Now that the Patient Protection and Affordable Care Act has been signed into law, the key question is whether it will lead to improved quality and better value in health care. While many people feel that this is an issue best left to the federal and state governments, many analysts feel that the reforms needed to improve quality and value cannot be done by governments alone but that real, lasting reform needs to occur at the community level.

It is unknown, however, whether communities have the capacity for such complex reform. An initiative currently being funded by the Robert Wood Johnson Foundation, called Aligning Forces for Quality (AF4Q), may give us a better idea whether communities have the capacity to facilitate such complex change. AF4Q is RWJF’s core strategy to help improve the quality of health care. As part of AF4Q, RWJF is currently investing in efforts to improve health systems in 17 communities across the nation. The initiative brings a commitment of resources, expertise, and training to turn promising practices into real results at the community level.

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This week’s post is the fourth in our five-part series “Viewpoints: Health Economics.” This series of posts from invited authors will examine issues in health economics and health policy following the passage of health reform. Watch for the final piece in the series in the coming weeks.

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AF4Q asks the people who get care, give care, and pay for care to work together toward common fundamental objectives to lead to better care. The initiative aims to lift the overall quality of health care, reduce racial and ethnic disparities, and provide models for national reform. RWJF is focusing their initiative on three interrelated strategies that experts believe are essential to improving health care quality: performance measurement and public reporting, consumer engagement, and quality improvement.

Researchers at Penn State (where I am a faculty member) and other universities are leading the evaluation of AF4Q. The overall objectives of the evaluation are to (1) chronicle and document the activities of the AF4Q communities; (2) understand the impact of these activities; (3) identify key barriers and facilitators of AF4Q community success; (4) document and communicate lessons learned for purposes of dissemination to other communities; (5) make suggestions to the AF4Q national program office regarding program activities, including technical assistance or other needs; and (6) provide valuable feedback and data to the communities for formative purposes.
As part of our evaluation, a key focus has been on the multi-stakeholder entities that oversee and coordinate activities within each of the communities—the alliances, as we call them. Vital to their ability to meet and maintain the objectives of the AF4Q initiative is the ability of alliances to develop the capacity to sustain efforts in the long term. This concept of capacity building is defined as the activities and structures that leverage existing resources in pursuit of common objectives and are sustainable in the long term.

Using qualitative data collected from early interviews with key stakeholders from four AF4Q communities, we conducted early assessments of capacity building. From our data, we identified two domains that are vital to capacity building. The first domain, infrastructure and governance, is composed of the following components:

• Establishment of the right organizational and governance structure,
• An appropriate balance of power and participation,
• A decision-making strategy,
• The ability to make collateral leadership work,
• Clearly defined staff and member roles, and
• The development of resource capacity.

The second domain, stakeholder relations and participation, encompasses the following:

• Building on cultural and historical relationships,
• The alignment of stakeholder goals,
• Active recruitment of stakeholders, and
• Successfully sustained participation.

One central finding from our work is that while alliances face similar challenges, there is no one-size-fits-all approach to capacity building. Environmental and market factors, as well as alliance goals, greatly influence what strategies for capacity building are appropriate for each alliance. We also note that there are many tradeoffs and challenges to capacity building, which are highly interdependent; strengths and problems in one area of the alliance can lead to strengths and problems in another. Finally, while developing a successful business model and securing monetary resources are vital for success, alliances must focus on all the domain components described above.

It is important to note two things. First, these results are from very early stages of alliance development. Capacity building is an ongoing process that involves a pattern of learning, reevaluation, and readjustment over time. Second, capacity building is just one of many issues related to quality improvement that we are examining as part of our evaluation of AF4Q. We also have preliminary findings regarding communities’ experiences with data aggregation for the creation and dissemination of public reports; the challenges faced by alliances in developing strategies to engage hospitals and doctors in quality improvement; and the use of benefit design changes, such as tiered hospital networks, to involve patients and consumers as drivers for improved quality of care. Research summaries describing these findings can be found at our evaluation website.

We are still unsure of the degree to which successful capacity-building positions communities to accomplish a charge as lofty as improving the quality and value of health care. However, the work of the AF4Q alliances will give us a better understanding of this and whether lasting reform truly begins via government intervention or at the community level.

It is important to remember that there are issues aside from community partnerships that are paramount to reform of the health care system including payment reform, information and outcomes transparency, patient and provider behavior change, the use of health information technology, and insurance coverage. Each of these is receiving attention as reform implementation commences. We will be interested to see if those communities that have developed a local capacity for quality improvement are able to make progress more rapidly.

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