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Most Hospitals Receive Failing Score in at Least 1 Quality Dimension of Their Community Health Needs Assessment
November 21, 2018

Most Hospitals Receive Failing Score in at Least 1 Quality Dimension of Their Community Health Needs Assessment

Neeraj Sood, PhD, is director of research at the Leonard D. Schaeffer Center for Health Policy and Economics, vice dean for research at the Price School for Public Policy, and associate professor at the Titus Family Department of Clinical Pharmacy and Pharmaceutical Economics and Pharmaceutical Economics & Policy at the University of Southern California. His prior work has focused on the economics of innovation, HIV/AIDS, health care financing, and global health. His research has been published in several peer-reviewed journals and books, including leading journals in economics, medicine, and health policy. Dr Sood is on the editorial boards of Health Services Research and Forum for Health Economics and Policy. He is a research associate at the National Bureau of Economic Research and standing member of the Health Services Organization and Delivery study section at the National Institutes of Health. Prior to joining USC, Dr Sood was a senior economist at RAND and Professor at the Pardee RAND Graduate School.
The Affordable Care Act mandated in 2010 that all nonprofit hospitals conduct a Community Health Needs Assessment (CHNA). The regulation requires a hospital organization to conduct a CHNA at least once every 3 years and adopt an implementation strategy to meet the community health needs identified following the assessment. The CHNA must consider input from persons who represent the broad interests of the community served by the hospital.

We believe that an implicit goal of CHNAs is to encourage hospitals to begin considering social determinants of health (SDOH) for their patient populations and develop partnerships with community organizations to address these identified factors. Therefore, the importance of a well-executed CHNA is paramount: it allows hospitals to better understand their communities, identify and address SDOH relevant to their community, and provide comprehensive care in partnership with patients and community organizations.

However, in interpreting the CHNA requirements and regulations, the Treasury Department and the IRS have sought to preserve the flexibility of hospital facilities to determine the best way to identify and meet the health needs of the specific communities they serve.

The goal of our study was to gauge the quality of CHNAs. We used CHNAs produced by a representative sample of California Hospitals in 2016 for this study. To understand how well California nonprofit hospitals were doing in preparing quality CHNAs, we sought to answer 2 key questions:

1. Did hospitals use the assessment as an opportunity to better understand the needs of their patient community? To answer this question, we examined the extent to which hospitals sought input from the community in developing the CHNA. We focused on both the depth and breadth of input. Depth of input was measured by evaluating whether hospitals conducted focus groups, presented secondary data on disease burden, conducted in-person interviews, administered a survey to community members, and presented data at a geographical level no higher than county. Breadth of input measured the diversity of stakeholders from whom input was sought. Specifically, we measured if hospitals sought input in 2 or more languages, and whether input came from diverse sources including underserved populations, patients, community leaders, physicians and other health professionals, hospital administrators, non-governmental organizations, public health departments, law enforcement, or government agencies.

2. Did hospitals develop a plan for addressing unmet needs by partnering with the community? To answer this question, we examined the steps that the hospital took to address patient needs based on the input they received from the community. We asked if hospitals created partnerships, awarded project grants, specified the amount of funding for each, made partnerships or awarded grants to non-medical organizations, identified the present resources in the community, and developed a success metric that they monitored to gauge progress on the project.

Grading CHNAs
Each hospital’s CHNA was graded on 3 dimensions—depth of input sought, breadth of input sought, and quality of implementation plan for addressing patient needs—and each dimension was assessed using objective measures as described above.

Next, we evaluated hospital performance compared with the median on a specific objective measure. A hospital earned 1 point for every measure where its performance exceeded the median. For example, one measure for input depth was the number of in-person interviews conducted by the hospital. The median number of interviews across all hospitals was roughly 10; so, a hospital got 1 point for this measure if it conducted more than 10 patient interviews when developing its CHNA.

Exhibit 1 presents the objective measures used to score performance in each dimension. A hospital could earn a maximum of 5 points in each dimension (input depth, input breadth, and implementation plan) for a total of 15 points. For each dimension, hospitals received an “A” if they scored 4 or more points, a B if they scored 3 points, and a F or a failing grade if they scored 2 or fewer points.

Exhibit 1: Metrics for Evaluating CHNAs
Depth of input sought (max = 5)
At least 4 focus groups were conducted
Secondary data on disease prevalence was presented
At least 10 in-person interviews were conducted
A survey with community members with a response rate of at least 25% was conducted
The lowest level of geography was not county
Breadth of input sought (max = 5)
Input collection was conducted in 2 or more languages
At least 25 stakeholders are from underserved populations
At least 20 stakeholders are patients or community leaders
At least 14 stakeholders are physicians, from allied health, or from the hospital
At least 13 stakeholders are from NGOs, public health departments, law enforcement, or government agencies
Depth and breadth of strategic implementation plan (max = 5)
At least 20 grants or partnerships were awarded
The funding amount was specified
At least 5 non-medical grantees were included
Present resources were identified and enumerated in CHNA
A success metric was presented and monitored
CHNA indicates Community Health Needs Assessment; NGO, non-governmental organization.

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