Creating and Sustaining Change: Early Insights From Aligning Forces

The Robert Wood Johnson Foundation (RWJF) has been working to improve healthcare quality since it became a national philanthropy in 1972. It has designed and implemented programs that change the way care is delivered (for example, with chronic illness and in the emergency department); addressed the needs of patients with specific conditions (eg, diabetes and asthma); created financial incentives for the provision of better care; focused on specific populations (eg, cardiac care for minority patients); and helped define and measure quality and disparities (ie, through organizations like the National Quality Forum). Many of these programs were successful, but some individual programs did not achieve transformational change—they did not have the far-reaching impact that the RWJF, as the nation’s largest foundation focused on health and healthcare, is committed to achieving. We also observed,as have others before us, that “all healthcare is local.” We do not have a national quality problem, we have quality problems in every community in America. Quality is a local issue that must be resolved where care is delivered.

The Aligning Forces for Quality (AF4Q) initiative grew from these insights. This program has been the cornerstone of the RWJF’s 10-year, $300 million commitment to improving quality and reducing disparities. The premise of the AF4Q initiative is that no single person, group, or profession can improve health and healthcare throughout a community without the support of others. The RWJF launched the first phase of the AF4Q initiative in 2006. A central theme of the program is transparency: to make performance information publicly available to those who give care, get care, and pay for care. This initial phase of the AF4Q initiative provided multistakeholder

community alliances in 16 markets—including 4 states—with grants and substantial expert assistance to help them work with physicians to measure and publicly report

on the quality of ambulatory care, to strengthen quality improvement capacity, and to engage consumers to make informed choices about their health and healthcare. The

program expanded in June 2008 to include inpatient care, to focus on reducing racial and ethnic gaps in care, and to enhance the central role that nursing plays in high-quality healthcare. In May 2011, the program began to emphasize community-developed goals related to quality and cost and required each alliance to begin addressing payment reform.

Since the launch of the AF4Q initiative in 2006, participating alliances (multi-stakeholder partnerships in each AF4Q community) have accomplished a considerable amount. For example, each of the 16 alliances launched and maintains a public website with both hospital and ambulatory performance data. All of the alliances have made strides in engaging consumers in their care and improving the quality of care that patients receive through quality improvement activities. The AF4Q alliance in Humboldt County, California, launched the Primary Care Renewal Program, which has led providers to turn to patients for input on practice redesign and patient outreach and engagement

strategies. In Cleveland, Ohio, the AF4Q alliance cultivated a network of 11 local and regional hospitals who are now working together to reduce unnecessary hospital readmissions; this is an atypical collaboration among hospitals in that region. All alliances are now working toward implementing payment reform locally. Some have just begun the conversation across stakeholders about what they want to do moving forward, and some are carrying out payment reform projects. For example, the Puget Sound Health Alliance and the state of Washington launched a multipayer medical home pilot program to align incentives with high-quality care.

This initiative has taught us many lessons about how to improve healthcare at the local level, too many to describe here, but many examples are included on the AF4Q website (www.forces4quality.org) and the RWJF website (www.rwjf.org). As a way to continue the conversation and share learning, the RWJF created an online Facebook community of people committed to improving healthcare called Transformation Has Begun. The discussion that follows offers a few lessons our team has learned and issues we expect to face in the future.

The impact of specific goals—When the RWJF issued the first call for proposals, our team identified 3 main areas of focus: performance measurement and public reporting; quality improvement; and consumer engagement. Compared with the latter 2, our goal for performance measurement and public reporting was the most specific: within 3 years, each alliance would be required to publicly report on ambulatory care performance by at least 50% of its community’s primary care providers. Because this goal was so specific, it was a major factor in determining which communities were selected to participate in the program. In the program’s early years, there were real benefits to giving multi-stakeholder alliances a concrete aim that drew them together, and a chance to achieve a relatively early win is critical to gaining momentum and keeping the stakeholders engaged in the work of the AF4Q initiative. However, a very specific goal in the context of 2 more general goals for quality improvement capacity and consumer engagement may have made it easier for alliances to focus on public reporting at the expense of the other areas of quality improvement capacity or consumer engagement.

Challenges to quality improvement at the community level—The original AF4Q call for proposals required alliances to make “progress toward a sustainable infrastructure to help providers improve the quality of the care they provide.” Rather than focus initially on practice-specific innovations, such as the patient-centered medical home, a key motivator of the strategy behind the AF4Q initiative is the understanding that providers cannot always engage in quality improvement activities on their own. Small physician practices in particular face many barriers to implementing quality improvement. Although some practices can overcome these barriers, there is still far too much poor quality care in communities to believe that this haphazard approach is sufficient. The RWJF believes that the best approach to solving this problem is to develop a communitywide quality improvement infrastructure that would provide a consistent source for quality improvement resources for providers in a community. This has been a very challenging area of the program. It is hard to define a quality improvement infrastructure that makes sense to communities as varied as Minnesota, Memphis, and Humboldt County, California. Once we settled on a clear definition using a broad set of key drivers for quality improvement, we encountered challenges in communicating and implementing it, although we are beginning to see some signs of progress. Some alliances’ success in this area is likely related to the ultimate sustainability of their efforts beyond RWJF funding. In Cleveland, Ohio, the AF4Q project team has created a business model that features quality improvement classes and other resources for dues-paying members.

The West Michigan AF4Q alliance has been involved in the launch of its own version of Minnesota’s well-known Institute for Clinical Systems Improvement, a long-standing

and well-known community-level quality improvement resource. Western New York’s alliance has developed its own practice coaching program. We have also learned that

patient-centered medical homes have proved themselves to be a powerful infrastructure for quality improvement capacity. So we know it can be done, and we are beginning to see some real progress.

Challenges to consumer engagement—Our consumer engagement goal at the program’s outset was to “engage consumers to take action based on the information they receive,” and initially, we let a thousand flowers bloom, believing that there was too little evidence about what works in consumer engagement to dictate 1 approach. Over time, we developed more specific direction for the consumer engagement area of work, which focused on encouraging consumers to use health information from public reports and other sources to make decisions about which provider to use, about healthcare treatments, and about managing their health. Under the redefined consumer engagement expectations, alliances supported many activities meant to increase engagement. However, we do not currently know whether these activities will result in significant changes to consumer behavior at the community level.

Strategic communications—Strategic communications are a fundamental part of how the RWJF approaches the work of social change, and that is perhaps the most highly

valued part of the technical assistance offered to communities. As part of the initiative, we offer strategic communications support to each of our AF4Q communities. Examples

of support include: (1) training on how to talk about quality and disparities with different audiences; (2) how to develop and deliver an effective elevator speech to describe the work of the AF4Q alliance in each community; and (3) research that as helped craft messages for a variety of audiences about quality, disparities, payment reform, and other topics. We also offered small grants to support convening activities at each site.

Sustainability—The RWJF’s commitment to fund the AF4Q initiative ends in 2015. As a result, there has been frequent discussion among the alliances, our advisors, and

the RWJF staff in the past year or so about the sustainability of the AF4Q efforts. The discussion has recently become very focused on demonstrating the business case for the efforts within the AF4Q initiative. Many point out that if the RWJF funding is removed and the AF4Q community leaders have not demonstrated a strong argument that their efforts have improved quality and reduced costs for their stakeholders, their efforts will not be sustained by other potential funders. One might conclude from this intense focus on the business case that each grant application should go through an additional level of review to determine whether there is a business case to support the activity. If not, it would be deemed undeserving of funds, since the grant-funded efforts would surely dissipate after the funding period was over. We would instead argue that it is often the responsibility of philanthropy to step in to create change in exactly those areas where a clear business case does not exist. There are many areas where a larger community benefit results from philanthropic activity that would never have occurred if left to the economic forces of the market. In some cases, it takes philanthropic investment before the business case can be established. In other cases, there may be a lag between establishing that an intervention is cost saving and, for example, the uptake by payers like Medicaid or Medicare when an evidence-based, costsavingnmedical intervention is established. In other cases, it may simply take a long-term investment by philanthropy to

achieve the change. In the case of the AF4Q initiative, payment reform is the most likely way for improvements in quality to be sustained, and only recently has this been seriously pursued in a number of AF4Q communities.

Reducing disparities at the community level—Our approach to disparities reduction was originally to encourage alliances to collect and use patient-reported race and ethnicity data in ambulatory and hospital settings. The AF4Q alliances were meant to stratify the quality information that was part of their physician performance reports to determine whether any disparities existed, and then form a plan to eliminate any disparities they identified. Collecting data in ambulatory settings in particular has been extremely challenging, and we have since shifted tactics to emphasize the spread of evidence-based interventions to reach diverse racial and ethnic populations.

The future—As we head into the later years of the AF4Q initiative, a number of opportunities and challenges are apparent. Passage of the Affordable Care Act (ACA) in 2010

has changed the landscape for healthcare quality and value. The new Center for Medicare and Medicaid Innovation, the new Medicare accountable care organization model, and other initiatives have offered AF4Q alliances new opportunities, and we have been pleased to see so many of them respond. We believe that, regardless of the future of the ACA and its specific provisions, there are ways to leverage the strengths of our community alliances to help promote federaland private sector payment and delivery system reform.

There has also been tremendous growth in the number and quality of public performance reports by Medicare, state governments, and healthcare organizations. The RWJF

may wish to put more emphasis on challenges faced by the measurement and reporting field more broadly, such as the difficulty of developing actionable, technically feasible,

meaningful measures of healthcare cost and spending.

Finally, at the initiative’s midpoint, we face the challenge of documenting and communicating about its impact. The initiative’s emphasis has shifted from monitoring alliances’

progress on process goals (eg, issuing public reports) toward their achievement of market-specific cost and quality goals. For example, Cleveland has committed to reducing hospitalizations for heart failure by 20%, an estimated savings of $91.2 million. A sharper focus on these goals should help the alliances maintain momentum and sustain their impact after 2015, and will help document the impact of the RWJF’s 10-year commitment to the initiative. This will not be the only definition of success, given that this is such a large and complex initiative. The independent evaluation, discussed elsewhere in this supplement, has its own research questions and methodology. The RWJF has used a set of milestones toward our strategic objective, which is to improve and sustain high-quality, equitable, patient-centered care in our communities. We believe that all of these measures of success are important, yet they complicate the challenge of telling our story: that 16 communities around the country are different and better for having taken on the AF4Q challenge—and spreading its lessons to the rest of the nation.

The authors would like to thank Alexis Levy for reviewing this paper and offering editorial comments and suggestions.

Author affiliations: Robert Wood Johnson Foundation (RWJF), Princeton, NJ (CBG, AFW).

Funding source: This supplement was supported by the RWJF. The Aligning Forces for Quality evaluation is funded by a grant from the RWJF.

Author disclosures: Dr Gibbons and Ms Weiss 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 (CBG, AFW); drafting of the manuscript (CBG, AFW); and critical revision of the manuscript for important intellectual content (CBG, AFW).

Address correspondence to: Claire B. Gibbons, PhD, MPH, Rte 1 and College Rd E, PO Box 2316, Princeton, NJ 08543. E-mail: cgibbons@rwjf.org.

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