US Hospital Awards and Community Health Improvement

In a 2016 report, the American Hospital Association (AHA) stated that “across the country, health care needs are growing and changing. . . . Now, more than ever, it’s important that hospitals effectively connect with their communities—with their patients, with their caregivers and with their neighbors” (bit.ly/2nMOurO).

National awards define and recognize excellence in the hospital industry. In general, awards are thought to have a net positive impact on participants’ motivation and performance.¹ Yet, few awards carefully assess and reward the work of hospitals to promote health in their communities. The criteria for these awards need to be updated to accelerate and recognize efforts by hospitals to improve outcomes and advance community health.

Several factors play a role in hospitals’ renewed interest in community engagement. For instance, under the Affordable Care Act, nonprofit hospitals must conduct community needs assessments and develop community benefit plans. According to these standards, hospitals must assess their community’s health needs, solicit input from knowledgeable community stakeholders (including governmental public health departments), and evaluate the impact of their community health initiatives.²

Another contributing factor is the emergence of payment reforms that reward improved outcomes. Accountable Care Organizations in the Medicare program, which can be led by hospitals, are required to “address the needs of [their] population” and “must describe how [they intend] to partner with community stakeholders to improve the health of [their] population.”³ Other payment arrangements that promote alignment with the community include all-payer global budgets (already in operation in Maryland and soon to be in Pennsylvania) and shared savings and risk arrangements across all payer lines of business.

These incentives are leading to productive community partnerships. For example, in Oregon, where innovations in the Medicaid program have aligned hospitals with community health outcomes, five major hospitals have announced plans to construct housing units for the city’s homeless and low-income populations.⁴ A health system in Maryland, where hospitals are paid according to global budgets, is working with churches, residents, and community-based organizations to establish literacy programs, family support services, and youth training and employment programs.⁵

Despite these changing incentives, however, relatively few hospitals lead major initiatives to address community health. A recent survey revealed that fewer than one in five hospital leaders strongly agreed that their hospital has programs to address socioeconomic determinants of health, even though more than 90% agreed or strongly agreed that population health improvement is aligned with their organization’s mission.⁶ Hospital leadership compensation and physician payments are seldom linked to community health advancement.⁷

One barometer of the culture of hospital management is how the field defines excellence. Of 14 major US hospital awards, however, six make no mention at all of community health. These include well-known awards such as the US News & World Report Best Hospitals Honor Roll, the Leapfrog Top Hospital Award, and Healthgrades America’s Best Hospitals Award (Table A, available as a supplement to the online version of this article at http://www.ajph.org).

One of the remaining awards, the John M. Eisenberg Patient Safety and Quality Award, includes in its marketing materials a promise to reward organizations for developing “healthy people and communities.” Yet, this award does not offer points or other criteria related to community health advancement.

The seven other awards offer points for community health involvement, ranging from 130 of 1000 points for the Malcolm Baldridge Award to all points conferred for the AHA Nova Award, the Foster G. McGaw Prize, and the Hospital Charitable Service Awards (Table B, available as a supplement to the online version of this article at http://www.ajph.org). These seven awards request outcome data for community initiatives. For example, in the case of the Hospital Charitable Service Awards, each applicant is asked to demonstrate the outcomes achieved in the preceding 12 to 24 months.

Only four awards, however, assess whether hospitals measure the health of their communities. One of these awards, the AHA-McKesson Quest for Quality Prize, evaluates applicants’ ability to “assess community health status.”

Only two awards request input from community partners. The Foster G. McGaw Prize asks applicants to “describe the community responsiveness to and participation in the organization’s community service initiatives” (bit.ly/1F28PRE), and this process includes McGaw Prize evaluators reaching out to community partners listed as references. The AHA Nova Award looks for “a high level of community response to, acceptance of, and participation in the health delivery organization’s community service initiatives” (bit.ly/1qKCt1K) and requests letters of support from community partners.

Not a single award requests feedback from a local public health entity.

Why do so few hospital awards recognize community health improvement despite industry trends toward value-based care and population health management?

One answer may be that the awards were developed during a different era. The traditional view of quality is that hospitals have enough work to do providing the right care to those who pass through their doors. However, this reactive posture is increasingly at odds with the shift of our health care system toward contributing to prevention efforts and achieving improved health outcomes at lower costs.

An alternative possibility may be lingering ambivalence in the hospital industry about the power dynamics of participation in community health activities. Engagement with the community means losing a degree of power and authority over what will happen next. It might be difficult for organizations to structure hospital awards around activities that require others to participate as well.

A third possibility might be the divide that remains between health care and public health. It is striking that, as noted, not a single hospital award asks for input from local public health leadership.

Awards and recognition programs are an important part of management culture. Modernizing hospital awards would send the message that hospital performance is inexorably tied to the health of surrounding communities. Stronger criteria to reward community health activities would encourage hospital leaders to look beyond their walls and build constructive relationships with public health agencies and other community partners.