As described elsewhere in this edition by Weiss et al,1 the creation of the Aligning Forces for Quality (AF4Q) program was one of the most significant investment decisions made to date by the Robert Wood Johnson Foundation (RWJF). Recognizing that this would be a highly complicated undertaking, from the outset, the RWJF sought the assistance of a National Program Office (NPO) whose role it would be to take the lead on managing the program day to day, and serving as the primary interface between the community-based grantees and RWJF. This piece is intended to reflect our perspectives as managers of the NPO for most of the program’s existence. (Dr Siegel served as the NPO Director from 2008 through 2010, and Dr Graham from 2011 through 2015; Ms Browne was the Deputy Director from 2008 through 2015.) In our comments to follow, we will focus on the creation and function of the NPO as the key operational element of AF4Q, and comment on the lessons we have gleaned from this experience. (Commentary based on a program with a similar structure has been previously published by Brown .2)
The AF4Q program faced several challenges from the outset. An ambitious program, AF4Q’s initial focus on public reporting of ambulatory performance data in 4 communities was expanded to include a greater focus on additional settings (eg, hospitals), and larger efforts to help patients use this data and providers meet higher performance expectations across 16 communities by program end. Through a planning process involving qualitative research at George Washington University’s Department of Health Policy together with input from RWJF, AF4Q was eventually conceptualized as encompassing 4 major domains: public reporting of performance data, engagement of consumers in using that data to better inform their decision making and healthcare choices; quality improvement by the providers of healthcare; and payment reform to reflect the value, and not the volume, of care.
Work in these areas would be performed by each AF4Q regional alliance, assisted by a set of national technical assistance (TA) providers designed to bolster their expertise, and with a clear set of national expectations set by RWJF. The NPO was to deliver and coordinate content expertise in these areas to the regional alliances; however, in some cases that expertise developed “in-house,” while in other cases it made sense to acquire this expertise through external contractual relationships. The NPO also helped set and monitor clear expectations of the alliances as grantees of RWJF, while also helping the alliances communicate with each other and RWJF.
Each of the 16 communities was unique and each alliance had its own history and set of priorities. While some were more mature entities with stable funding, an existing business model, and a track record of working across organizations and sectors, others were nascent organizations for which AF4Q represented a sizeable infusion of new but temporary resources. Their preexisting priorities also created quandaries. An alliance, with roots in bringing hospitals and doctors together around improvement, often found it difficult to develop the stakeholder will to publish performance data. Similarly, alliances with roots in the consumer and purchaser worlds were suddenly faced with clear expectations of developing an infrastructure to spur and support local provider quality improvement.
The changing landscape of the US healthcare system, itself, created unanticipated challenges and confounding factors: The AF4Q program saw the passage and implementation of major healthcare legislation, including the Medicare Improvements for Patients and Providers Act and the Affordable Care Act, which changed expectations and priorities. The “rules of the road” suddenly, and dramatically, shifted. Meanwhile, other trends such as the growth of many forms of data reporting from sources, as diverse as Consumer Reports and Yelp, continued unabated. The NPO had to manage a cadre of very different alliances under fairly uniform expectations in a fluid and dynamic landscape.
The NPO was structured into 3 teams: communications, administration/finance, and—at its center—a regional support team charged with being the day-to-day contact with the alliances. The regional support team interfaced directly with the alliances and served the mixed roles of coach, communicator, and sometimes, enforcer, with each alliance. They served to match alliances with sources of expertise and TA under contract to the NPO in program focus areas such as consumer engagement or broader capacity-building needs, such as leadership development and sustainability. Initially, the NPO also contained considerable in-house expertise in areas of quality improvement and equity. Additional resources in communications, program expectations, and contract administration were required, given the need to communicate learning between the alliances, achieve measureable progress, and manage a stable of upwards of 20 organizations that provided TA and consulting. Thus, the NPO had many roles, and the tension between some of those roles (eg, coach and enforcer) could be considerable.
The Conceptual Approach
RWJF recognized that impacting the healthcare system necessitated a “place-based” approach, and that working with only 1 stakeholder group (be it hospitals, health plans, or employers) wasn’t sufficient. Driving real and lasting change would require a new approach: working across sectors by bringing together employers, consumer advocacy organizations/consumers, health plans, hospitals, and physicians. As originally conceptualized, AF4Q was an early experiment in collective impact. (Collective impact initiatives typically have 5 conditions that, together, produce true alignment and lead to powerful results: a common agenda, shared measurement systems, mutually reinforcing activities, continuous communication, and backbone support organizations. Additional information is available at the Stanford Social Innovation Review website.3) However, in AF4Q, specific goals or outcomes were not precisely defined; this reflected the fact that the healthcare landscape is unique in each market (ie, “all healthcare is local”) and that it is constantly evolving, especially given the scope and pace of changes in federal and state legislation and regulation. As independent forums within a community, alliances served unique roles including: (1) coordinating and aligning varied health improvement activities; (2) measuring and reporting the performance of the region’s healthcare providers; (3) helping healthcare professionals improve care delivery; (4) facilitating payment and delivery system reforms; and (5) educating and engaging consumers regarding their care.
Even when a community’s stakeholders agreed, in principle, that a particular strategy should be pursued, for example, public reporting of ambulatory performance information, no single entity had the authority to impose it on others. The stakeholders had to voluntarily define and operationalize the strategy. Funding this sort of work (complex versus simple philanthropy) is an exercise more in adaptive leadership than deploying an existing, known solution. The goals of AF4Q couldn’t be achieved by providing additional TA, know-how, or consultants to grantees. It took building political will, first and foremost. Complex solutions are messy, individualized, and dynamic, and therefore, it’s people on the ground who will make or break the effort. In AF4Q, we observed that the most effective communities had leaders who were able to perceive changes, threats, and opportunities and to orchestrate—subtly, but with surety and conviction—the activities and commitments of key players to achieve a larger goal or outcome. They created enough healthy tension to keep progress and momentum going, but not enough to tear apart a fragile coalition.
The NPO saw a strong correlation between performance/impact and robust personnel/talent (both leadership and management). In short, people will make or break the success of the initiative. Leaders will define the pace, scope, and scale of change or improvement that’s being sought. While there is a body of research that speaks to network design and alliance building, it’s important to note that because the AF4Q alliances are focused on driving improvements in the healthcare sector, they must balance the inherent tensions both across competitors (health system vs health system), but also recognize that the pool of healthcare dollars is limited and will need to get reallocated; the status quo is unsustainable; and that people’s lives, health, professions, and economic well-being are on the line. Driving improved quality of care, reducing cost, and transforming the healthcare system into one that is patient-centered means driving forward a profound, even revolutionary concept. Indeed, sometimes the many members of these coalitions were interested in slowing or diminishing the scope or the pace of change; they were often keenly interested in defending the status quo.
Maximizing Program Effectiveness and Long-Term Impact
All organizations interested in driving social change (ie, foundations, public sector, non-profits, etc) have a vested interest in seeing their programs brought to fruition effectively and efficiently, thereby having the highest impact possible given the dedicated resources. Thus, leadership, organizational capacity, ability to execute, and sustainability of the organization and/or the program goals often play an integral role in program design considerations. Recognizing that health system transformation is an iterative process; an essential component of the AF4Q work was to identify alternative funding sources and opportunities for revenue generation, to ensure the innovative work occurring in each community continues after AF4Q grant funding ends. (Additional information regarding AF4Q sustainability efforts is available on the AF4Q website.4)
Throughout the project, all alliances were working to improve the quality and value of healthcare; however, their approaches and execution varied according to organizational characteristics, market composition, available data, agenda-setting choices by alliance staff and stakeholders, and local needs. The ongoing impact of AF4Q and the ability to further AF4Q goals will be dependent, in some part, on how well alliances demonstrated, produced, and articulated tangible value to stakeholders—physicians, hospitals, health plans, consumers, purchasers, and employers. Building alliance and community capacity, knowledge, and skills to sustain the work of AF4Q had been an ongoing priority from the beginning of the project. At the end of an 8-year journey, each of the 16 alliances is at a different point on the path toward sustainability. While many struggle to balance the day-to-day activities defining their organizations with the foundational work required to sustain system transformation beyond the AF4Q grant’s conclusion, many have developed a solid foundation from which to springboard the next evolution of work.
Assessing the extent to which alliances had organizational/community capacity, a deep bench of talent, functioning structure, and resilience in a fast-paced environment came late in the life cycle of the program. While the grant reapplication process required that communities submit a sustainability plan, these plans didn’t provide robust detail or realistic financial projections, and many alliances struggled to articulate the program’s value in economic terms to different stakeholders.
A focused business strategy is only as good as an organization’s ability to execute it. Capacity was a leading concern across the alliances. There was a consistent need for more time and resources. This is a common challenge in the social sector, but it can be particularly hard within the collaborative context, when accountability and ownership can be unclear. To achieve sustainability and adapt to change, collaboratives must plan to work with and continually build the right talent, including leadership, stakeholders, board, and staff.
Measuring and reporting the quality of care that doctors and hospitals deliver is a cornerstone of regional healthcare improvement. To do this, alliances collected and aggregated data from multiple sources for use in public reporting, quality improvement, and payment reform. Alliances were formed around this portfolio of work with the understanding that stakeholders—consumers, providers, plans, and employers—need access to uniform, actionable data in order to affect change. However, data alone are not valuable. Many alliances created value by aggregating data across payers and systems, and analyzing the data to facilitate quality improvement and payment reform strategies.
Improving healthcare quality and value requires targeted clinical quality improvements and transformative change to delivery and payment systems. Alliances supported providers in these activities through knowledge transfer and use of their rich data sets. Knowledge transfer activities included leading learning collaboratives, exchanging best practices, facilitating agreement on new models of care delivery, piloting new models, and spreading successful ones. Establishing or augmenting the capacity to conduct ongoing and meaningful quality improvement in a region is a complex undertaking. Financial resources and staff must be dedicated and quality improvement viewed as 1 of the core functions within a community. AF4Q alliances varied in whether they directly provided such capacity or relied on partners to do so.
Throughout AF4Q, many alliances subsidized the cost of providing quality improvement services to healthcare providers using grant funding. Alliances are now faced with the challenge of transitioning services formerly provided at no charge to a fee-based business model. Several alliances developed capacity to create a line of business around the provision of quality improvement services to healthcare providers. While not yet fully sustainable, ultimately, they hope that providing quality improvement services could eventually provide an income stream that contributes to sustainability.
The alliances that were best positioned to sustain their impact were those with leaders who had a strong vision, a clear understanding of the impact they needed to make in the community, and the team with the right skills and competencies to support the alliances’ most valuable programs and services. To ensure that this investment in talent is a direct investment in impact, it is critical to have a deep understanding of the skills and competencies the team needs to deliver the programs and services that benefit the community, as well as create revenue streams for the alliance.
Parting Thoughts and Lessons Learned
Looking back over our experience with AF4Q, we would offer the following “Top 5” lessons to be kept in mind by those who want to drive system change at a community or regional level in the future:
1. Although each community may have similar broad goals and objectives, no 2 communities will have the same operational assets or challenges. As “backbone” organizations in their own markets, they will face a different mix of constituents, stakeholders, and political frameworks. Funder, program offices, and intermediaries must be sensitive to these differing circumstances, recognizing that each site may need to accomplish its goals in a unique way, and according to differing timelines. This has implications for site selection and program design—for example, what is the level of flexibility funders will allow for communities to define their own specific goals, strategies, and tactics?
2. Providing TA to multi-stakeholder collaborative efforts is a powerful lever that funders can utilize to drive the pace of change and attain programmatic goals; however, TA is not a silver bullet nor a quick fix. Given the differing environments in which the AF4Q project sites operated, and communities’ differing needs and capacity, TA must be able to be customized and adapted in terms of the content, timeline, and the approach. Funders and intermediaries can play an important role in ensuring the TA provider embraces the philosophy that, indeed, one size doesn’t fit all. Piecing together a cadre of different consultants, researchers, and experts (ie, effectively outsourcing the provision of TA) allows an organization to flex contracts and intensity of interactions with grantees based on their needs; however, it will also necessitate the dedication of significant time and energy to coordinate these individuals/organizations, as well as capture and synthesize their experiences working with the communities and the collective lessons learned.
3. At some point in the project, the communities themselves will develop significant expertise in their own right. They are on the ground every day, and will develop insights and expertise in problem identification and solving that exceed that of the NPO staff and TA providers. The NPO needs to be sensitive to this inflection point and provide additional opportunities for the local project directors and staff to meet, learn from, and assist one another. Ultimately, this will contribute to communities being able to sustain their efforts. In this respect, private and public sector funders can be viewed as incubators for social change and talent development.
4. Times change, and inevitably, during the course of the project the local and national environment will become different—perhaps substantially so. (Note the passage of the Affordable Care Act in our case.) Although the overall objectives from the funder may not change, the paths to success locally may be very different. This will make the characteristics of “adaptive leadership” critical on the part of the project leadership and their staff. Assessing and nurturing this type of talent and leadership can be a critically important role that funders and intermediaries can (and should) consciously build into the program design. This should be a concerted effort over the life of the project.
5. Sustaining the goal of community-level system transformation is a multi-faceted endeavor. In our experience, it is dependent on the ability of an alliance or backbone organization to (1) demonstrate, produce, and articulate tangible value to stakeholders; (2) create a “deep bench” of talent within their management and leadership team, as well as within partner and other stakeholder organizations; and (3) define and produce products or services by which the alliance can generate and earn ongoing streams of revenue. Sustainability, of an organization or its work, is a key consideration and an important one to integrate into the design of a program or intervention from the very beginning.
Author affiliation: Constellation Consulting, Washington, DC (KOB); Alliance for Health Reform, Washington, DC (BG); America’s Essential Hospitals, Washington, DC (BS).
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: Ms Browne, Dr Graham, and Dr Siegel report receipt of grants from RWJF.
Authorship information: Concept and design (KOB, RG, BS); acquisition of data (BS); analysis and interpretation of data (BS); drafting of the manuscript (KOB, RG, BS); critical revision of the manuscript
for important intellectual content (KOB, RG, BS); provision of study materials or patients (BS); obtaining funding (BS); and administrative, technical, or logistic support (KOB).
Address correspondence to: firstname.lastname@example.org.
1. Miller CE, Weiss AF. The view from Aligning Forces to a Culture of Health. Am J Manag Care. 2016:22(suppl 12):S333-S336.
2. Brown P. The experience of an intermediary in a complex initiative: The Urban Health Initiative’s national program office. Chapin Hall website. https://www.chapinhall.org/sites/default/files/old_reports/283.pdf. Published 2005. Accessed March 3, 2016.
3. Kania J, Kramer M. Collaboration: collective impact. Stanford Social Innovation Review website. http://ssir.org/articles/entry/collective_impact#sthash.pApml9GL.dpuf. Published 2011. Accessed March 3, 2016.
4. Aligning Forces for Quality: improving health & health care in communities across America—sustainability and long-term viability. Aligning Forces for Quality website. http://forces4quality.org/topic-statement/sustainability-and-long-term-viability.html. Accessed March 3, 2016.