and temporal origins of an alliance, context, by definition, is typically unique to a particular market. Therefore, a prescribed model or best practice for dealing with these unique contextual features is likely to be elusive and possibly even counterproductive to promoting an alliance’s objectives. Instead, it may be more useful for alliance leaders to have a keen awareness of an alliance’s context—past, present, and projected future—that can be used to develop customized approaches to leverage the positive while mitigating the negative aspects of the relationships that constitute the background for an alliance’s activities. Likewise, advocates such as funders and policy makers may be able to help promote alignment by flexibly designing programs that allow for, or even encourage, alliances to account for their unique contexts. For instance, funding for the alliances participating in the AF4Q initiative supported the use of existing organizational structures (eg, preexisting alliances, sponsoring organization) or the development of a new alliance. The decision between these different approaches often relied upon local, contextualized knowledge about which one presented the best opportunity to pursue the goals of the AF4Q initiative.

Second, within the alliances, what seemed to differentiate more highly aligned from less highly aligned alliances were not necessarily the types of challenges they confronted, but rather their approaches to overcoming these challenges. For example, all alliances were challenged to find ways to achieve consensus on decisions in ways that build commitment to programmatic activities without disenfranchising stakeholders. Where the alliances differed was in their perspective on how consensus would emerge, with more highly aligned alliances taking a more active approach, and less highly aligned alliances taking a more passive approach. One potential explanation for this difference is because many stakeholders participate voluntarily, in addition to their responsibilities to their employer/home organization. Therefore, their role in the alliance may be their second, third, or fourth priority. Under these conditions, more passive approaches may fail to reach these stakeholders with the information needed to decide, commit, and act, while more active approaches may counteract this shortcoming. Such an explanation is consistent with other research that argues active participation is the lifeblood of an alliance and that a critical alliance management activity is promoting participation among a wide range of stakeholders.14-16

Similarly, our findings also highlight several factors that may be more universal in their ability to promote alignment. In particular, leadership credibility and stability were important factors for cultivating commitment from, and consensus among, disparate stakeholders, both of which are building blocks of alignment among stakeholders. Trust among stakeholders was also identified as a common facilitator of stakeholder alignment. One potential explanation for why these factors are so important, regardless of the level of alignment in an alliance, is again related to the unique design of these organizations. Specifically, the voluntary, nonhierarchical nature of alliances, the low barriers to exit, and the rather fluid informal structures and processes, mean that participation may be more of a leap of faith than a calculated risk based on some cost-benefit analysis. Under these circumstances, intangibles such as credibility and trust may be the best indicators of whether participants decide to invest their time and effort in the alliance.

More generally, our findings with respect to leadership, trust, and decision-making approaches highlight the importance of alliance processes and the need for alliance leaders to attend to such processes when trying to align stakeholders. Unfortunately, more attention is often devoted to how to structure the work of the alliance, especially in the early stages of development, while process-related aspects may be overlooked or their impact underestimated.8 While arguably less tangible than structural characteristics (eg, bylaws, organizational charts), our findings suggest that attention to alliance processes, by both alliance leaders and advocates, is an important factor to consider when trying to promote stakeholder alignment. Similarly, future research may want to focus more explicitly on alliance processes to consider questions such as what alliance processes are most important for promoting alignment, whether these processes vary across alliances, and how these variations may affect alignment.

Finally, it is worth noting that, although we presented our results based on domains or groups of factors (eg, market context, alliance climate), they were not mutually exclusive, and these factors intersected and overlapped in a multitude of ways to promote and hinder stakeholder alignment. For example, we found that trust is a common facilitator of alignment among alliances, yet the factors that contribute to the presence of trust vary considerably across alliances as a function of the market context. Such intersections suggest that these factors interact in their contribution to stakeholder alignment. That is, the influence of some alliance attributes on stakeholder alignment may be strengthened (or attenuated) by the presence or absence of other factors. For example, our results suggested that trust tended to play a complementary role to leadership credibility and stability. Whereas leadership credibility and stability often directly contributed to alignment by fostering commitment and consensus and sustaining participation, trust tended to play a more indirect, supporting role by enabling alliances to work together, even in the absence of factors believed to be important for cultivating alignment (eg, formalized governance structures, equal voice, and influence). Such findings suggest that these 2 factors may be most effective at promoting alignment when they are present together. Additional research, however, is needed to examine whether this is the case and which intersections hold the most promise for fostering alignment.

The findings described above should be interpreted in light of several considerations. First, the study examined these relationships in 6 alliances that were selected to maximize variation in alignment. While we believe these alliances were illustrative in highlighting important issues related to alignment, future research may want to explore if, and to what extent, alliances at different points on the alignment continuum share these same issues. Second, the alliances in our study were all relatively new participants in the AF4Q initiative, with many activities still in the early stages of development. Therefore, future research may want to consider whether these findings vary between alliances in different developmental stages or life cycles. Similarly, program expectations have evolved over time; thus, the degree of alignment achieved, and the factors associated with alignment, may have evolved over time as well. Future research is needed to longitudinally study these relationships and evaluate how they change over time.


A fundamental premise of the AF4Q initiative is that community-wide improvements in health and healthcare can be best achieved when the efforts of a diverse range of stakeholders are aligned. Alignment in an alliance context is believed to be 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 of this study highlight the need for multifaceted approaches to promote stakeholder alignment, a need born out of a complex intermingling of alliance characteristics (eg, structure, member composition) and the contextual milieus within which these alliances operate.

Author affiliations: Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, MI (JAA); Jeff Beich Consulting, Grand Island, NY, and Penn State University, University Park, PA (JB); Health Services Administration, University of Alabama at Birmingham, Birmingham, AL (LRH); Department of Health Policy and Administration, Penn State University, University Park, PA (JNM, JLO).

Funding source: This supplement was supported by the Robert Wood Johnson Foundation (RWJF). The Aligning Forces for Quality evaluation is funded by a grant from the RWJF.

Author disclosures: Drs Alexander, Beich, Hearld, and Mittler and Ms O’Hora report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship information: Concept and design (JAA, JB, LRH, JNM, JLO); acquisition of data (JAA, JB, JNM); analysis and interpretation of data (JAA, JB, LRH, JNM, JLO); drafting of the manuscript (JAA, LRH); critical revision of the manuscript for important intellectual content (JAA, JB, LRH, JNM, JLO); statistical analysis (LRH); and supervision (LRH).

Address correspondence to: Larry R. Hearld, PhD, University of Alabama at Birmingham, 3201 1st Avenue N, Birmingham, AL 35222. E-mail: lhearld@uab.edu.

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