Published as a pamphlet for The Hospital Community Benefits Standards Program.
A NEW CERTIFICATION PROGRAM FOR HOSPITALS THAT MEET HIGH STANDARDS OF COMMUNITY SERVICE
The Hospital Community Benefits Standards Program
Community hospitals in the United States are invited to participate in the Hospital Community Benefit Standards Program (HCBSP) and demonstrate the value of a systematic approach to community service, in accordance with national standards.
These new Standards, developed by the Program's distinguished National Steering Committee, are based on the Community Service policy positions of the. American Hospital Association and the American College of Healthcare Executives. They call for a disciplined, management approach to community benefit objectives, similar to the approach required of hospitals by certification programs related to patient care quality assurance, infection control, medical and nursing education and all other activities.
All hospitals accredited by the joint Commission on Accreditation of Healthcare Organizations or the American Osteopathic Association are eligible to participate. Hospitals interested in participating can file a Letter of Interest with the Program Office at New York University at any time.
Hospitals that could be ready for early certification are invited to apply as pioneering Demonstration Hospitals through February 1, 1991. Interested hospitals should contact the Program Office as soon as possible.
Why Community Benefit Standards for Hospitals?
Rising public concern about the high cost and inaccessibility of quality health services has focused on the community hospital as one of the major causes of the problem, rather than as a catalyst for reform. Increasingly, the hospital is viewed as more concerned with:
- Generating income for survival than with the health of the community;
- Competing to offer the latest application of high technology than with meeting community need and avoiding unnecessary duplication of facilities;
- Meeting the needs of professionals than with serving the poor and disadvantaged; and
- Filling beds with inpatients than with responding to community problems affecting the health status and pocketbooks of the people.
A wide variety of recent initiatives to redirect the energies of community hospitals in the public and community interestthrough the forces of the marketplace, payment incentives and government regulationhave fallen far short of expectations.
These efforts have failed, in part, because they have not enlisted the other major force that has always influenced hospitals: the commitment of most hospital leaders to meet the highest professional standards in fulfilling their mission to serve and benefit their communities. The issue has not yet been addressed in terms of hospital standards.
Today, a hospital can meet every legal and accreditation standard without giving any explicit consideration to the community, except in time of disaster. These standards do not address current issues of community cost effectiveness, redundancy of facilities and accessibility to humane care.
Explicit professional standards have been developed for quality assurance programs for patients and for teaching programs for professionals. There are no comparable standards for the hospitals leadership role in serving the community through development of the most cost-effective and accessible health care system.
The major professional organizations have developed excellent guidelines and codes of ethics spelling out the community service responsibilities of hospitals beyond patient care, but these have never been translated into well-defined community benefit programs at any hospital. Almost all hospitals are committed to serving and benefiting their communities beyond patient care and can identify a wide range of community benefit activities
In the absence of explicit standards for community benefit programs and the rewards associated with meeting the highest standards, however, all but a few hospitals fall far short of their potential for leadership in solving the health service and cost problems in their communities.
In the absence of explicit standards, historical preferential treatment for "community benefit" hospitals is under serious attack, possibly to be limited to those providing adequate "uncompensated care" resulting from inadequate insurance and welfare programs.
The Hospital Community Benefit Standards Program has been funded by the W.K. Kellogg Foundation to address this issue. This new national initiative is designed to demonstrate that:
- New, credible standards, based on established policy positions of the major professional hospital organizations, can assist and encourage leading hospitals to manage highly effective community benefit programs, and
- Community benefit programs based on these standards can put the hospital in the forefront of efforts to reform the health care system and help to resolve the perception of a national health care crisis.
How Are Community Service and Community Benefit Defined?
Many hospital leaders and policy makers have considered community service to be synonymous with uncompensated care and service to the poor. Some take a more expansive view, including health promotion activities, patient education programs and even professional education and medical research activities in their definition.
However, few take the even broader and more focused public health perspective and think of community service as being directed toward improving the cost effectiveness of services and health status of everyone in the hospital's community.
The general thrust of the HCBSP and its Standards is based on the broad notions of community service in the policy positions of the American Hospital Association ("AHA Guidelines on Ethical Conduct for Health Care Institutions," revised November 1987) and the American College of Health-care Executives ("Policy Position on the Community Service Ethic," adopted August 1989, and the ACHE's Code of Ethics, revised August 1988). These policies call for hospitals and health care executives:
- To "be concerned with the overall health status of their communities while continuing to provide direct patient care services."
- "To work to identify and meet the health care needs of the community."
- "To provide access to comprehensive and affordable health care services of high quality."
- "To communicate and work with other health care and social agencies to improve the availability and provision of health promotion, education and services as well as patient care."
In addition, these policies call for hospitals "to take a leadership role in enhancing public health and continuity of care" in their communities. By making the interest of the community a critical element in hospital decision-making, these policies expand hospitals' responsibility beyond the fair and effective use of their own resources "to include efforts to coordinate with others ... and to share in community solutions."
To accomplish these aims, hospitals are expected to "communicate and encourage concern for the community through the entire health care organization-governance, management and direct care givers." The hospital should "become a visible community advocate through greater involvement in community service, social projects and participation in public dialogue on health care policy issues affecting the community."
The Standards are designed to help hospitals translate these national policies into systematic, well-organized programs. This approach is similar to the one taken with hospitals' quality assurance or infection control programs, in which hospitals have shown the value of a standardized, programmatic approach in translating broad aspirations into measurable outcomes.
The Four Standards
The Standards (shown in their entirety on pages 7-8) follow the familiar format of those developed by the joint Commission on Accreditation of Healthcare Organizations. The HCSBP has developed four Standards for hospitals to attain, each followed by a number of required characteristics.
Together, these Standards call for the hospital to develop a systematic program consisting of various activities and projects designed to give more explicit shape and identity to what the hospital is doing to fulfill its community commitment.
Many hospitals will not need to launch new community projects to conform to the Standards. However, nearly all participating hospitals will have to make some changes in how their community service activities are governed, planned, organized, managed, reported and evaluated.
The Standards will serve as effective guidelines to help many hospitals move into previously uncharted waters. For a few leading hospitals, preparation for certification will focus on the sometimes unpleasant task of fitting activities into the framework that any set of credible standards requires. For most hospitals, the impact of the Standards will lie somewhere between these two extremes.
Nevertheless, the Standards were designed to provide hospitals with maximum flexibility to adapt to a uniform framework and to encourage their application to a wide variety of community and hospital circumstances nationwide. Here is an overview of the four Standards:
Standard CB.1: There is evidence of the hospitals formal commitment to a community benefit program for a designated community.
This "umbrella" Standard and its required characteristics focus on the hospital's overall community benefit program. They outline structural and procedural components that assure that the hospital's commitment to its community service mission is community-specific and an integral part of its governance and operations.
For HCBSP purposes, community is defined as all persons and organizations within a reasonably circumscribed geographic area with a sense of interdependence and belonging.
In developing a community benefit program, a hospital needs to determine, with appropriate interaction with community representatives and others serving the community the proper size of its community.
This decision is important because no hospital can set up an effective community benefit program without the active participation of a targeted community.
An approved community benefit program includes commitments by the hospital to:
- Carry out projects to improve health status in the target community, address problems of the underserved and contain the growth of the community's health care costs,
- Provide leadership to stimulate other organizations and individuals outside the hospital to join together in carrying out a broad health agenda for the target community, and
- Foster an internal hospital environment that encourages widespread involvement in the program for the target community within the hospital and among its various constituencies.
Standard CB.2: The scope of the program includes hospital-sponsored projects for the designated community in each of the following areas:
- Improving health status.
- Addressing the health problems of minorities, the poor and other medically under-served populations.
- Containing the growth of community health care costs.
This Standard requires the hospital to sponsor projects that address three essential aspects of a communitys health care system. The Standard also requires that each project have measurable objectives to be achieved within a specified time frame. This approach is similar to the format of the USPHS's Healthy People 2000 objectives and provides a framework that hospitals can use to participate in the attainment of local public health goals.
While the required characteristics suggest alternative projects, at least one in each of the three areas must be designed to increase community awareness and understanding of the underlying issues.
A hospital may not need to initiate projects to meet the requirements of this Standard if it already is carrying out projects that can be continued and extended to the community's benefit.
In addition, a single project may meet requirements for two or more of the required areas. For example, a hospital-sponsored project to encourage full-term obstetrical care might fulfill requirements for all three areas by having the objective of improving health status, being designed to address special problems of an under-served population and reducing overall costs of obstetrical and pediatric care for the community.
Standard CB.3: The hospital's program includes activities designed to stimulate other organizations and individuals to join in carrying out a broad health agenda in the designated community.
This Standard emphasizes the leadership role that a hospital often plays as the leading health organization in the designated community. The hospital is asked to join in partnership with all of the important elements of its designated community. Such a coalition should allow each partner to play an appropriate role in helping to address the community's health care problems.
With the current health care emphasis on competition rather than collaboration, meeting this Standard will require many hospitals to plan group activities carefully and to carry them out with a great deal of patience.
The initial emphasis in meeting this Standard generally will not he on showing concrete results, but rather on a pragmatic process that shows some promise of success. Without appropriate hospital leadership, however, the community cannot achieve optimum results in health status, access or costs, regardless of the significance of individual hospital-sponsored projects.
Targets of this outreach effort include a broad range of health care providers and other individuals and organizations.. Since the hospital has the least control over the elements for success in community outreach, meeting this Standard will be the most difficult in many community situations.
Standard CB.4: The hospital fosters an internal environment that encourages hospitalwide involvement in the program.
This Standard calls for activities and mechanisms to assure appropriate involvement in the community benefit programs by the medical staff organizations and individual physicians, various departments of the hospital, the volunteer program and employees, especially those living in the designated community.
These activities assure that the hospital's program of community benefit is fully integrated with the hospital's more traditional activities and not viewed as an isolated "add-on."
Beginning in 1991, the HCBSP will award national certification to community benefit hospitals that meet the Standards. Compliance will be determined based on a one- to two-day site visit to the hospital and its designated community by peer review teams.
To be eligible for a site visit, a hospital will be required to submit evidence that it has worked with its community in developing a community benefit program that meets the Standards. Once the hospital adequately demonstrates its readiness to receive a site visit, a team of hospital peers and other health care leaders will visit the institution to meet with the hospital and community leaders.
Certified hospitals will be pioneers in establishing the credibility of the new certification program. Various organizations are expected to provide support to such hospitals. For example, certified community benefit hospitals may receive preferential treatment in allocation of capital resources and expenditures for health services.
Meeting the Standards may be a difficult task for many hospitals and may not be suitable for all. Nevertheless, a sufficiently committed hospital leadership trustees, medical staff, nurses and other care givers, management and support staff, employees and volunteers should be able to work with the communities to meet the requirements.
How to Participate in the Program
All U.S. nonfederal short-term general hospitals accredited by the JCAHO or AOA are eligible to participate in the program. Hospitals interested in becoming participants may submit a Letter of Interest signed by the hospital's chief executive officer to the HCBSP office at New York University. In addition to stating an interest in HCBSP participation, the letter should name a contact person at the hospital.
The hospital will then be placed on the program's mailing list to receive the HCBSP newsletters, technical assistance materials and other mailings. It also will have an opportunity to participate in conferences and instructional sessions on community benefit issues and will receive materials to be used in applying for a certification site visit. A modest annual maintenance fee is anticipated to cover costs associated with these services.
Hospitals seeking certification will be expected to pay for the direct costs of a site visit. Such fees will cover the expenses of the site visit team and related costs associated with the certification process.
Becoming a Demonstration Site
The W.K. Kellogg Foundation has provided support to help pay for the site visit expenses for a limited number of pioneering demonstration hospitals. Such hospitals are expected to be ready for early certification and to work closely with the HCBSP staff in helping to refine the certification process.
Hospitals that are interested in becoming demonstration sites can obtain applications from the Program Office at New York University. Applications will be accepted and reviewed on a rolling basis through February 1, 1991. Any hospital that plans to apply for demonstration site status should contact the HCBSP staff as soon as possible.
Two or more hospitals that want to work cooperatively on the requirements of the HCBSP may develop a joint program. In most cases, these joint programs will be carried out in only one designated community.
Some Commonly Asked Questions
What is the long-term goal for the Hospital Community Benefit Standards Program?
The ultimate goal is to demonstrate that our nation's hospitals can be productive catalysts that stimulate community efforts to improve health status, address the special problems of the disadvantaged and contain increases in health care costs.
How does HCBSP expect to accomplish this goal?
By demonstrating that a sufficient number of hospitals can successfully carry out their community service missions under a systematic framework that adds value and credibility to their efforts. If successful, the HCBSP is expected to lead to a self-sustaining organization committed to certifying hospitals that can continue to meet the standards.
What other goals does HCBSP have for itself?
A number of other goals will greatly contribute to the programs long-term success. These include:
- Developing credible standards that hospitals will test to see whether these standards add value to their efforts to undertake community service missions.
- Developing a meaningful certification process that encourages continuous improvement in the carrying out of a community service mission.
- Developing a means to properly identify hospitals committed to being community benefit organizations.
- Identifying ways to protect and enhance various forms of monetary and non-monetary preferential treatment (such as differential payment by third-party payers, special eligibility for grants and various tax preferences) for hospitals that successfully undertake a community service mission.
Have the Standards been developed for government use in determining which hospitals should retain tax exemption?
No! The Standards are designed to identify hospitals committed to doing much more for their communities, in a systematic way, than the government could require. Nevertheless, as governments develop more explicit requirements for granting tax exemptions to hospitals, hospitals meeting the Standards will undoubtedly be in a strong position.
Is the program designed only to identify a small number of elite hospitals?
Definitely not. At the onset, it is important to identify hospitals that can set an example for others and to demonstrate that these hospitals can meet the Standards. But the basic goal of the program and the expectation, is that by the end of the three-year program, most hospitals will seek certification as community benefit hospitals.
Why is it that the Standards make no reference to "uncompensated care"? Shouldn't this be part of any hospital's community benefit program?
In meeting its community's health care needs, a hospital should take steps to assure adequate access to patient care services for all persons, regardless of their financial status. In the absence of adequate insurance coverage and government entitlement for all, hospitals are continually called upon to meet a wide range of patient care needs without reimbursement to cover the full costs of providing care.
While such unreimbursed care is of great importance to the individuals who lack insurance, their families and the overall community, such services are viewed as basic to a hospital's patient care mission rather than as part of its community benefit program. The justification for such thinking is evidenced by the need for hospitals and their committees to make special efforts to address the health problems, of the disadvantaged that go far beyond the provision of uncompensated care.
The HCBSP staff and national steering committee hope that insurance entitlement will soon be made available to all. Nevertheless, even if this occurs, hospitals and their communities still will need to undertake special initiatives for the disadvantaged in their communities.
Why would a hospital want to be certified by the HCBSP when it neither receives any money for its success nor is required to do so by the government?
Those who conceived and funded the HCSP are convinced that a number of hospitals are so committed to serving their communities that they will want the special recognition and other benefits that certification can bring. Also, many hospitals realize that continuous improvement in their community service efforts will be enhanced by participation in the HCBSP, which provides both a systematic framework and peer consultation as support.
What is the relationship between HCBSP Standards and the Joint Commission's standards?
HCBSP Standards are intended to supplement, not substitute for, JCAHO standards. One possible outcome of the program would he adoption by JCAHO of the HCBSP Standards for accredited hospitals that want to be identified as meeting additional community benefit standards.
The Standards seem very process oriented. Isn't the HCBSP also concerned about outcomes?
Nobody can quantitatively measure how much community benefit a hospital provides. Likewise, the HCBSP cant set outcome standards for determining how much community benefit is enough for a hospital to earn certification. For those reasons, the HCBSP has chosen to use a set of structure and process standards.
Hospitals are required to set outcome objectives for their specific projects. The point is that the hospital, not the HCBSP, should set these objectives.
The Standards call for participating hospitals to contain the growth of community health care costs. Can a hospital be eligible for certification if the health care costs of its community continue to rise at a rate exceeding the national average?
Yes. The hospital can be certified as long as it has selected a number of appropriate projects to contain community health care costs and is carrying out these projects effectively. Some hospital-sponsored projects may not show demonstrable results for two, three or even five years. In the meantime, progress toward achieving the goal can be assessed.
Also, the hospital is not solely responsible for containing community health care costs. Instead, its responsibility is to provide leadership in the community's efforts to deal with the problem. Site visit teams will take these factors into consideration.
How large must a designated community be to meet Standards requirements?
No specific size has been set, in terms of either area or population. Instead, in designating a community, a hospital should consider its ability to design programs and work with others in a manner that is neither overwhelming nor unwieldy. It may be advisable to start with a small community, one that is much more limited than the hospital's service area for patient care.
How do hospitals, particularly in metropolitan areas, avoid overlap in designating communities?
In metropolitan and other multi-hospital communities, overlapping is almost inevitable. When this occurs, the Standards call for cooperation among affected hospitals to coordinate efforts so that they do not conflict or create confusion within the community.
How much of a commitment of resources, personnel and otherwise, will it take for a hospital to meet the standards?
The answer to this question depends on how the hospital currently employs its personnel and other resources in relation to the community. While some hospitals may have to spend more money initially, others may be able to develop a community benefit program by redirecting their current resources.
Some hospitals may find that their community benefit efforts will result in their being able to attract both philanthropic and government grants to help support their community service efforts.
Who will serve on the site teams that will visit participating hospitals?
The HCBSP plans to use respected peers in the hospital field to act as site visitors. Such persons are expected to serve in this capacity on a volunteer basis. Many of these people will ultimately be drawn from community benefit certified hospitals that have been able to carry out a community service mission in an exemplary manner.
Are investor-owned or governmental hospitals eligible to be HCBSP demonstration sites or program participants?
Yes. All nonfederal JCAHO or AOA-accredited hospitals are eligible to participate in the program, regardless of their organizational form.
Will demonstration hospitals receive any money for their pioneering efforts?
No. They will not receive any cash grant. However, they will receive technical assistance and advice to support their efforts to make the necessary changes to meet the Standards. They also are likely to receive much public attention and support for their efforts.
Hospital Community Benefit Standards
Standard CB.1 There is evidence of the hospital's formal commitment to a community benefit program for a designated community.
In these standards, community is defined as all persons and organizations within a reasonably circumscribed geographic area, in which there is a sense of interdependence and belonging. Although the singular form of "community" is used, a hospital may designate two or more communities to be part of its community benefit program, as appropriate.
CB.1.1 The governing body is responsible for designating a community as the focus of the hospital's program.
CB.1.2 The governing body adopts a mission statement that includes a commitment to carry out the program.
CB.1.3 The governing body establishes goals and objectives, and approves an operating plan to enable the hospital to:
CB.1.3.1 Carry out projects to improve community health status: address the health problems of minorities, the poor and other medically underserved populations; and contain the growth of community health care costs (See CB.2);
CB.1.3.2 Stimulate other organizations and individuals to join in carrying out a broad community health agenda (See CB.3): and CB.1.3.3 Foster an internal environment that encourages hospitalwide involvement in the program (See CB.4).
CB.1.4 The community benefit program is effectively managed and regularly evaluated.
C22.214.171.124 The governing body delegates to the chief executive officer the responsibility for overall management of the program.
CB.1.4.2 The chief executive officer or designate carries out managerial tasks including: development of program goals and objectives, program planning, liaison and outreach activities, development of data and information, and day-to-day monitoring and control.
CB.1.4.3 There are mechanisms established to evaluate the program's effectiveness and appropriateness on at least an annual basis.
CB. 1.5 There are hospital resources identified to carry out the program activities.
CB.1.6 The hospital participates in the preparation and dissemination of an annual program report which includes:
CB. 1.6.1 A disclosure of relevant communitywide data including information on health status; the special problems of minorities, the poor and other medically underserved populations; and health care costs of the community.
CB.1.6.2 A description of hospital-sponsored projects.
CB.1.6.3 A description of the hospital's activities that further a broad community health agenda.
CB.1.6.4 An evaluation of program activities and their respective contributions in achieving program goals and objectives.
CB.1.7 The hospital provides a means for annual public comment on the program's overall effectiveness and appropriateness.
Standard CB.2 The scope of the program includes hospital-sponsored projects for
the designated community in each of the following areas:
- Improving health status;
- Addressing the health problems of minorities, the poor and other medically underserved populations; and Containing the growth of health care costs.
C13.2.1 The hospital sponsors projects that are designed to improve the community's health status.
CB.2.1.1 Measurable objectives are specified for these projects to be achieved within a specified time frame
CB.2.1.2 One project involves an effort to increase awareness and understanding of health status indicators, and the activities that are expected to favorably affect these indicators.
CB.2.1.3 Other projects to accomplish health status objectives may include:
CB.126.96.36.199 Sponsoring disease prevention and/or health education programs.
CB.188.8.131.52 Sponsoring health care programs for individuals with special health care problems.
CB.184.108.40.206 Sponsoring efforts to improve the community's health through economic and community development
CB.2.I.3.4 Developing quality assessment programs for community health care settings that currently lack these programs and, if feasible,assisti. in their implementation.
CB.220.127.116.11 Implementing other projects to improve community health status.
CB.2.2 The hospital participates in projects to address the health problems of minorities, the poor and other medically underserved populations.
CB.2.2.1 Measurable objectives are specified for these projects to be achieved within a specified time frame
CB.2.2.2 One project involves an effort to increase awareness of the special health care problems of minorities, the poor and other medically underserved populations, and the activities that might address these problems.
CB.2.2.3 Other projects to accomplish these objectives may include:
CB.18.104.22.168 Improving accessibility and continuity of care for minorities, the poor and other medically underserved populations.
CB.22.214.171.124 Working to reduce the disparities in health status which exist among racial and ethnic minorities.
CB.126.96.36.199 Sponsoring efforts to increase the number of minorities, poor and other medically underserved populations who enter health professions and who work in medically underserved communities.
CB.188.8.131.52 Participating in other activities that address the health problems of minorities, the poor and other medically underserved populations.
CB.2.3 The hospital participates in projects that are designed to contain the growth of the communitys health care costs.
CB.2.3.1 Measurable objectives are specified for these projects to be achieved within a specified time frame.
CB.2.3.2 One project involves an effort to increase awareness of the magnitude and the rate of growth of the Communitys health care costs, and the activities that might contain the growth of these costs.
CB.2.3.3 Other projects to accomplish these objectives may include:
CB.2.3.3. 1 Improving the efficiency of specified health care services.
CB.184.108.40.206 Improving case management and continuity of care for individuals with special health care problems.
CB.220.127.116.11 Sponsoring health promotion, disease prevention or self-care activities that lead to the containment of the growth of health care costs.
CB.18.104.22.168 Reducing and/or avoiding redundancy of specific health care services.
CB.22.214.171.124 Carrying out other activities to contain the growth of health care costs.
Standard CB-3 The hospitals program includes activities designed to stimulate other organizations and individuals to join in carrying out a broad health agenda in the designated community.
CB-3.1 The hospital cultivates and maintains effective relationships with other health care and community organizations to increase common awareness and sensitivity to the designated community's health care problems.
CB-3.2 The hospital works with others to identify specific community health care problems and approaches to their solutions.
CB.3.3 The hospital works with others to assist in the implementation of activities that further a broad community health agenda.
CB-3.4 The hospital encourages the involvement of leaders from the following community groups in fulfilling Required Characteristics CB.3.1 through CB.3.4.1 Minorities, the poor and medically underserved populations: B.3.4.2 Other hospitals and health care organizations: B.3.4.3 Other community organizations: B.3.4.4 The local public health department and other governmental agencies; B-3.4.5 Educational institutions: CB.3.4.6 Physicians, nurses and other health professionals; and B-3.4.7 Other individuals as deemed appropriate.
Standard CB.4 The hospital fosters an internal environment that encourages hospitalwide involvement in the program.
CB.4.1 The medical staff is appropriately integrated into the activities of the program.
CB.4.1.1 The medical staff organization has a mechanism to encourage medical staff participation in program activities.
CB.4.1.2 Individual members of the medical staff are provided specific opportunities to participate in the activities of the program.
CB.4.2 Hospital employees are appropriately integrated into the activities of the program.
CB.4.2.1 There is a special effort to include those employees who reside in the designated community.
CB.4.2.2 Individual employees are provided specific opportunities to participate in the activities of the program.
CB.4.3 There is a mechanism to foster cooperation among all departments in the hospital that should participate in the program.
CB.4.4 The hospitals volunteer activities are appropriately integrated into the program.