Cover Story
Hospitals And Communities
By Ernest R. Sutton
Restoring The Relationship
As the "face" of health care in America, the hospital symbolizes everything the public believes about the field. And in these turbulent times, the community often sees more to blame than to praise when they look at their local hospital. The insurance crisis, billing and collection, expensive prescriptions--hospitals may often be seen as the chief
cause of what's wrong with health care, when in truth, they are often as much victims of the system's flaws as are their patients. Add in increased public apprehension about patient safety, and it's easy to see why hospital reputations are much more easily lost than won. How can hospitals win back their community's trust and loyalty? First, enlist them as partners in problem-solving by explaining what's happening nationally and locally in health care, then make their concerns your own.
"The average American is ignorant of [what's going on in] health care--there is a disconnect--and this disconnect is very dangerous," says James E. Orlikoff, president of Orlikoff & Associates Inc., Chicago, and senior consultant for the AHA's Center for Healthcare Governance. Because the hospital is the "final social safety net," Orlikoff says, it "is the first target for animosity. The community feels less loyalty and ownership to the extent that they don't understand what's happening ... and the more the community doesn't understand, the more adversarial [its relationship to the hospital] could be." For example, he says "it can seem paradoxical [to the public] that hospitals may spend money on building a new wing, and yet still say they are losing money. The greatest challenge is to explain that paradox."
And trustees stand as some of the best ambassadors to advance that understanding. "Board members are in other community groups--the Chamber of Commerce, for example--it's their opportunity to educate community leaders about what's going on," Orlikoff advises. This becomes even more true as hospital leaders' responsibilities and pressures grow. "If management is so stretched that they don't have time to be on other boards and join other groups, it's a mantle of responsibility that boards need to take on ... a key governance responsibility" to make community connections on behalf of the hospital.
"The key is to get ahead of the curve, to build a relationship before you need it, to take a proactive, thoughtful approach," Orlikoff says. "The community that feels involved will protect the hospital. You need to set it up so that when a hot issue arises, you've already built the foundation to work on strategies to address the crisis. That relationship and foundation will sustain the hospital during tough times." And if the relationship is not there and the public becomes upset about a health care issue, "they will get angry at what's right in front of them"--the hospital.
Information Resource
Orlikoff recommends beginning by being strong information providers to the community, offering insight into the health care field on both a clinical and policy level, "not asking for something." He suggests that trustees could begin with talking points on five to 10 key issues to communicate to their community and colleagues. Those talking points could fall into two general categories, he says, first explaining the overall health care environment and the various pressures and struggles that hospitals face nationwide. Examples might include explaining how niche hospital competition affects the hospital's bottom line, or how state Medicaid cuts mean more uninsured patients and a more crowded emergency department. Following this, trustees should get specific on what their hospital is doing in and for the community, always "keeping the subtext of the greater national picture," Orlikoff says.
He recommends that hospitals use different forums to send the same message many times. Examples might include a newsletter, formal public speaking, such as to the Rotary Club, and more informal speaking among business colleagues and friends. He further advises hospitals to "build a routine communication with the media--letters to the editor, going to lunch with the editor ... Educate the media, so that they see the hospital as a resource, not an adversary," Orlikoff says.
As a prime example, for the past six years, Stanley Hupfeld, CEO of INTEGRIS Health, Oklahoma City, has written a monthly column for the city's daily business newspaper. He gives his point of view on a broad range of topics covering the challenges and politics of health care. He does it partly, "to connect the dots for the public," he says.
For instance, by discussing potential state Medicaid cuts, he can explain how raising eligibility requirements will create more uninsured residents and their uncompensated care will drive up costs for the insured.
"It strikes a chord a lot of the time--sometimes irritation, sometimes compliments," Hupfeld says. Regardless of the reaction, however, he thinks it's a good idea to put his name and the INTEGRIS name in front of the community consistently. He feels it is important that the public understand the broader context within which INTEGRIS and all health systems are struggling to fulfill their mission. "We are a very special field and maybe we haven't talked about the heroes [of it] enough," he says. "Mistakes get played up more. In the absence of positive information, the negative comes through. We must be vigorous in telling our story to the public."
He adds that trustees are indispensible to getting this word out and the public's belief in them is paramount. "It's not for nothing they're called trustees," Hupfeld says. "It is their responsibility to engage in philanthropic activities, to enlighten the business community and their colleagues--to speak loudly for hospitals"--and to make sure local residents know the hospital belongs to them.
"The community owns the hospital, so it needs the community's understanding," Orlikoff says. Trustees need to explain clearly that "hospitals are charities under financial pressure governed by the community and on behalf of the community." To create this sense of ownership, he recommends sponsoring health fairs, golf tournaments, walks and runs for health care causes, school health care career days, open house presentations--and creating community advisory boards.
Once that ownership is understood and appreciated, the next step is briefing your "fellow owners" about the challenges hospitals are facing. "Lay out the issues, the challenging choices to come, and ask the public to help figure it out," Orlikoff says. "Have them realize that [hospitals] can't do everything. [Tell them] 'We are making decisions in the best interest of the community over the long-term. We have to make tough decisions, and we have to decide what we most need.'" In other words, the trade-offs and limitations hospitals face can become a shared decision-making process, or at least better appreciated.
He adds that, "An educated public is better prepared to participate in a discussion of how to redesign health care delivery and financing. And the undereducated will be intolerant."
Ongoing Town Meeting
One health care system that embodies the advice to communicate and educate its community "early and often" is Licking Memorial Health System (LMHS) in Newark, Ohio. Comprising 183-bed Licking Memorial Hospital, a 70-physician medical group and a foundation, it sends out monthly report cards to its service area, comparing its success with such quality measures as best practice first interventions for treating pneumonia or cardiac arrest, measuring itself against how it did the year before and against national benchmarks. Last year, LMHS also began sending out a monthly newsletter to 35,000 area homes, covering health topics, health system news, and offering enrollment in community health care classes and screenings.
It's an open appeal for loyalty. Because they cover a largely rural area--Newark is a city of 47,000, but the system's service area covers 145,000 county residents--communication efforts are very much geared toward telling residents to "stay local," proving that there is no need to go to the nearest larger city of Columbus, to get the "best" care, according to Veronica Link, Licking Memorial's vice president of development and public relations. "We need our community to realize that we are leaders in patient safety and quality of care," she says. "The community tends to think bigger is better, so we need to show we are special."
To make the message more personal, since 1987, LMHS has sponsored a Development Council, a group of 75 residents Link describes as "ambassadors of the community," representing a broad cross section of the area's small business owners, professionals and others. Licking Memorial's president, William Andrews, says the council was originally formed for fund raising, but hospital leadership quickly realized that it could be a useful liaison for communicating what the system was doing and why to the larger community.
Divided into three committees--community relations, education/membership, and fund raising--the first of these sponsors community roundtables, which are monthly hospital luncheons hosting small groups of business leaders. Guests hear a presentation from one of the system's physicians on a particular health topic, accompanied by words from Andrews and followed by a question-and-answer session.
"The communication is the best benefit, the ability to get 75 people in a room to explain the reasons why we're doing what we're doing," Link says. "The roundtables are wonderful for helping us educate community leaders ... change has become more rapid in recent years ... it's all too complex to communicate with ads in the newspaper."
Taking candid communication even more seriously, three years ago, LMHS leaders decided on a "full disclosure" policy, pledging to fully disclose any adverse inpatient event immediately to affected patients and their families, regardless of whether it resulted in a medical error. Andrews says the policy follows the example of the Veterans Administration and advice from the Joint Commission on Accreditation of Healthcare Organizations. But beyond this, he explains, "It's our mission to make sure the patient is the customer. That's what drives everything we do ... that's why we communicate so much. In that vein, if you do something that the customer didn't expect to have happen, it only makes sense to disclose it. It doesn't take away the hurt or anger, but the honesty helps."
Creating a Patient Health Record in Whatcom County
It also improves patient and community relations when better control of their health care is put in the hands of patients. As a recipient of the Robert Wood Johnson Foundation (RWJF) "Pursuing Perfection" project grant, the Pursuing Perfection in Whatcom County (Wash.) coalition has taken a fresh look at giving patients more say in their treatment--and the result has been "strange, lucky and brilliant," according to the coalition's executive director, Marc Pierson. He is also the vice president of clinical information systems at St. Joseph's Hospital in Bellingham, Wash., the hospital component of the coalition, which additionally comprises two payers, a cardiology group, several primary care clinics and a senior health center.
The Pursuing Perfection project was created and funded by RWJF in response to the Institute of Medicine's "Crossing the Quality Chasm" report. Led by the Institute for Healthcare Improvement in Cambridge, Mass., the project began in 2001 with the goal of "totally transforming health care." Thirteen health care organizations in the United States and Europe were asked to find ways to "perfect care" by aligning goals with the IOM's six aims of improving patient care: timeliness, safety, efficiency, effectiveness, equity and patient-centeredness.
Whatcom County has taken the IOM's "patient-centeredness" goal literally, by bringing patients currently dealing with chronic conditions of heart failure and diabetes onto the project team to find ways to improve their care. "That was the thing that changed everything," Pierson says.
Patients were chosen by clinical team members who knew them personally and were currently treating them for their chronic conditions. Patients had two major requests: they wanted a "clinical care specialist"--a nurse or social worker--to help them and their families navigate the health care system; and they wanted a medical record that they controlled themselves. The resulting document, the "Shared Care Plan," is stored on an individually owned secure Web site, allowing patients to gather all their health data in one place for their own use as well as for their family and their multiple caregivers. On their Web sites, patients enter all their medications, including herbals, their diagnoses, list of caregivers, types of treatments and their treatment goals. They can then take a printout of the record with them to review with caregivers and literally make sure "everyone is on the same page." The document is less dense than a traditional medical record, avoiding the fragmentation that chronologically recorded data from multiple locations and providers often produces.
"It's actually an intervention," Pierson says. Creating the record has "integrated us with the real world" of what chronic care patients need, he says. "The only one who really knows what they're taking and doing is the patient. And when they take that paper version with them [to their appointments], it is critical for changing the quality of the interaction between doctors and patients. You sit at the table and discuss--it's much more a partnering."
When the Pursuing Perfection initiative was first proposed at a St. Joseph board retreat four years ago, Pierson says "it was the most meaningful thing our board says they've ever done as board members ... and their enthusiasm drove it." St. Joseph trustee David Nichols says the project "captured the imagination of the board. Over the 21 years I've been [a trustee], we've always been wrestling with quality and patient safety. We've just recently realized that [we needed] a total culture change."
Nichols says he believes their Pursuing Perfection project is unique because they are the only grant recipients who are approaching their goals "from the outside." He explains, "The hospital doesn't run it, it's run by the people around the community table--patients, doctors, insurers, hospital staff. Usually management tries to sell an initiative and there is always some pushback from physicians. But this change is being implemented by its authors, those who will use it."
Since the Shared Care Plan was introduced, two board members--one of whom was Nichols--have been diagnosed with cancer and created their own Shared Care Plan. "When I became a cancer patient last year, it became obvious that 90 percent of a patient's well-being has to do with his or her mental stability, and 10 percent is treating the illness." He says that his ability to participate more in his care and to consequently experience the difference between a "healing culture" and a "curative culture," increased his sense of "ethical discernment," i.e., making board decisions more in line with the health system's mission.
For hospitals that wish to create something similar, Pierson counsels that it must belong to those it is designed to serve. The local hospital should act as the sponsor and the community resource, bringing together patients and physicians to talk about how such a shared record could work in their system--and he strongly advises staying small. "Each community needs to figure out how to gather and do this locally ... if you start too big, it will fail," he warns.
Whatcom County has been using the Shared Care Plan for three years and currently tracks 600 patients. Pierson says both sides of the equation have benefited. "Hospitals are critical to the spread of this information, and patients respect and like the hospital for supporting this." Their good will comes in no small part from the fact that the program extends beyond the hospital itself, which gives St. Joseph's powerful credibility, Pierson believes.
"What's wrong is [hospitals using] branding or marketing strategies for their gain," he says. "If we had branded this as a hospital [owned] project, it would have been the death knell." He believes seeking credit is "the antithesis" of what hospitals should represent, "to force patients to pretend that they only come to you for care."
By contrast, giving the community more of a say in improving their own health and interacting more directly with health care providers is "a great opportunity for hospitals to live their mission, not their naive, competitive business strategy," Pierson believes. As hospitals struggle to find the larger, long-term solutions to the health care system's challenges, gaining that broad-based community support and understanding becomes increasingly important.
"From a political standpoint, [the public] has to appreciate the uniqueness of an acute care hospital, that we take all comers--our support comes from their understanding," Hupfeld says. "This is a unique field. No American business is expected to give away things for free, as part of either their mission or their business plan. No one else would do that."
"Right now, we don't have a basic level of connectivity in health care," Orlikoff says. "People only see it from their own perspective, but it needs to be placed against a national perspective. There needs to be an integration of personal experience with broader intellectual understanding."
Pierson believes that, in many cases, it is not that parts of the health care system are broken, but rather that "they have never been built. To make sense of what it means to be successful, [hospitals must focus on] cooperation, not competition. Hospitals are the only place in the community to be the focus of cooperation. The way to be recognized as a leader is to spend all your energy supporting others. Others will learn by your example how to acknowledge you."
So, rather than the Golden Rule of "do unto others," perhaps the lesson here is "do for others without regard for what it does for you." Share all your resources. Find out what patients want. Get known in the community as a big-picture health partner. Loyalty may come first by putting the bottom line last.
Laurie Larson is Trustee's associate editor.
This article 1st appeared in the December 2099 issue of Trustee Magazine.
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