This special issue, highlighting findings from the Robert Wood Johnson Foundation’s (RWJF) Aligning Forces for Quality (AF4Q) initiative’s evaluation team, marks the end of a journey that began more than 10 years ago. When we started, there were few expectations of national health reform. We did not know that in 2016, we would be in the midst of a major transformation of the nation’s healthcare system. The lessons learned on our journey helped lay the groundwork for this transformation in local communities and nationally, and have informed RWJF’s subsequent programming efforts and vision for building a Culture of Health.1
A description of the program’s focus, structure, implementation, and operations can be found in this issue and elsewhere.2 This piece reflects on just a few of the accomplishments of AF4Q, the lessons learned, the challenges presented by an endeavor of this magnitude, and some of the many ways in which AF4Q informed the Foundation’s thinking around how to build a Culture of Health through an emergent or adaptive strategy approach.
AF4Q Was a New Approach for RWJF
In the years leading to the AF4Q initiative, RWJF investments in healthcare quality improvement sought to improve measurement and care delivery, often through program intervention development and evaluation in widespread locations. The Foundation supported efforts to define and measure healthcare quality and disparities by national organizations including the Institute for Healthcare Improvement, the National Quality Forum, and the Leapfrog Group; define and measure patient engagement; and deliver care more efficiently (eg, supporting the development of the chronic care model). Although many of these programs and interventions provided valuable data and advanced knowledge in healthcare quality improvement, the true system-wide, transformational change in healthcare that RWJF was striving to achieve was not being realized through these individual program activities.
AF4Q represented a course change for RWJF funding strategy. By using a more multi-pronged, locally focused design that targeted a limited number of communities, we could go deep with multiple approaches and work to create the conditions for change in the healthcare system at the local level. This shift in strategy emerged from an increased understanding that, while shaped by state and federal policy, healthcare is essentially local and there is no “silver bullet”—no single role, organization, or intervention that could fix the complex and troubled healthcare system. Thus, RWJF decided to take a regional market approach and bring together the individuals who provide care, receive care, and pay for care around shared information about the performance of their local healthcare system. This kind of community-level, multi-pronged, and comprehensive approach to improving healthcare was unique and had an audacious goal: to transform the quality, equality, and value of healthcare in regional markets.
Learning Along the Way Through an Adaptive or Emerging Strategy Approach
The accomplishments of this decade-long, $300-million initiative and the lessons learned along the way are difficult to summarize in one article and have been well documented in other publications from RWJF, the National Program Office (NPO), the evaluation team, and the alliances themselves throughout the program.
From the beginning, the evaluation and monitoring of AF4Q initiatives have provided key information to help the Foundation refine the program’s structure, goals, and expectations to adapt to the changing healthcare environment and the emerging capabilities and capacities of the alliances. Throughout the initiative, we adjusted strategy based on what we learned and changes in the context for our work in order to structure and expand the programs for the future. As an example, each new round of funding required reflection on program learnings to date and changes in the context in which communities were operating. This reflection and learning led to new areas for action and some new requirements, as well as increased autonomy for communities to set their own priorities and goals within specified areas of focus.
Specific Goals/Expectations Versus Community Autonomy
In the initial phase of the program, the Foundation identified areas for action and set goals that were intended to help make expectations clear and provide a focus for action for the alliances and the technical assistance contractors. The approach was based on a pragmatic reading of what was, and was not, possible at the time. For example, in the program’s first phase, we set specific goals in some areas (public reporting), but not others (consumer engagement), based on the development and effectiveness of potential strategies in each area.
By setting specific expectations for public reporting (where evidence-based strategies provided more concrete direction), we hoped to encourage the AF4Q alliances to develop new partnerships and hone their data skills. However, the lack of evidence-based strategies or even a clear definition of consumer engagement led the Foundation to allow communities to decide for themselves how to approach this focus area.
As the program evolved, the communities matured, and the landscape changed, RWJF felt it was appropriate to increase autonomy across program areas and encourage communities to set their own goals and define signs of progress. This evolution came about, in part, because of the development of relationships and increase in trust between RWJF and the alliances, and because of the expansion of alliance capacity.
The increased community autonomy allowed the alliances to showcase their particular skills—some excelled at engaging consumers in communitywide health improvement while others proved to be first-class healthcare measurement and data organizations. Many took on the role of neutral convener in otherwise polarized communities, and others developed robust quality improvement programs in ambulatory or hospital settings. However, without specific consumer engagement goals and expectations early on, some communities struggled with defining the concept and identifying strategies. Preliminary evaluation findings suggest that some communities felt that more concrete and specific goals in this area would have been helpful, while others felt that autonomy across program areas was late in coming and would have been appreciated from the start. Given the diverse nature of these alliances, one approach did not always serve the needs of all of the communities.
Program evolution around community autonomy taught us that communities need support that is sensitive to their particular capacity, meets them where they are, and allows them, as they mature and progress, increased autonomy to decide for themselves where to focus their energies. Attaining the right balance and timing in terms of setting specific goals versus encouraging community autonomy is difficult in a large-scale program such as AF4Q with a diverse set of communities all at different stages of development.
The Foundation made a long-term commitment to work with these communities to create change in healthcare systems, and from the beginning, we thought it was a priority to help the alliances build capacity, knowledge, and skills to sustain the work of AF4Q after program funding ended. The alliances, however, did not see sustainability as a priority in the early stages; preoccupied with daily organizational activities, many found it difficult to balance this day-to-day work with the more foundational work required to ensure sustainability beyond 2015.
While recognizing the alliances’ struggle to focus on sustainability planning in those early years, yet aware of its importance, the NPO partnered with Community Wealth Partners to understand the performance of the alliances across key drivers of sustainability and to identify specific performance gaps and needs across particular areas. With this understanding, the NPO and technical assistance providers were able to help alliances with their sustainability needs when they were ready.
During the last few years of AF4Q, with the end of program funding looming, the alliances focused more directly on sustainability plans. These efforts were more successful in some communities than in others. However, at least half of the alliances have created strong organizations that will continue their work and have impact long into the postgrant years. Some are new organizations, some existed prior to AF4Q, and others are small organizations in the context of a bigger network of local organizations aligned around common goals. The diversity of the alliance models that appear to be successfully continuing their work highlights the lesson that there is no one-size-fits-all model for success in improving healthcare quality locally.
Although it was difficult for the alliances to focus directly on sustainability planning early on, sustainability was being addressed indirectly through their work. AF4Q support and capacity building helped the alliances become well positioned to take advantage of policy changes and funding opportunities under the Affordable Care Act. From our adaptive strategy around these sustainability efforts, we learned that an outcome of this type of multi-pronged, system-based approach is that the system develops more effective strategies to adapt and co-evolve within its environment. For example, many AF4Q communities were poised for the adoption of myriad federal initiatives related to primary care improvement and payment reform.
From Aligning Forces to a Culture of Health
In 2012, during the celebration of RWJF’s 40th anniversary, the Foundation was engaged in reflections on our past and discussions of the future of health and healthcare. These discussions and reflections led us to a shared vision of building a Culture of Health that enables all Americans to live longer, healthier lives—now and for generations to come. The tremendous journey we took through the AF4Q initiative and the insights we gained via this project helped shape our new vision and continue to impact our work to build a national Culture of Health. The work of AF4Q and the alliances is reflected in RWJF’s Culture of Health vision and Action Framework.1
When AF4Q was developed, the Foundation was moving from programs specifically focused on changing care delivery, addressing the needs of patients with specific disease/condition(s), providing financial incentives for better care, and addressing quality of care and disparities, to initiatives with a broader view—that is, getting persons who get, give, and pay for care to work together to improve quality. The Foundation’s vision for a Culture of Health leads us further toward comprehensive communitywide integration of healthcare and public health with other sectors such as housing, transportation, and education to focus on improved population health and well-being.
The premise of the AF4Q initiative was that no individual, group, or profession could improve health and healthcare throughout a community without the support of others.3 The Culture of Health vision posits further that no single sector (healthcare, public health, social service, community organizations, individuals, or families) can improve individual and population-level health and well-being without the support and commitment of all community partners.
The Culture of Health Action Framework reflects the close connection between AF4Q lessons and the areas of action we believe are needed to realize progress in building a Culture of Health. Part of the Culture of Health vision, as seen in Action Area 4 (Strengthening Integration of Health Services and Systems), in the Outcome area (Improved Population Health, Well-being and Equity), and in the principle of equity that runs throughout the framework, is that everyone has access to affordable, quality healthcare; healthcare is efficient and equitable; and the economy is less burdened by excessive and unwarranted healthcare spending. The lessons from AF4Q are especially helpful here.
The community-level focus of AF4Q is reflected in Action Area 2 (Fostering Cross-Sector Collaboration to Improve Well-being); that is, setting goals based on local context, bringing different stakeholders together to tackle tough problems, and looking more broadly to include sectors in addition to healthcare and public health. Through lessons learned from AF4Q around allowing communities the autonomy to decide on their focus, the message of a Culture of Health is that there is no right or wrong way to build a Culture of Health, no one model of success.
As the Foundation works to build a Culture of Health, guided by the Action Framework, we will follow an adaptive and emerging strategy approach: moving away from driving a specific, targeted type of change in one system toward supporting and creating the conditions for change across multiple integrated systems, and working to be more flexible and engaged in co-creating our strategy with others. We will focus on a systems-thinking approach as we did in our work with AF4Q, but broaden it even further. Through the Aligning Forces initiative, RWJF was looking to create the conditions for system change at the local level, with a particular focus on healthcare system change. Now, with the Culture of Health vision, we are looking more broadly to create sustainable systems change across the multiple systems involved in the production of health and well-being.
In her letter to the field in November 2015,4 RWJF President and CEO Risa Lavizzo-Mourey spoke of the need to use a compass, rather than a roadmap, to reach a Culture of Health because there is no defined path that will lead us there. In each community, the path to a Culture of Health will depend on current circumstances, the terrain, and adapting to surroundings; it will require ongoing course correction based on monitoring, reviewing data, and evaluating strategies. We anticipate that this will occur in much the same way that Aligning Forces communities grew, adapted, and evolved throughout the program, and in much the same way that the Aligning Forces evaluation, presented and described in this and many other publications, grew, adapted, and evolved over time. The evaluation was designed along with the program right from the earliest phases of the program itself—the program and its evaluation grew, evolved, and changed together over time.
Health is about the environments in which we live, learn, work, and play—this extends beyond the boundaries of AF4Q and involves multiple systems that are complex in their own right, yet interconnected. We need to work to create the conditions that allow each of these systems to improve health—both independently and together—in order to build sustainable change across these multiple systems.
More than a decade ago, RWJF made a 10-year commitment to the AF4Q program. That long-term commitment provided communities with the space and time to evolve and mature and work toward the
ambitious goal of community health improvement. In similar fashion, RWJF’s Culture of Health vision is a generational commitment to catalyzing conversation and action around making health a shared value; fostering cross-sector collaboration to improve well-being; creating healthier, more equitable communities; and strengthening integration of health services and systems in order to improve population health, well-being, and equity.
Author affiliations: Robert Wood Johnson Foundation, Princeton, NJ (CEM, AFW).
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 Miller reports employment with, and receipt of grants from, RWJF. Ms Weiss reports employment with RWJF.
Authorship information: Concept and design (CEM, AFW); analysis and interpretation of data (AFW); drafting of the manuscript (CEM, AFW); and critical revision of the manuscript for important intellectual content (CEM).
Address correspondence to: firstname.lastname@example.org.REFERENCES
1. Plough A, Chandra A. From vision to action: a framework and measures to mobilize a culture of health. http://www.rwjf.org/content/dam/files/rwjf-web-files/Research/2015/RWJF_From_Vision_to_Action_2015-FullReport.pdf. Published Fall 2015. Accessed March 1, 2016.
2. Blumenthal D, guest ed. The Aligning Forces for Quality initiative: early lessons from efforts to improve healthcare quality at the community level. Am J Manag Care. 2012;18(suppl 6):S89-S164.
3. Gibbons, CB, Weiss, AF. Creating and sustaining change: early insights from Aligning Forces. Am J Manag Care. 2012;18(suppl 6):S96-S98.
4. Lavizzo-Mourey R. In it together—building a culture of health. http://www.rwjf.org/en/library/annual-reports/presidents-message-2015.html. Accessed March 1, 2016.