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Objective To explore why and how health systems are engaging in care delivery redesign (CDR)-defined as the variety of tools and organizational change processes health systems use to pursue the Triple Aim. Study setting A purposive sample of 24 health systems across 4 states as part of the Agency for Healthcare Research and Quality's Comparative Health System Performance Initiative. Study design An exploratory qualitative study design to gain an "on the ground" understanding of health systems' motivations for, and approaches to, CDR, with the goals of identifying key dimensions of CDR, and gauging the depth of change that is possible based on the particular approaches to redesign care being adopted by the health systems. Data collection Semi-structured telephone interviews with health system executives and physician organization leaders from 24 health systems (n = 162). Principal findings We identify and define 13 CDR activities and find that the health systems' efforts are varied in terms of both the combination of activities they are engaging in and the depth of innovation within each activity. Health system executives who report strong internal motivation for their CDR efforts describe more confidence in their approach to CDR than those who report strong external motivation. Health system leaders face uncertainty when implementing CDR due to a limited evidence base and because of the slower than expected pace of payment change. Conclusions The ability to validly and reliably measure CDR activities-particularly across varying organizational contexts and markets-is currently limited but is key to better understanding CDR's impact on intended outcomes, which is important for guiding both health system decision making and policy making.

Objective To understand how health systems are facilitating primary care redesign (PCR), examine the PCR initiatives taking place within systems, and identify barriers to this work. Study setting A purposive sample of 24 health systems in 4 states. Study design Data were systematically reviewed to identify how system leaders define and implement initiatives to redesign primary care delivery and identify challenges. Researchers applied codes which were based on the theoretical PCR literature and created new codes to capture emerging themes. Investigators analyzed coded data then produced and applied a thematic analysis to examine how health systems facilitate PCR. Data collection Semi-structured telephone interviews with 162 system executives and physician organization leaders from 24 systems. Principal findings Leaders at all 24 health systems described initiatives to redesign the delivery of primary care, but many were in the early stages. Respondents described the use of centralized health system resources to facilitate PCR initiatives, such as regionalized care coordinators, and integrated electronic health records. Team-based care, population management, and care coordination were the most commonly described initiatives to transform primary care delivery. Respondents most often cited improving efficiency and enhancing clinician job satisfaction, as motivating factors for team-based care. Changes in payment and risk assumption as well as community needs were commonly cited motivators for population health management and care coordination. Return on investment and the slower than anticipated rate in moving from fee-for-service to value-based payment were noted by multiple respondents as challenges health systems face in redesigning primary care. Conclusions Given their expanding role in health care and the potential to leverage resources, health systems are promising entities to promote the advancement of PCR. Systems demonstrate interest and engagement in this work but face significant challenges in getting to scale until payment models are in alignment with these efforts.

Objective Adoption of health information technology (HIT) is often assessed in surveys of organizations. The validity of data from such surveys for ambulatory clinics has not been evaluated. We compared level of agreement between 1 ambulatory statewide survey and 2 other data sources: a second survey and interviews with survey respondents. Materials and methods We used 2016 data from 2 surveys of ambulatory providers in Minnesota—the Healthcare Information and Management Systems Society (HIMSS) survey and the Minnesota HIT Ambulatory Clinic Survey—and primary data collected through qualitative interviews with survey respondents. We conducted a concurrent triangulation mixed-methods assessment of the Minnesota HIT survey by assessing level of agreement between it and HIMSS, and a thematic analysis of interview data to assess the respondent’s understanding of what was being asked and their approach to responding. Results We find high agreement between the 2 surveys on questions related to common HIT functionalities—such as computerized provider order entry, medication-based decision support, and e-prescribing—which were widely adopted by respondents’ organizations. Qualitative data suggest respondents found wording of items about these functionalities clear but encountered multiple challenges including interpreting items for less commonly adopted functionalities, estimating degree of HIT usage, and indicating relevant barriers. Respondents identified multiple errors in responses and likely reported greater within-group homogeneity than actually existed. Conclusions Survey items related to the presence or absence of widely adopted HIT functionalities may be more valid than items about less common functionalities, degree of usage, and barriers.

Background Multiple international organizations have called for exercise to become standard practice in the setting of oncology care. The feasibility of integrating exercise within systemic chemotherapy has not been investigated. Methods Patients slated to receive infusion therapy between April 2017 and October 2018 were screened for possible inclusion. The study goal was to establish the acceptability and feasibility of embedding an exercise professional into the chemotherapy infusion suite as a method of making exercise a standard part of cancer care. The exercise prescriptions provided to patients were individualized according to results of brief baseline functional testing. Results In all, 544 patients were screened, and their respective treating oncologists deemed 83% of them to be medically eligible to participate. After further eligibility screening, 226 patients were approached. Nearly 71% of these patients (n = 160) accepted the invitation to participate in the Exercise in All Chemotherapy trial. Feasibility was established because 71%, 55%, 69%, and 63% of the aerobic, resistance, balance, and flexibility exercises prescribed to patients were completed. Qualitative data also supported the acceptability and feasibility of the intervention from the perspective of patients and clinicians. The per-patient cost of the intervention was $190.68 to $382.40. Conclusions Embedding an exercise professional into the chemotherapy infusion suite is an acceptable and feasible approach to making exercise standard practice. Moreover, the cost of the intervention is lower than the cost of other common community programs. Future studies should test whether colocating an exercise professional with infusion therapy could reach more patients in comparison with not colocating. Lay summary Few studies have tested the implementation of exercise for patients with cancer by embedding an exercise professional directly into the chemotherapy infusion suite. The Exercise in All Chemotherapy trial shows that this approach is both acceptable and feasible from the perspective of clinicians and patients.

Background Multistakeholder alliances-groups of payers, purchasers, providers, and consumers that voluntarily work together to address local health goals-have increasingly been used to improve health care quality within their communities. Under the Robert Wood Johnson Foundation's Aligning Forces for Quality (AF4Q) initiative, 16 multistakeholder alliances were charged with advancing payment reform as part of a larger effort to achieve dramatic and sustainable quality improvement. Methods Drawing upon key informant interviews with alliance leaders and document reviews conducted from 2010 to 2014, we describe the payment reform projects undertaken by the AF4Q alliances and the roles that the alliances played to advance them. Results The most common types of projects pursued by alliances were those that introduced supplemental payments to fee-for-service reimbursement and built upon alliances' ongoing quality improvement initiatives. Alliances advanced payment reform through 4 roles: (1) educating and advocating, (2) designing payment reform projects, (3) recruiting participants, and (4) supporting the operation of projects. However, less than half of alliances' payment reform projects were operational by 2014. Conclusions Quality improvement-focused multistakeholder alliances may play meaningful roles to advance payment reform, but they are not a panacea for overcoming well-documented barriers to reform.

This analysis assessed the evolution of public reporting of provider performance in Aligning Forces for Quality (AF4Q) alliances, contrasted alliances that stopped reporting with those that plan to continue, and drew insights from alliance public reporting efforts for the national transparency movement.Combined with document review, qualitative research methods were used to analyze interview data collected, over a nearly 10-year period, from the 16 participating alliances.AF4Q alliances made their greatest contributions to provider transparency in reporting ambulatory quality and patient experience measures. However, reporting ambulatory cost/efficiency/utilization measures was more challenging for alliances. Alliances contributed the least with respect to measures of inpatient performance. Six alliances ceased reporting at the end of the AF4Q program because of their inability to develop stable funding sources and overcome stakeholder skepticism about the value of public reporting. Insights provided by alliance leaders included the need to: focus on provider, rather than consumer, responses to public reports as the most likely avenue for improving quality; address the challenge of funding the reporting infrastructure from the beginning; explore collaborations with other entities to increase public reporting efficiency; and develop a strategy for responding to efforts at the national level to increase the availability of information on provider performance.The AF4Q initiative demonstrated that a wide variety of voluntary stakeholder coalitions could develop public reports with financial and technical support. However, the contents of these reports varied considerably, reflecting differences in local environments and alliance strategies. The challenges faced by alliances to maintain their reporting efforts were substantial, and not all alliances chose to report. Nevertheless, there are potential roles for alliances going forward in contributing to the national transparency movement.

The Robert Wood Johnson Foundation's (RWJF's) Aligning Forces for Quality (AF4Q) program was the largest privately funded, community-based quality improvement initiative to date, providing funds and technical assistance (TA) to 16 multi-stakeholder alliances located throughout the United States. This article describes the AF4Q initiative's underlying theory of change, its evolution over time, and the key activities undertaken by alliances.Descriptive overview of a multi-site, community-based quality improvement initiative.We summarized information from program documents, program meetings, observation of alliance activities, and interviews with RWJF staff, TA providers, and AF4Q alliance stakeholders.The AF4Q program was a dynamic initiative, expanding and evolving over time. The underlying theory of change was based on the notion that an aligned, multi-stakeholder approach is superior to independent siloed efforts by stakeholders. Participating alliances developed or strengthened programming to varying degrees in 5 main programmatic areas: (1) measurement and public reporting of healthcare quality, patient experience, cost, and efficiency for ambulatory physician practices and hospitals; (2) efforts to engage consumers in health, healthcare, and alliance governance (consumer engagement); (3) adoption and spread of effective strategies to improve care delivery; (4) advancing healthcare equity; and (5) integration of alliance activities with payment reform initiatives.The AF4Q initiative was an ambitious program affecting multiple leverage points in the healthcare system. AF4Q alliances were provided a similar set of expectations, and given financial support and access to substantial TA. There was considerable variation in how alliances addressed the AF4Q programmatic areas, given differences in their composition, market structure, and history.

This study provides insight into the potential of local community health information websites to cultivate and support consumer engagement through website positioning and content choices.This descriptive study compared health-related websites maintained by 16 multi-stakeholder community alliances charged with improving consumer engagement and public reporting of provider performance data.We systematically assessed website messaging, content, and the presence of explicit connections among information and tools related to consumer engagement behaviors for 32 websites maintained by alliances as of November 2011. These findings were triangulated with information about alliances' public reporting activities from key informant interviews (2007-2011) with stakeholders in 14 alliances.A total of 25 of the 32 alliance websites contained information for consumers, and 14 of those included information related to at least 3 of 4 consumer engagement behaviors: shopping for high-quality providers or treatments, self-advocacy in healthcare encounters, self-management of illness, and partaking in general healthy behaviors. Positioning strategies and tactics to attract consumers varied widely across alliances. Some targeted specific conditions or behaviors; others took a broader community approach. Two alliances had strong alignment between website messaging and consumer engagement content, 7 had moderate alignment, and 7 had limited alignment.Although alliances have been experimenting with a wide array of website approaches, their promise as a tool to improve consumer engagement is still uncertain. Further research that addresses the comparative value of different website approaches is needed.

To describe the approaches used by the Aligning Forces for Quality (AF4Q) alliances in producing community-based reports of physician quality and to assess the contribution of these reports to existing physician performance information.The study included semi-structured interviews with alliance stakeholders and tracking of the number and content of physician performance reports in 14 AF4Q initiative communities and 7 comparison communities.The study used qualitative analysis of interview data and systematic tracking of the number and content of physician performance reports over time.Report production occurred in several stages including initiation, measure selection/specification, measure construction, and dissemination. The measure selection/specification process was often the first major act undertaken by alliances under the AF4Q initiative grant. Alliances utilized nationally endorsed performance measures and made a strategic decision to gain buy-in with physicians. Alliances have experienced greater difficulty in producing buy-in for patient experience measures. The primary decision point for measure construction was the use of administrative claims data or physician-provided medical records data. Overall, AF4Q alliances have contributed to an increase in physician performance information in their communities.Our findings suggest that the AF4Q initiative has accelerated the development and content of physician performance measures in AF4Q communities.