Back in 2006, the Robert Wood Johnson Foundation began a four-site pilot program called Aligning Forces for Quality (aka AF4Q). It's now a multi-faceted laboratory for reform, active in 17 very different communities, home to 38 million people. We wrote about it a bit in 2008 (here) and took a closer look at one diabetes program, but decided it was finally time to chat with Bruce Siegel, who directs its national program office based here in DC. We’ll delve more deeply into some aligning forces projects in the future, (we are still working our way down our March to-do list… is it going to stay this busy all the way through 2014?) but here is some of what we learned from Seigel.
Quality -- attaining it, improving it -- is at the heart of health reform. Coverage is immensely important, but access to care only goes so far if it's not access to quality care. Quality is attainable. There are examples all over America. There are examples in all the Aligning for Quality communities.
"Most of what you see in health reform is already happening in our communities," Siegel told me. Health reform can accelerate the process of improvement, by changing payment incentives and by creating new pathways for change, i.e. the Center for Medicare and Medicaid Innovation.
Quality has many strands. Performance must be measured. Measurements must be reported publicly. And the reporting has to be accessible -- accessible in the sense that people can actually use it, not just see it on a spread sheet on a website. Consumers must be engaged in ways that let them make informed choices about their medical care.
Health IT has to be part of the quality process, but health IT has to be deployed in ways that actually enhance care. "It’s more than electrons," Siegel said. AF4Q also finds ways for doctors, hospitals, consumers, payers and employers to come together to "try to move the ball in terms of improving health care."
One example Siegel cited is in Minnesota, where colorectal cancer screening is up, because physician practices have become engaged. "A core piece is public reporting," Siegel said. When there is transparency, when patients can see how doctors are doing, and doctors can see what their peers are doing, understanding deepens, and quality improves.
"If you shine a light on it, you get physicians more aware." Without data collection and reporting, physicians may sincerely believe they are doing a perfectly fine job. Once data are compiled and reported, doctors have a clearer picture and a yardstick to measure improvement. "It can be an 'Aha moment' and create a thirst for change."
Other programs aim to help patients -- for instance, diabetics -- do more and better self-care and monitoring, as well as learn to communicate better with their physician so they know what to ask and how to ask it at an appointment. In other words, not just to be an engaged consumer, but to be a smartly engaged consumer. In the Buffalo area, there’s an additional twist, where “practice enhancement associates” (often but not always nurses) do a stint in the offices of participating doctors. They teach them how to analyze their own patient charts differently and do basic quality measures, which in turn can help doctors make care more consistent. (This can be done on old-fashioned paper charts for practices that have not moved to electronic medical records.) Once the physician or physicians in the practice learn, they can continue it themselves without the “enhancement” associate.
Of course, the task is not just finding isolated projects that work in specific pilot program settings. It’s making sure these projects work (perhaps with some local variation) in multiple settings and then making them be part of the fabric of tomorrow’s health care world. The communities taking part in AF4Q vary socioeconomically and geographically but they already had some record of innovation, they were ready to be early adopters. The challenge now is to spread what works into other communities who may not be change-friendly. Siegel said there is also more focus on the cost-quality connection -- how to improve care while restraining cost increases or even bringing down cost. Payment reforms that will incentivize quality and value will help.
Though Siegel is a medical doctor, he does research and policy and public health and doesn’t currently see individual patients. (His wife is a practicing pediatrician.) So his experience in AF4Q isn’t changing how he, personally, practices medicine. But he told me it has changed his experience as a patient, or "engaged consumer." He finds it frustrating that in his home state of Maryland, he can’t get all the quality and performance data that he would like. "How do I know the doctor I go to is good?" he wondered. He also prepares for a visit to the doctor differently than he used to, writing down questions in advance. In the past, he said, even though he is a physician he would still go in and not realize what he missed until he got home and "my wife would say, 'Did you ask about A,B,C and D.'" He has aligned his own force for quality care.