Does Margaret Mead's oft quoted statement about change hold true for health care?
“Never doubt that a small group of thoughtful, committed, citizens can change the world. Indeed, it is the only thing that ever has.” Margaret Mead
With an investment which will total $300 million by 2015, The Robert Wood Johnson Foundation (RWJF) placed its bet on the ability of multi-stakeholder coalitions to bring about sustainable change in local health systems and achieve real, measurable improvement in quality and outcomes. On Monday, the American Journal of Managed Care released a special issue chock full of early experiences from Aligning Forces for Quality, RWJF's signature initiative to improve quality of care in 16 communities across the country.
I wrote one of the commentaries in the special issue, others were authored by Debra Ness, Scott Cook and colleagues, Randy Cebul and colleagues, and Claire Gibbons and Anne Weiss from the Foundation. In some cases, it seems Mead's conclusion holds true and that thoughtful, committed individuals have affected significant change. But in general, it is clear that health care is local, and local leadership is essential to transform care.
I encourage you to read the full issue, which also has reports on all of the key aspects of the initiative, namely the coalitions, public reporting, consumer engagement, quality improvement, and efforts to address disparities. It makes for a good read, with many important lessons for mounting successful change initiatives, especially around how much time and effort it takes to achieve results. These are lessons that communities throughout the country can benefit from right now as the numerous initiatives spawned by the Affordable Care Act are implemented.
I also had the honor of serving as the chair of a terrific panel (Bruce Bradley, Tracy Moorehead, and Lew Sandy) charged by RWJF to conduct a mid-course assessment of the initiative. In the course of our six months of activities we talked with more than 30 individuals from the Foundation, the National Program Office, the National Advisory Committee, and a subset of the sites. My commentary and perspective were clearly informed by my learning from this process.
With that perspective, I’d tease out the following considerations as you review the articles:
Historical perspective: When the Aligning Forces for Quality (AF4Q) initiative was launched in 2006, the public policy agenda had a fragmented focus on quality. Today, the policy and innovation landscape has shifted dramatically and new federal authorities provide vital levers for advancing quality that the communities are well positioned to use. These levers can support and accelerate the efforts of AF4Q communities in many ways; however, their greatest impact at a time of continuing cost concerns may be in creating an environment in which the status quo is no longer a feasible alternative. This provides an opportunity for the AF4Q communities and their partners (e.g., the National Program Office, other communities, the Foundation) to pause, consider their strategy, and align their efforts with this new policy landscape.
Coalitions can be difficult to sustain over time: A focus on multi-stakeholder coalitions as a platform for change is not a new concept, however it has rarely been supported, tested, and refined to the extent that the AF4Q communities have done. This approach has since been embraced by federal initiatives, including the Beacon Communities Program. However, multi-stakeholder coalitions have their challenges. Coalitions are by their nature fragile, and even in the best circumstances, may affect change slowly.
Sustaining interest and investment by disparate partners, especially in more competitive markets, requires demonstrating impact in ways that are tangible and provide a clear return on investment for the various players, particularly the payer and business communities where the dominant concern is cost. These forces could undermine the trust established by coalitions and fragment the unified vision that coalitions have worked so hard to attain.
Forging new ground in public reporting and consumer engagement: The AF4Q communities have spent considerable time developing public reports on quality. Going forward the question is how all the new reporting requirements in the ACA can or should replace these regional efforts. One potential solution could be to use public funding to support regional public reports — thus balancing standardization and tailoring to community needs. In addition, the communities have learned that consumer engagement can and should be viewed as far more complex than just consumers’ use of quality information for health care decision making. When consumers are engaged at all levels, it can be transformational.
Infrastructure, infrastructure, infrastructure: Building a shared capacity for quality improvement goes well beyond a sustainable source of financial resources. It also requires an appropriate organizational home for collaborative learning across practices as well as requiring the training, staffing, consulting services, and information technology to support systematic quality improvement. Several policy initiatives are now available to reduce the substantial barriers to achieving this infrastructure, including new meaningful use incentives, health plan reporting of quality improvement activities, and physician re-certification requirements.
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