Aligning Forces for Quality Multi-Stakeholder Healthcare Alliances: Do They Have a Sustainable Future

Objectives: Multi-stakeholder healthcare alliances in the Robert Wood Johnson Foundation’s Aligning Forces for Quality (AF4Q) program brought together diverse stakeholders to work collaboratively to improve healthcare in their local communities. This article evaluates how well the AF4Q alliances were collectively positioned to sustain themselves as AF4Q program support ended.

Methods: This analysis relied on a mixed-methods design using data from a survey of more than 700 participants in 15 of the 16 AF4Q alliances (1 alliance was unable to participate because it was in the process of closing down operations at the time of survey implementation), qualitative interviews with leaders in all 16 of the alliances, and secondary sources. Qualitative analysis of interview data and secondary sources were used to develop a classification of alliance strategic directions after the AF4Q program relative to their strategies during the AF4Q initiative. Descriptive analyses of survey data

were conducted in the following areas: (1) alliance priorities for sustainability, (2) alliance positioning for sustainability, and (3) alliance challenges to sustainability.

Results: The likelihood of sustainability and the strategic direction of the former AF4Q alliances are both decidedly mixed. A substantial number of alliances are at risk because of an unclear strategic direction following the AF4Q program, poor financial support, and a lack of relevant community leadership. Some have a clear plan to continue on the path they set during the program. Others appear likely to continue to operate, but they plan to do so in a form that differs from the neutral convener multi-stakeholder model emphasized during the AF4Q program as they specialize, make a major shift in focus, develop fee-for-service products, or focus on particular stakeholder groups (ie, employers and providers). In most cases, preserving the organization itself, rather than its programmatic activities from the AF4Q program era, appeared to receive the greatest emphasis in sustainability efforts.

Conclusion: As their core strategy, most alliances will not perpetuate the original AF4Q program vision of diverse local stakeholders coming together to implement a prescribed set of aligned interventions centered on healthcare improvement.

Am J Manag Care. 2016;22:S423-S436

Multi-stakeholder healthcare alliances—also known as collaboratives, partnerships, or coalitions—are organizations that bring together diverse stakeholders to work collaboratively to improve healthcare in local communities.^1,2 Many of these organizations have been created in response to misaligned incentives and persistent poor quality of care, and are intended to promote local collaboration among stakeholders that have traditionally operated independently and sometimes in a conflicting fashion on health-related issues.^3,4 An alliance’s ability to accomplish its goal of improving the value of healthcare is predicated on sustaining the interest and participation of community stakeholders over extended periods.^2,5

The Aligning Forces for Quality (AF4Q) program was the signature effort of the Robert Wood Johnson Foundation (RWJF) to improve the overall quality of healthcare in targeted communities, reduce racial and ethnic disparities, and provide models for national reform through activities rooted in the efforts of local multi-stakeholder alliances.⁶ An article by Scanlon et al in this supplement provides a detailed description of the specific components and development of the AF4Q program.⁷ As the program entered its final years, AF4Q alliances were asked by RWJF to consider their respective futures and how to build on the progress made during the program. Alliances were provided with technical support for that effort. Questions of sustainability were particularly germane because RWJF’s vision was not to permanently support these alliances but to “prime the pump” by giving alliances a chance to establish themselves and get new programs off the ground, or to strengthen existing multi-stakeholder approaches to launch or enhance programs.

The goal of this article is to provide an initial examination of how the AF4Q alliances were collectively positioned for the future as the AF4Q program ended. Using data gathered through an online survey, key informant interviews, and alliance documentation, the following were examined: (1) the strategic directions of the alliances after the AF4Q program, (2) priorities for sustainability for the alliances after the AF4Q initiative, (3) how well the alliances were positioned to accomplish their goals at the conclusion of the AF4Q program, and (4) perspectives on the likely challenges the alliances will face in pursing their goals. This article ends with a general conclusion about the state of AF4Q alliances and their collective future. Our assessment is intended to provide a window into how community-based, multi-stakeholder alliances transition from participating in a long-term program—characterized by direct funding, ample technical assistance, and prescriptive programmatic requirements—to a more uncertain, but open, future.

Conceptual Framework: the Central Importance of Value

A recent review of the literature on collaborative sustainability concluded that most studies emphasized operational and management aspects of collaboratives thought to promote sustainability but largely neglected first-order issues, such as the value provided by the collaborative.⁸ Research in this area typically assumes that collaboratives and their activities should be sustained, even in the absence of evidence that they provide value. Such assumptions are problematic because the absence of a clear value proposition that stakeholders agree on is likely to be a deterrent to stakeholders joining or maintaining membership in a collaborative, regardless of how well the alliance is managed. Conversely, if participants see value or have a hand in shaping the priorities and direction of the alliance, the chances of commitment and ongoing support by stakeholders increase.

Given these issues, the future of the AF4Q alliances was by no means clear or certain at the conclusion of the AF4Q program. Alliances faced the challenge of maintaining commitment and investment from diverse, sometimes disparate, partners while attempting to identify priorities and a strategic direction that create value for their stakeholders. To gauge how well AF4Q alliances were positioned to sustain themselves and their activities after the AF4Q program, we evaluated how alliance leaders and participants viewed their alliance and its likely future direction. We focused specifically on issues related to creating value for stakeholders and the community, notably the strategic direction of the alliance, opinions on necessary alliance priorities, assessments of current alliance positioning to sustain itself or its activities, and likely future challenges to alliance sustainability. Collectively, these areas provide insights into the potential value that may (or may not) accrue to the alliance as a result of different ways of using its resources in pursuit of a particular goal. In contrast to previous research that emphasized the specific actions of the alliance as an independent agent, we emphasize how alliance participants perceive value through their priorities and concerns about their alliance’s direction and likelihood of success.

Methods

Data

This mixed-methods study utilized both qualitative and quantitative data collected from the AF4Q alliances. A brief description of each AF4Q alliance is located in the eAppendix of the article by Scanlon et al in this supplement (eAppendix available at www.ajmc.com).⁷ Qualitative data focused on the strategic direction of the 16 alliances after the AF4Q program relative to their strategic direction during the program. Strategic direction is defined as the alliance’s stated goals and the major course(s) of action the alliance has chosen to pursue them. Data on the strategic direction of the alliances following the AF4Q program were collected via a multi-stage process over the 6 months following the April 2015 end of the program. Specific qualitative data sources included key informant interviews with alliance staff and board leaders, alliance strategic plans and related process documents, and alliance website captures. Data on alliance strategies during the AF4Q program were collected through key informant interviews with alliance leaders and alliance documentation, including periodic progress reports that were submitted to the AF4Q National Program Office.

Quantitative data were drawn from an internet-based survey (alliance survey) of alliance participants in 15 of the 16 AF4Q alliances administered at the end of the AF4Q program (1 alliance was unable to

participate because it was in the process of closing down operations at the time of survey implementation). Survey content was based largely on the results of a systematic critical review of the literature on healthcare alliance sustainability.⁸ The survey sampling frame was developed from a comprehensive list of alliance participants provided by each alliance (ie, staff and consultants, board and leadership team members, committee and work group members, advisory group members, and members-at-large). The survey was conducted from June 2015 to September 2015.

The alliance leadership first sent a recruitment e-mail to all alliance participants. This e-mail alerted potential respondents to the survey request and served as an introduction to the purpose and administration of the survey. After the leadership’s introductory e-mail, the Penn State Survey Research Center sent a second e-mail containing the survey link to targeted respondents and subsequently followed up with 3 e-mail reminders, sent approximately 1 week apart. A total number of 638 individuals (38.6%) completed the whole survey (range across alliances, 21.8%-92.9%). In addition, 77 (4.7%) provided responses for a portion of the survey. Survey respondents included representatives from a broad range of stakeholder groups including insurers (9.9%), providers such as physicians and hospitals (26.1%), government agencies (11.2%), employers (5.1%), consumers (4.5%), alliance staff (17.5%), and unaffiliated participants (2.1%).

Analysis

A classification of alliance strategic directions was developed to group alliances into distinct categories based on a comparison of their strategies and focal activities during the AF4Q program against their anticipated strategic direction after the program ended. A primary research associate developed a table for each alliance that summarized its programmatic focus during the AF4Q program and its plans following the AF4Q initiative. A second research associate and the lead investigator reviewed each table. When information gaps were identified, additional existing data were consulted (ie, past key informant interview transcripts and alliance documents on file) to verify or clarify the table. Using a predefined set of mutually exclusive categories developed by the authors and the summary tables, the lead investigator and the primary research associate independently assigned each alliance to 1 of the 3 classification system categories and then compared their assignments. While there was agreement across the classification for nearly all of the alliances, any classification decisions that differed for the 2 team members were discussed by the full set of authors before final assignment to a category.

The quantitative analysis utilized 2 univariate statistics for 12 survey items grouped into 3 categories: (1) alliance priorities for sustainability, (2) alliance positioning for sustainability, and (3) alliance challenges to sustainability. The first univariate statistic was the top-box score,^9,10 which reflected the percentage of respondents who chose either of the 2 highest scale responses for each of the items (ie, “high priority” or “essential”; “agree” or strongly agree”; and “very likely” or “completely likely”). The second univariate statistic was the coefficient of variation (CV), a standardized measure of dispersion calculated as the standard deviation divided by the mean. A larger CV indicates less agreement or consensus regarding an item. Both statistics were constructed as an overall mean across respondents from all alliances and separately for respondents from each alliance.

Because absolute standards regarding magnitude for top-box and CV do not exist, interpretations of these statistics focused on relative values across survey items (ie, 1 item relative to another). Given the aim of providing a summative description of how well all AF4Q alliances were collectively positioned to sustain their efforts after the AF4Q program, the discussion of survey results emphasizes relative patterns across all alliances rather than specific results for individual alliances. Data for all 15 alliances are provided to allow more nuanced assessments of any general patterns or exceptions, when appropriate. Select responses to the open-ended question in the survey (“Please let us know what other thoughts you have about the effectiveness, future, or sustainability of the alliance”) provide specific examples of respondents’ opinions about alliance priorities, positioning, and challenges to sustainability. Descriptive findings and categorization of the alliances’ strategic direction following the AF4Q program, based on the strategic direction classification system results, are presented first and are then followed by key differences and similarities among responses to survey items within categories, based on top-box scores and degree of agreement (ie, CV).

Strategic Direction Classification Results

To provide a broad description of where AF4Q alliances appeared to be headed at the conclusion of the program, we identified 3 major categories and 3 subcategories of strategic directions pursued by the 16 AF4Q alliances. The main categories were: (1) no clear strategic direction, (2) pursuing the same strategic direction following the AF4Q program, and (3) pursuing a change in strategic direction after the AF4Q program. This final category was further broken down into 3 subcategories: expansion, retrenchment, and reinvention. Definitions of each category, and the frequency with which they were obtained among the 16 alliances, are presented in Table 1.

Perhaps the most striking finding is that the largest category (7 alliances) was represented by alliances that did not indicate a clear strategic direction following the AF4Q program. Although all alliances in this group engaged in a strategic planning process with their stakeholders or boards of directors, the process did not result in a clear direction or value proposition by the end of the summative data collection period. For example, 1 alliance in this group underwent a leadership change at the end of the AF4Q program, which stimulated a systematic reassessment of the alliance’s strategic direction. Although the alliance director was able to articulate a new strategy for the alliance, it had yet to be vetted by the board. Further impeding the potential change in strategy was the fact that the alliance’s current sources of funding emphasized different priorities and therefore did not provide strong fiscal incentives for setting a new direction. In another instance, an alliance restructured to emphasize a purchaser-led approach to its work following the AF4Q program. However, it was not clear how this change in focus would affect the alliance’s strategic direction and how the alliance would organize its work to accomplish its priorities. Also included in this category were several alliances that struggled to clearly define their focus after the end of the program and 2 alliances that ceased to exist as organizational entities at the conclusion of the AF4Q initiative.

The second major category consisted of 4 alliances whose strategic directions were essentially unchanged from the approaches taken under the AF4Q program. One alliance in this category defined its strategic direction early on in its history (prior to joining the program) and has not deviated from that direction. This alliance routinely prepares a master 5-year strategic plan and annual plans based on the master plan. During its participation in the AF4Q program, it did not fully embrace all aspects of the initiative; at times, the alliance negotiated with RWJF to maintain its traditional mission. In contrast, a second alliance in this category was created de novo for the AF4Q program and attained nonprofit status during the program. Following the AF4Q initiative, this alliance continues to work within the strategic framework it established during the program and is expanding its activities and reach within this framework.

The final category, change in strategic direction, comprises 5 alliances. Although each signaled a change in strategic direction relative to the strategies pursued under AF4Q, the nature of their changes was markedly different. The largest subcategory (ie, expansion) included 3 alliances that adopted a strategy of adding 1 or more new major goals and related activities while continuing the strategies undertaken during the AF4Q program. As an example, one alliance’s expansion was driven by community leaders’ recommendation to formally merge the alliance and 2 other health-related organizations. The strategic direction and programs of the resulting organization extend well beyond the original alliance’s direction and programs, including activities such as disaster preparedness education and training, healthcare workforce assessments, group purchasing, and physician recruitment.

A single alliance made up the subcategory of retrenchment. Alliance leaders in this community conducted a comprehensive review of their alliance’s work and concluded that the alliance should return to its “roots” as a provider-driven, dues-paying organization that provides a service/product to its members. As a result, the alliance has concentrated its efforts in a few areas perceived to be its core strengths.

The final subcategory was represented by one alliance that adopted an entirely new strategic direction with limited connection to the activities pursued under the AF4Q program. This alliance is pursuing an integrated, whole community approach to health through a purposeful alignment of healthcare system, social service, and community resources.

Alliance Survey Results

Table 2, Table 3, Table 4

Survey results () are displayed for 15 AF4Q alliances. Because partnership alliances (3 or more distinct organizations collaborating to guide the implementation of the AF4Q program) differ structurally from the majority of AF4Q alliances, survey results for these alliances are provided separately.

Priorities for Sustainability

On average, alliance participants assigned differential priority to the 4 listed strategic objectives: preserving the alliance as a viable organization, maintaining alliance status as a neutral convener, maintaining current programs/initiatives, and starting new programs and expanding reach (Table 2). Alliance participants assigned the highest priorities to goals related to maintaining the alliance as a neutral forum (grand mean [GM] = 0.85) and preserving the viability of the organization (GM = 0.79). These priorities also received the most agreement among survey respondents (CV = 19.6 and 22.1, respectively). Sustaining existing initiatives received lower priority (GM = 0.59) and somewhat more disagreement relative to the other listed priorities (CV = 24.5). By contrast, there was relatively higher priority and agreement given to starting new initiatives or serving new populations (GM = 0.64, CV = 23.2). When examining the survey findings across alliances, it is notable that participants in all 3 partnership alliances gave substantially less priority to preserving the alliance as a viable organization relative to other alliances, but assigned somewhat higher priority to preserving or sustaining existing alliance programs.

Current Positioning for Sustainability

Four indicators of how well participants viewed their alliance’s current positioning for sustainability were assessed: having a clear set of future goals, a coherent strategy to achieve those goals, having the appropriate community partners, and having sufficient financial resources (Table 3). Respondents were more positive about alliance positioning with respect to clarity of alliance goals (GM = 0.74) and were generally less positive about whether the alliance had appropriate community partners (GM = 0.37) or sufficient financial resources to achieve its future goals (GM = 0.11).

Of the 4 indicators, the most negative perceptions were expressed about the sufficiency of financial resources. Participants in the 3 partnership alliances expressed somewhat more positive assessments of having the right community partners/leaders to accomplish their future goals than those in the other alliances, but were less positive about the adequacy of financial resources than those in the other alliances. Finally, none of the 15 alliances displayed high positive assessments across all 4 elements of sustainability positioning, indicating that all of the pieces may not currently be in place to ensure sustainability for alliances, generally or specifically. In general, alliance participants showed less agreement (ie, a higher CV) about whether the alliance had the right community partners (CV = 31.1) or sufficient financial resources (CV = 39.8) than they did on clarity of alliance vision (CV = 24.1) and having the right strategies to achieve future goals (CV = 23.6).

Future Sustainability Challenges

Alliance participants were asked to assess the likelihood of 4 major potential challenges to their alliance’s future sustainability: attracting or keeping the “right” people (defined as people with the skills, talents, or political connections needed) on the alliance board/key leadership group, getting broad-based support from the community, securing financial resources, and competition from other entities/organizations doing similar work (Table 4). Overall, alliance participants expressed only modest concerns about the likelihood of future challenges (range of grand means, 0.10-0.29). Of the 4 listed challenges, alliance participants expressed relatively more concern about potential competition from other organizations (GM = 0.29) and the ability to secure financial resources (GM = 0.24). Considerably less concern was expressed about meeting challenges related to the commitment and participation from leadership and the community at large.

The level of agreement about the likelihood of these challenges varied across respondents. The least agreement regarding likelihood of alliance challenges appeared to be in the areas of competition from other organizations (CV = 44.9) and attracting or keeping the “right” people on the alliance board (CV = 46.2), suggesting that these challenges were not viewed by all alliance participants with the same level of concern.

Discussion

Five major themes emerged from classification of the alliances’ strategic directions and analysis of the survey data. These are discussed below and include illustrative examples from the survey respondents’ open-ended comments.

Many Alliances Are Still Working to Identify a Clear Strategic Direction for Their Future Following the AF4Q Program

Sustainability planning requirements and technical assistance for the design of community-specific sustainable business models were built into the final 2-year phase of the AF4Q program. Despite these requirements and support, many alliances were not able to finish the program with a clear strategic direction or value proposition. These alliances were confronting a host of issues, such as developing a clear identity in the community, balancing a pressing need for resources against the risk of diluting their core mission, creating programs of value for key stakeholders, and managing the potential conflict between developing fee-for-service, revenue-generating products and maintaining their role as a neutral convener. As noted by one respondent, “The alliance is at an inflection point—moving from grant dependence to services and program dependence, but without losing the role of neutral convener.”

Additionally, prior research on alliances indicates that capacity building often conflicts with other priorities early on in their development as organizations.¹¹ For example, funding agencies that stress accountability create pressure to produce and measure short-term outcomes, possibly at the expense of processes that support and sustain long-term capacity.¹² Paradoxically, programs that focus more on capacity-building activities have been shown to obtain less external funding than programs that predominantly focus on measuring short-term results.¹³ Similarly, research has found that the demands of implementing programs can undermine long-term capacity-building goals, as the operational and monitoring requirements of implementing these programs can dominate staff time and effort, resulting in a loss of focus on long-term program goals.¹⁴ All of this suggests that long-term programs that focus on externally driven interventions may distract communities from building internal capacity and decision-making processes.

The Desired Future Goals for Alliances Are Often Clearer Than the Means to Get There

In relative terms, participants were more positive about the alliance having established a clear and important direction heading into the future than they were about whether their alliance currently has the capacity to achieve its vision. Doubts about current positioning for sustainability in the areas of a clear strategic plan, financial support, and a lack of involvement of community leadership created uncertainty about the future of the AF4Q alliances, despite relatively stronger participant support for the stated goals of their alliance. As one respondent expressed, “[The alliance] should be a viable organization and should play a lead role in communitywide health initiatives. Funding and sustainability are serious concerns. Pilot programs with grant funding are difficult to transition into scalable and sustainable models that move the needle.” This is not altogether surprising given the end of a major funding program and the inherent fragility of alliances. To their credit, however, most alliances have recognized the significance of this critical juncture and have employed resources and technical assistance from the AF4Q program to try to map a vision for the future and a strategy for realizing that vision.

The relatively lower confidence expressed in appropriate community leadership and finances is consistent with other research suggesting that alliances often face greater difficulty establishing consensus among participants when trying to operationalize their broad-based vision into more tangible actionable plans. Such transitions often require more sustained negotiation to resolve conflicts and tensions that emerge among stakeholders during this process.¹⁵ Greater disagreement about these specific issues may also be a reflection of the changing environment that has created more uncertainty for many participants about their future in a more competitive landscape. Healthcare reform, in particular, has resulted in consolidation among providers in many states and communities, as well as the incubation of other multi-stakeholder efforts in some of the AF4Q program regions. Under these conditions, participants may share similar opinions about the alliance’s goals but have greater doubts and more divergent beliefs about recruiting and retaining the requisite partners and the resources they can provide for alliance activities.

Sustainability Priorities Emphasize More Focus and More Flexibility

As noted above, alliance participants assign high priority to the preservation of the alliance as a neutral convener and to preserving the alliance as a viable organization. As one respondent stated: “[The alliance] is an organization uniquely chartered to help keep the marketplace honest and accountable (proprietary interests of the stakeholders notwithstanding) and needs to be preserved.” These priorities reflect infrastructure support and development, which many alliances have found difficult to fund. By contrast, alliance participants placed considerably less emphasis on maintaining the current initiatives of the alliance going forward. Alliance participants appear to want their alliances to move in new directions programmatically and are willing to abandon or substantially change their existing initiatives as they focus on sustainability planning. This suggests that current programs are too costly to maintain (individually and collectively) or lack stakeholder support, or that other programs may simply be a better fit for the alliance and the current needs of the community.

Survey respondents provided support for these diverse explanations: “[The alliance] used to be able to do 2 or 3 programs/objectives well and now it seems to have diversified into many programs/objectives, but none of them seem to be done with the same excellence. A company that intends to be around for a long time needs to make the difficult decision of choosing a few programs, do them consistently well, and allow them to morph as necessary.” Or, as another respondent stated: “With the end of RWJF funding, I believe it will be difficult to raise the funds to maintain the status quo. A reinvention of their [AF4Q] objectives will be required to become more efficient.” This suggests that first-order priorities are the infrastructure and role of the alliance in the community, not the specific initiatives that funders have supported in the past.

This may also speak to the desire of alliance participants to have the alliance be a vehicle for sustaining collaboration in the future and for maintaining the flexibility to respond to community health challenges as they arise. The notable exception to this pattern was partnership alliances, which typically lack the formal structure and governance arrangements of other AF4Q alliances. Because of these differences and their possible implications for sustainability, future research should contrast this more informal type of collaboration with alliances that are organized as more traditional stand-alone entities to assess which form engenders greater stakeholder commitment and more responsiveness to changing community needs.

Financial Support and Community Leadership Are Missing Pieces in the Sustainability Puzzle

If there was one major area of current concern that alliance participants consistently expressed, it would be the lack of sufficient financial support to accomplish the goals laid out in the AF4Q strategic plan. This was echoed repeatedly by the comments of survey respondents who emphasized that grant funds would not be a sustainable source of support for the alliance and its initiatives going forward. As one respondent noted, “Much of the work has been grant-funded, but now the community needs to decide the relative value of the services and impact and fund appropriately.” This suggests that if the alliance provides services or programs that are valued by the community, then community stakeholders will be more likely to provide support through membership dues, sponsorship, or in-kind contributions.

There was also concern expressed about having the right community leadership and support, which was somewhat surprising because the AF4Q program placed considerable emphasis on the importance of having key stakeholders involved. This may stem from several factors. First, alliance participants may feel that a leadership change is necessary to move the alliance in new directions after the AF4Q program concludes and that these new strategies might require a set of experiences and skills different from those needed to manage programs under a large grant like the AF4Q initiative.¹⁶ In a related vein, it may also suggest that the current composition of the alliance or its governing board is missing key players in the community to successfully take it in a new direction. As one respondent noted, “Sustainability is tied to developing linkages with organizations/entities beyond those currently involved in the alliance.” It could also signal that the alliance needs to focus on getting key decision makers from participating organizations directly involved in their work rather than lower-level staff or representatives who are not empowered to make decisions about resource expenditures and strategic direction for their home organizations.

Overall, alliances that facilitate more congruence between alliance and participant goals can provide a foundation for more effective coordination of effort and stimulate internalization of alliance goals and those of participating organizations.¹⁷ This may engender more deeply rooted institutionalized change that extends beyond the work of the alliance and results in sustainable communitywide improvements in health. Obviously, this is a greater challenge if key leaders are not involved in alliance decision making, are unaware of the alliance’s initiatives, or see participation in the alliance as a “community service” obligation rather than a core activity. Indeed, participation itself may be a catalyst for change, as prior research shows that the level of alliance participation is significantly associated with a participant’s level of engagement and perception of benefits and costs.^18,19

Stakeholder Optimism About Meeting Future Sustainability Challenges is High

Taken together, alliance participants did not view the future challenges to alliance sustainability as particularly significant. These findings stand in contrast to alliance participants’ views of current strategic positioning where there was much more concern expressed about several of the foundations for sustainability. Divergence between current realities and perceptions of future challenges may not be surprising given that responses to questions about future states may require more conjecture on the part of respondents as opposed to, say, how well the alliance is currently positioned for the future.^20-23 In this case, such biases may have resulted in participants being more optimistic about an alliance’s ability to overcome its challenges, despite the recognition of its current deficiencies.

Additionally, the general lack of significant concern about the likelihood of sustainability challenges does not mean that these future challenges do not exist, only that they are seen by many as surmountable. Further, this optimism is not universal. For example, some voiced strong opinions that financial support was going to be critical for alliance sustainability and success going forward: “Admirable mission, but inadequate community leadership participation and funding sources are challenges to be fully successful.” Similarly, some open-ended comments reflected concerns about the inherent competing roles and interests of participants in a multi-stakeholder alliance: “Sustainability challenges are heightened by the unusual fact that essential alliance members can act in several or all of the following capacities: key supplier, valued customer, direct competitor, substitute service provider, or [a] barrier to pursuit of new activities. It is difficult to think of another industry with such role fluidity.”

Where Are AF4Q Alliances Headed?

By definition, sustainability is a future state and, as such, cannot be reliably predicted. Unanticipated changes in factors both internal and external to the alliances—such as leadership transitions, economic pressures, state and federal policy changes, and staff turnover—are all likely to alter the trajectory of alliances going forward.²⁴ That said, however, it can be speculated how alliances were positioned to achieve a sustainable future at the conclusion of the final data collection process.

Based on the analysis of survey results, qualitative data, and secondary sources, the sustainability picture is decidedly mixed, and there is cause for concern about the future viability of a substantial number of the former AF4Q alliances. Of the 16 alliances, 2 have ceased operations and 5 more have no clear strategic direction. Some appear to be on the verge of dissolution but can probably continue to operate in some capacity in the short term because of traditional continuing support. Adding to this picture, less than half of survey respondents across all alliances indicated that their alliance had a well-thought-out strategy and set of programs that would position their alliance for the future. These findings reflect the inherent difficulty of transitioning from a grant-dependent organization to one that is more competitive and requires clear demonstration of value for the community and key stakeholders.

Of the alliances that were able to articulate a clear strategic direction, or were on the path to developing one, it is likely that many will continue to operate, although some plan to do so in a form that differs from the neutral convener multi-stakeholder model emphasized during the AF4Q program. For example, some alliances are restructuring and shifting their orientation to particular stakeholder groups that control significant resources, such as employers, large healthcare systems, or even the state. Still others are attempting to “diversify” by building off their AF4Q program experience in areas such as measurement development to offer fee-for-service products. In the process, however, alliances are creating potential conflict with their traditional role as neutral convener for all stakeholder groups and their mission to promote community health more broadly.

Overall, survey respondents emphasized the need for a clear alliance focus that is centered on activities that are valued enough to be financially supported in the local or regional market. Although this may seem obvious, it was not always the case under the AF4Q program because alliances were often “protected” from accountability to their markets through generous funding by RWJF. Indeed, survey respondents gave relatively low priority to retaining existing programs/activities, and there is evidence that some AF4Q “public good” activities, such as public reporting and consumer engagement, are already being phased out by a subset of alliances because of little stakeholder or financial support. (Other papers in this supplement address the future of specific programmatic areas.)

All of this raises the more fundamental question of what alliances are trying to sustain. In most cases, preserving the organization itself appears to receive the greatest emphasis, certainly more than some existing programs. Whereas organizational self-preservation and infrastructure development may be necessary as a foundation to achieve broader aims, it is important to gauge these efforts against the more fundamental objective of improving community health, whether through programmatic efforts of the alliance, the efforts of particular alliance members, or nonalliance efforts that target such issues as the social determinants of health.

The last decade was significant in terms of healthcare policy change. Current national and local realities differ greatly from those at the outset of the AF4Q program in 2006. For many of the alliances, it remains to be seen how, and if, they will apply their AF4Q program experience to their current realities to provide value, meet evolving stakeholder needs, and ultimately improve the quality of healthcare in their communities. What is more evident is that most alliances will not perpetuate the original AF4Q program vision of diverse local stakeholders coming together to implement a prescribed set of aligned interventions centered on healthcare improvement.

Limitations and Conclusion

The findings of this analysis should be interpreted in light of several study limitations. First, the relatively low survey response rate could introduce nonresponse bias (ie, more committed and involved members of the alliance responded to the survey). Although such a possibility cannot be ruled out, a nonresponse analysis conducted on previous rounds of this survey with similar items suggested that nonrespondents did not significantly differ from respondents with respect to their perceptions of leadership, agreement on the vision and strategy of the alliance, and level of participation.¹⁷ These analyses, along with the representation of different stakeholder groups among the respondents to the current survey, provide greater confidence in the findings reported in this study.

A second limitation relates to the timing of the survey. By design, data were collected at the end of the AF4Q program. However, such an assessment at a particular point in time does not take into account the very real possibility that alliance strategies and stakeholder assessment of value may evolve as market conditions shift and other contingencies arise.

Finally, the results presented within were an initial effort to address the question of where AF4Q multi-stakeholder alliances were headed after the program ended. The analyses and conclusions were intentionally broad given the objective to characterize the population of AF4Q alliances as a whole. However, results indicate that variation exists among the AF4Q alliances, suggesting that the general patterns observed cannot necessarily be attributed to alliances individually.

Indeed, there are individual stories of how alliances are addressing their sustainability challenges, some successfully and others less successfully. Similarly, more fine-grained comparative analyses of the operations, leadership, and contexts of these alliances may suggest actionable steps that alliances might take to increase the chances of sustainability. Hopefully, the next generation of studies will use these findings as a platform for examining these cases in depth and comparatively to advance the understanding of how multi-stakeholder alliances provide long-term value to their stakeholders and community.

Author affiliations: School of Public Health, The University of Michigan Ann Arbor, MI (JAA); School of Health Professions, University of Alabama at Birmingham, Birmingham, AL (LRH); Center for Health Care and Policy Research, Penn State University, University Park, PA (JMV, LJW).

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: Dr Alexander, Dr Hearld, Ms Vanderbrink, and Ms Wolf report receipt of grants from RWJF.

Authorship information: Concept and design (JAA, LRH, LJW); acquisition of data (JAA, LRH, JMV, LJW); analysis and interpretation of data (JAA, LRH, JMV, LJW); drafting of the manuscript (JAA, LRH, JMV, LJW); critical revision of the manuscript for important intellectual content (LRH); statistical analysis (LRH); administrative, technical, or logistic support (JMV, LJW); and supervision (JAA).

Address correspondence to: jalexand@umich.edu.

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