In 2007 we launched the first phase of Aligning Forces for Quality: The Regional Market Project, a long-term, multimillion-dollar commitment to help a number of test communities reweave the fabric of their own local health care system into a stronger, more resilient, higher-quality tapestry of care across its fullest continuum.

The delivery and quality of health care is determined by a mix of factors unique to each distinct locale. Coast-to-coast, many of the problems may be common. But market-to-market, the solutions are not. What works well in one region may not work at all in another. Though each community struggles to find its own answers, so far none have succeeded.

The reasons are varied and complicated. Progress may be impeded by tough, even adversarial competition among providers. Some stakeholders may not know how to talk to each other. What is best for patient care may be overridden by the corporate focus on the bottom line, especially in uncertain economic times. The absence of commonly accepted standards of quality care may make accountability for providers’ practices and outcomes difficult. And the lack of clear, reliable public reporting on hospital and physician performance leaves patients and consumers perpetually in the dark.

Put simply, forces and factors that should be in alignment are out of alignment. Our new program will help local and regional health care leaders and stakeholders realign themselves to provide their people and communities with better quality health care.

We call it AF4Q. This is not piecemeal, incremental, short-term (and unsuccessful) health system reform as usual. It has no politics or partisanship of its own. If it did, it wouldn’t work and we wouldn’t do it. Rather, it is an unprecedented regionally determined clinical, social and economic market realignment that calls upon enlightened and aspirational local leadership, intentional collaboration, reliance on evidence-based action, public reporting and accountability, and public participation in deciding how quality health care is delivered to the community.

AF4Q is a first-of-its-kind effort that is as much a call to community action as it is a potent formula to bring the best possible medical care and peace of mind to as many people and their families as possible.

Each AF4Q community is typically American and typically one-of-a-kind. They include significant urban-suburban centers, small stand-alone cities, exurban and semi-rural counties, even entire states. Differences in geography, history, demographics, economics, politics and social structures would suggest they have little in common.

Yet, there are dynamic similarities. Each region has one or more energetic, self-motivated entities already working on their own to give people better care. In one community it may be physicians, in another the hospitals, in a third the business community. Many players are proven veterans of teamwork and predisposed to collaboration. All want to deliver better care.

As the organizing philanthropy, we are the catalyst that motivates and mobilizes AF4Q regional stakeholders with a shared vision and common goals. We help develop their leadership, support them with expertise and resources, and guarantee to stick with them until momentum is secured, their own benchmarks are met and success achieved, as determined by evidence and evaluation.

AF4Q is not realignment by top-down edict but by bottom-up leadership and innovation. Decisions, actions and accountability are in local hands from start to finish. It is up to community, civic, health care and business leaders—and the people themselves—to agree on their own quality improvement goals and desired outcomes. This is their trek; we are merely the sherpas.

Our vision of the way forward is framed by our understanding that quality of care improves (1) when providers cooperate in a system that is safe, fair, inclusive, and devoted to getting it right; (2) when providers openly report to the public how they measure up to quality performance standards; and (3) when people are well-informed and take an active role with doctors, nurses and hospitals in the management of their own care.

Aligning Forces communities are at work now. They are tailoring their strategies to conform to the regional scale of local solutions while matching the wider scope of an obviously national challenge. True trailblazers, they seek not small gains but improvements dramatic enough to trigger significant advances in quality that can be measured, replicated and built upon.

We feel fortunate to be supporting them. The lessons they are teaching us are encouraging enough that we can grow and expand these efforts. Like that long-ago study in Vermont, we expect AF4Q to stand as a beacon that illuminates health care’s way far into the future.

“Record Number of Students Apply to Medical Schools”

The Bloomberg.com headline caught my attention right away. The story reported that the country’s 126 medical schools attracted 42,315 applicants in 2007, the most ever. Nearly 18,000 students were accepted, also a record.

One associate dean explained that today’s medical school applicants “are in a world that is changing and scary and unstable.” In medicine, he said reassuringly, they see a way to “do something for the benefit of mankind.’’

It takes about eight years to become a fully functional novice physician, so today’s new pre-med students will receive their M.D.s in 2015. That’s not that far away; it is the same year we expect to have measurable results from AF4Q.

When this newest generation of physicians steps out into their profession we want them to find a realigned realm of health care that is vastly improved by the collective experiences of our AF4Q innovators. A world where . . .

• Health care works the way it’s supposed to work.
• Health care is affordable, accessible, appropriate and equitable.
• The care that is delivered is the care that should be delivered.
• People choose care providers based on public performance information.
• Problems of quality, safety and inequality are fading memories.
• Safety and accountability are a given.
• The system centers on taking care of patients, rather than taking care of itself.

Creating this improved world is all about the art and science of discovery and change, familiar territory for the Robert Wood Johnson Foundation and the people, organizations and communities we work with. We believe improving quality is, indeed, the tipping point issue for health care in America.

How to fix health care has confounded the people of this country and our leaders for most of four generations. That includes every Congress from the 80th through the 110th and every president from No. 33, Truman, through No. 43, G. W. Bush. Each has tried and all have failed. The reasons are manifold, the culprits plentiful, and through the advancing political seasons the forces of divisiveness, cynicism, self interest, greed and gridlock seem to doom each new attempt before it barely gets off the ground.

This time, though, is different. This time a set of different forces are at play.

It has been said that “America is the civilization of people engaged in transforming themselves,”¹⁸ an awesome endeavor that demands vision, hard work, leadership and organization. In most other societies that means government.

In America, however, that more often means what Duke Law and Public Policy Prof. Joel Fleishman calls the “civic sector.” Not the public or the private sector, but a third and transformative force in how we as a people take care of ourselves. Philanthropy is at the civic sector’s center, taking private action for the common good in ways that public and for-profit sectors cannot or will not attempt. In other words, don’t tell us what to do—show us what to do—and we will do it.

In what reads like a mission statement for AF4Q, Prof. Fleishman says that foundations such as ours seed a problematic field with research and trials, clarify a vision for change, define clear and achievable goals, devise evidence-based strategies to get us there, recruit the partners needed to get the job done, and drive society toward the sweet spot on the horizon. It is not our role to dictate what exactly should be done. But we can cultivate and maintain an environment that allows others to find common ground and agree on common action where none existed before.

We know how to do this. We have years of experience working with communities, power players and strange bedfellows. We know what it takes to turn wary competitors into enthusiastic partners capable of connecting the dots and trusting one another as they do it.

Our only agenda is the success of others in transforming their own spheres of interest and influence. Washington and the usual crew of insiders cannot do this. Philanthropy and the civic sector can. Informed by solid evidence, led by the best minds and tested leaders, and empowered by an informed public that expects—demands!—better health care.

This is hard work, social transformation down in the trenches, where far-reaching and consequential change must begin. Some will wish us well; some will not. Some will share our vision; some will choose not to see at all. Some will embrace quality and change; some will fight it; some simply will hide from it.

As for us, we turn to the time-tested wisdom of an old Nigerian tribal proverb, the one that tells us . . .

“In the moment of crisis the wise build bridges, the foolish build dams.”

Health care in America is in its full moment of crisis. As a people, we have a choice to make. Do we fight or do we flee? Do we build bridges or do we build dams? The Robert Wood Johnson Foundation is in the business of building bridges. We think America and Americans are too.

Respectfully submitted,

Risa Lavizzo-Mourey, M.D., M.B.A.

President and Chief Executive Officer