As printed in Michigan Health & Hospitals Magazine, July/August 1999

BY ROBERT M. SIGMOND

Almost all tax-exempt health care organizations were created to benefit their communities, and that mission influenced every aspect of the organization, its management and structure. Eventually, the commitment to community benefits has become so taken for granted that it is missing from most organization charts and strategic plans that I have reviewed recently. Understandably, quality patient care and economic survival are the major factors currently influencing decisions about organization and management.

Today, there is renewed interest in community benefits, sometimes more closely associated with uncompensated care, tax status and bottom line than with organized activities to benefit target communities. An increasing number of institutions are systematically organizing and managing their community services to assure measurable results. Organizational models are available from the recent Kellogg Foundation-funded Hospital Community Benefits Standards Program at New York University and elsewhere (see sidebar). To date, however, there is no generally accepted model for the organization and management of such programs.

The earliest examination of this question at NYU in 1988 did not recommend assigning this function to a particular department. Rather, these standards called for the chief executive officer to assume overall responsibility. In this formulation, the CEO or a designee carries out the managerial tasks, including development of program goals and objectives, program planning, liaison and outreach activities, development of data and information, and also day-to-day monitoring and control. This approach reflects an important insight of the NYU study group: That community benefit initiatives can be nurtured in any managerial unit of the organization when initiatives are strongly supported by the CEO and the CEO's staff.

Moving in a different direction, some institutions assign the management responsibility to an existing department, such as public relations, marketing, community health improvement, community affairs or community relations. A few have created a separate community benefits office reporting to one of the senior executives. Some of these organizational arrangements have been more successful than others. The most successful emphasize the dependence of the overall program management on the community service activities of every other department.

In my experience, when community benefit initiatives are seen as nothing more than an element of the institution's public and community relations, marketing or community health improvement program, there is usually limited buy-in by the many individuals in other departments who are already involved in some form of community service. Understandably, their initial reaction is to avoid becoming a managed element of another department's community benefits program that they do not understand. As a result, in managing a community benefits program, the widest involvement and collaboration of all elements of the organization is at least as important as collaboration with organizations in the community. Managing a community benefits program is very much a job in building effective relationships and commitment throughout the organization, much like managing a risk management program, an infection control program, or a cost containment program. In a community benefits program, the real activity is in all the departments that have interactive community contacts.

In some organizations, the department managing the community benefits program sees its job as promoting and supporting initiatives outside the medical model, with little involvement of the medical and nursing staffs and others involved in patient care. As important as these activities are, bringing community initiatives within the medical model is the real challenge for health services organizations, even as they support initiatives outside the medical model.

Accordingly, a community benefits program will have the greatest impact if it devotes the most energy internally to help all managers develop community benefits goals, involving disciplined relationships with various community organizations with shared interests. Most frequent examples are obstetrics, pediatrics, the emergency service, ambulatory service and social service. But there are many other examples, including dietary departments involved with community initiatives such as diabetes, or maintenance departments deeply involved in community approaches to asthma control.

For further reading about organization and management in increasingly complex health system environments, I recommend a book just published by the VHA Michigan Inc., titled Edgeware (see sidebar). Edgeware applies complexity theory to health care in a way that can help you manage community benefits initiatives as vital bridges between every aspect of the organization and the communities it serves. Edgeware introduces a new way of seeing the whole organization as a complex adaptive system composed of interdependent relationships among the various somewhat autonomous elements of the health care establishment, such as the medical staff members, and with all of the elements of the communities served.

ROBERT M. SIGMOND IS A SCHOLAR IN-RESIDENCE AT THE DEPARTMENT OF HEALTH ADMINISTRATION AT TEMPLE UNIVERSITY, PHILADELPHIA, AND SPECIAL ADVISOR TO THE HEALTH RESEARCH AND EDUCATIONAL TRUST AT THE AMERICAN HOSPITAL ASSOCIATION.

07/06/2000