The Aligning Forces for Quality initiative: background and evolution from 2005 to 2015

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.