As printed in Michigan Health & Hospitals Magazine, May/June 1998

BY ROBERT M. SIGMOND

Community accountability is much more complex than accountability for care of patients or populations. This is because there are many more variables the health services organization cannot control. Even in care of patients, the organization cannot be in complete control, as reflected in breakdowns in patient compliance. In care of enrolled or entitled populations, the inability to control people's lifestyle is a constant challenge. In care of communities, the much larger challenge involves the added dependence on collaboration with a multitude of independent community organizations that together have the greatest potential impact on community health.

Community benefits accountability is the process of keeping promises about doing good for targeted communities. Organizations with community benefit experience have learned to be conservative in this respect, avoiding promises that may not be kept. That is because credibility is undermined by failure to live up to community expectations. In making such promises, my advice is to assume that the bookies are taking bets on your promises; be a visionary, but a very pragmatic one!

Community accountability necessarily calls for

1. involvement with targeted communities,
2. quantifiable benefits promised to these communities,
3. building community accountability into management processes, and
4. evaluation of results. Each of these accountability elements are not as simple as they might seem.

Community service is not usually identified with specific communities. For community benefits accountability, however, identification of one or more target communities is essential.

Organizations that still refer to their community in the singular have not yet begun to address accountability issues. Every organization, like every individual, is identified with a multiplicity of communities, each of which can be targeted for community benefit initiatives.

Remember the basic community definition for community benefit programming: All persons and organizations within a reasonably circumscribed geographic area, in which there is a sense of interdependence and belonging. Following this definition, the organization can target the neighborhood in which it is located, nearby ethnic neighborhoods, sections of town, the city, the county, the region, the state, the nation and even the world - or all of the above! The larger the community, the more difficult to keep promises because of the extent of effective collaboration required. Most organizations are well-advised to focus initially on promises to the immediate neighborhood and to limited populations in the service area, expanding their commitments as they gain necessary experience and reliable collaborators for results in larger areas. No organization can do it alone!

Most promises involve initiatives designed to improve the health status of the community's population, narrow the gap between the health status of more and less disadvantaged populations, or contain the costs and improve the effectiveness of the community's health system. Other initiatives might be designed to improve the quality of life, expand employment opportunities, and much more. Initially, promises that build quantitative goals into ongoing community services generally take precedence over initiatives that have higher priority when implementing a formal needs assessment. Recognizing that the organization's chief community assets are the staff actively involved in unstructured community service is why many institutions conduct an internal community assets assessment before undertaking a needs assessment. Committed physicians, nurses, social workers and others involved in obstetrics, pediatrics, emergency service and geriatrics are usually the most important resources to draw upon.

Promises should be expressed in terms of time-dated measurable results. Some institutions promise specific health status outcomes, but these usually have to be dated too many years ahead to be useful by themselves. Initially, short-term results, measuring improvements in structure or processes rather than outcomes, will have greater credibility. Promising more pre-natal clinic sessions or staffing for a larger number of pre-natal visits will be more credible than simply promising a reduction in infant mortality.

Keeping community promises is dependent on changing organizational management structures and processes to treat these commitments as important as other commitments to accreditation and regulatory bodies, bonding authorities, managed care organizations and other payment agencies. This frequently calls for basic changes in internal accountability arrangements and incentives, as well as expanded application of principles of total quality management beyond the organization's walls.

Community accountability requires explicit attention to evaluation of results. The most important test is the response of community organizations with interest in the results. Do they agree that the promised results were achieved and are relevant? From the beginning, the organization is well-advised to incorporate well-known processes for evaluation by the targeted communities themselves. Beyond that, the organization should share the results with official agencies, accrediting bodies and collaborating organizations for their input, as well as with professional evaluation specialists.

As an organization becomes more involved in accountability for community benefits, it will inevitably support the development of healthy community collaboratives in each of its targeted communities. As these collaboratives gain strength, they will play an ever more dominant role in the organization's community benefits accountability. In the long-term, the organization's community accountability should be folded into the accountability structure of these collaboratives. At present, however, most hospitals and health systems must have the courage and patience to set their own course in community benefit collaboration, working with many different organizations, even as they help each community organize effectively to take charge of its future.

ROBERT M. SIGMOND IS A SCHOLAR-IN-RESIDENCE AT THE DEPARTMENT OF HEALTH ADMINISTRATION AT TEMPLE UNIVERSITY, PHILADELPHIA

07/06/2000