Throughout the United States, efforts are being made to improve the overall quality of healthcare, reduce racial and ethnic disparities, and provide models for national reform. One such effort is the Aligning Forces for Quality (AF4Q) program. Supported by the Robert Wood Johnson Foundation, the AF4Q program brought together hospitals in 16 geographically, demographically, and economically diverse communities that together cover 12.5% of the U.S. population. Ranging from major metropolitan areas to a Northern California county of 260,000 people, each community partaking in the program makes concerted efforts to address public reporting of quality, patient engagement in care decisions, and physician payment.

Each of the 16 communities participated in the AF4Q Hospital Quality Network (HQN). Teams at participating hospitals came together for learning sessions via webinars to identify where problems existed and how they had been addressed. According to Robert Graham, MD, two of the areas focused on for the HQN program were reducing readmissions and improving language services. Catherine A. West, MS, RN, adds that process and outcomes measures were collected and reported monthly to the AF4Q National Program Office at George Washington University.

Reducing Hospital Readmissions

“The AF4Q program focused strongly on readmissions among patients with congestive heart failure because of their high risk for being readmitted,” says Dr. Graham. “Across the board, participating hospitals achieved the most success with early identification of these patients and participation in transitions programs [Table 1]. These programs allow for patients to know—as they’re discharged—exactly what they need to do, what has changed, why it’s changed, and how to link with physicians in the community. The key is to ensure that contact with patients isn’t lost.”

Improving Language Services with Patients

Communicating in a language patients can understand is fundamental for the receipt and provision of safe, high-quality healthcare, says West. Efforts to improve language services in AF4Q included screening for preferred spoken and written language for healthcare and assuring that patients received language services from qualified providers. Dr. Graham adds that “providers must know the characteristics of their patient population to determine if disparities are present. Unfortunately, many hospitals were not acquiring that data.”

Hospitals were trained in the standardized collection of patient self-reported race, ethnicity, and language data, explains West (Table 2). “This allowed hospital staff to determine the role of language and understanding of discharge instructions in readmission rates,” says Dr. Graham. “This information can be used to determine if hospitals need to be prepared to communicate with patients in languages other than English.”

Achieving A Culture of Teamwork

“The AF4Q program was successful because it helped hospitals tackle key issues that are local and national priorities,” says West. “The virtual format of the program enabled participants to reduce expenses and encourage learning and sharing of ideas and strategies with others across the country. Hospitals used multidisciplinary teams to identify needed changes and solve problems, and to test changes to ensure their efficacy before implementation.”

A culture of teamwork was critical to the program’s success, according to both West and Dr. Graham. “Collaborating with team members who bring their own unique skill sets to address a particular problem can improve outcomes more than working in isolation,” adds Dr. Graham.

Hospitals that implement practices from the HQN program are likely to experience similar successes, according to Dr. Graham. “Barriers do exist,” he says, “but with proper leadership, supportive administration, and staff who care about quality issues and take responsibility to see it through, hospitals will reap the rewards.”


Robert Wood Johnson Foundation. Aligning forces for quality hospital quality network: what did the collaborative accomplish? Available at

Hood V, Weinberger S. High value, cost-conscious care: an international imperative. Eur J Intern Med. 2012;23:495-498.

Chin J, O’Dowd S, Wan Md Adnan W, et al. Using the MDRD value as an outcome predictor in emergency medical admissions. Nephrol Dial Transplant. 2011;26:3155-3159.

Morris D, Reilly P, Rohrbach J, et al. The influence of unit-based nurse practitioners on hospital outcomes and readmission rates for patients with trauma. J Trauma Acute Care Surg. 2012;73:474-478.

Chadaga S, Shockley L, Keniston A, et al. Hospitalist-Led medicine emergency department team: Associations with throughput, timeliness of patient care, and satisfaction. J Hosp Med. 2012 Aug 3. [Epub ahead of print]. Available at;jsessionid=FDC32009F30AB97DFDCE1434D4435602.d03t02.

Imperato J, Morris D, Binder D, et al. Physician in triage improves emergency department patient throughput. Intern Emerg Med. 2012 Aug 3. [Epub ahead of print]. Available at

White B, Biddinger P, Chang Y, et al. Boarding inpatients in the emergency department increases discharged patient length of stay. J Emerg Med. 2012 Jul 4. [Epub ahead of print]. Available at