Aligning Forces for Quality (AF4Q) was the Robert Wood Johnson Foundation’s signature effort to lift the overall quality of health care in targeted communities, as well as reduce racial and ethnic disparities and provide real models for national reform. As with other major initiatives, the Robert Wood Johnson Foundation (the Foundation) contracted with a national program office (NPO) to implement and manage all aspects of AF4Q. The AF4Q program, however, was unique given its duration (nine years), its scope (multiple areas of focus), and the ramifications of major health care legislation enacted during the program. The AF4Q multi-stakeholder collaboratives in each community, called “Alliances,” went through four rounds of funding. Program expectations evolved with each new phase. Alliances were expected to work in many different areas, including performance measurement and public reporting, consumer engagement, patient experience, ambulatory quality improvement, hospital quality improvement, disparities, payment reform, cost reduction, and care across settings. Alliances also established and pursued community-specific quality and cost goals. In the middle of the AF4Q program, federal legislation, namely the HITECH Act and the Affordable Care Act, greatly impacted the policy environment.

Given the scope and complexity of AF4Q, the NPO focused substantial resources on building the infrastructure needed to support such a long-lasting and comprehensive project. The structure of staff, processes, and communication mechanisms constantly evolved over the course of AF4Q in order to make the Foundation’s vision operational and to support the grantees in their efforts to meet program expectations. The NPO’s ability to be flexible was critical given the changing program expectations accompanying each new funding phase. The NPO was the vehicle for implementation, coordination, and knowledge capture and was responsible for ultimately translating the Foundation’s conceptual vision into day-to-day strategies.