San Francisco is a diverse community of approximately 812,000 people, the subject of many songs and movies, and the home of a number of landmarks recognized around the world. Comprised of many small, yet distinct neighborhoods, the city is a relatively small, but mighty population center, with a variety of organizations serving those that live, work, play, and learn there. Due to a nearly ten year old state law requiring non-profit hospitals in California to complete a community health needs assessment (CHNA), the eight hospitals serving San Francisco have a history of completing health assessment work collaboratively through the San Francisco Community Benefit Partnership. This Partnership has grown over time and now includes representatives from a number of related sectors, and is co-led with the San Francisco Department of Public Health (SFDPH) and the University of California-San Francisco (UCSF). Through the Community Benefit Partnership, these hospitals, the local health department, and the academic partner, recently completed a CHNA that will help the hospitals meet the IRS requirement and the State of California requirement and also positions the SFDPH to conform to the Community Health Assessment (CHA) and community health improvement plan (CHIP) requirements for national, voluntary, public health department accreditation.
Given their relative comfort and experience in working together on health assessment and improvement planning efforts, San Francisco’s Partnership, decided to approach their most recent efforts, begun in 2011, with a focus on improving the quality of particular aspects of their process. Two areas of focus were ensuring that their CHIP goals were truly realistic given the many demands on partners’ time and resources and the community’s needs, and deepening their level of community engagement across San Francisco’s diverse communities.
Articulating and applying values to guide their work set their course. “These values are around alignment, equity, and community connections,” reported Abbie Yant, Vice President of Mission, Advocacy, and Community Health at St. Francis Memorial Hospital, one of the participating hospitals. Staying focused on these values helped the collaborative work together with the aim of having greater collective impact and to focus on reducing the burden of similar processes across the city to improve the likelihood that the resources and efforts that would be needed to achieve their health improvement goals would truly be applied. “We really focused our efforts to get down to three to five goals this time and managed to come down to three. That’s a significant difference from the past. That’s part of the iterative learning process; it takes attempts at this, not to get it right, but to get it better each time,” said Jim Soos, Assistant Director of the Policy and Planning Department at San Francisco Department of Public Health. These three priorities feel more comfortable to the partners and is a big change from the ten priority areas identified in their Community Vital Signs health improvement work in 2010.
With multiple, related initiatives happening around the city, the partners recognized the need to bring these local efforts in alignment to improve effectiveness, reduce duplication, and better position each agency to make a meaningful contribution to health improvement efforts. The multiple efforts included the following: UCSF’s San Francisco Health Improvement Partnerships; the city’s Health Care Services Master Plan; a health department Community Transformation Grant; the State of California and IRS requirements for non-profit hospitals to complete a CHNA ; and the health department’s preparations to apply to the Public Health Accreditation Board (PHAB) program. This meant that the same organizations were being pulled in for each of these initiatives and for Partnership members it made sense to work together.
San Francisco also considered alignment of their final CHIP priorities with those at the state and national levels. Their current priorities, Access to Quality Health Care and Services, Physical Activity and Healthy Eating, and Safe and Healthy Living Environments, reflect those of the Let’s Get Healthy California initiative and mirror those set forth by Healthy People 2020 and the National Prevention Strategy. By adopting the Healthy People methodology of setting a ten percent improvement over the most recent citywide baseline measure for the respective indicator, San Francisco also set targets for their health improvement objectives for 2016 (intermediate) and 2020 (long-term) in alignment with Healthy People 2020 measures.
Their local alignment efforts are ongoing and will take time, and it has been met with challenges. For example, with the CHNA and CHIP completed, the hospitals are now each working on a technical document to translate this into a CHNA and implementation plan that will meet both the State of California and IRS requirements. “I think it’s good learning going forward to know that these requirements for CHA and CHIP and CHNA and implementation plan on a high level are very similar. But, on a technical level, I wouldn’t say it [the difference] is significant, but there is important variation that has to be attended to,” explained Yant. Ensuring the Partnership’s recently completed CHA and CHIP meet the needs of several different hospitals also poses a challenge. “In San Francisco we have this long history and we have this great partnership and the California law is pretty forgiving so [doing this together makes sense], but Dignity Health, my hospital system, Kaiser, and Sutter, all have different corporate standards for how we’ve done things. In a parallel process that I have done is bring together those entities to agree on the format for the CHNA that will meet both IRS requirements and the California requirements [across different hospital systems]”.
Despite these challenges, Soos and Yant both feel that they are well-positioned for success. Soos explained, “I think we’ve done really well. We’re coming from diverse agencies and organizations. Our missions are fairly well-aligned, but not in complete alignment. I think we’ve managed to find the points of intersection where our interests are really aligned and made the most of those”. Yant added, “I would agree that it’s been a good example of shared governance. We’re pretty conscious of resources that we each hold and try to use them in a complementary fashion We always seem to find a way to muscle up to get the work done. That’s really been a pleasure.” Soos and Yant also feel good about the focus on the three priorities and feel like it is manageable going forward. “I think with this leadership discussion, we’ll make some decisions on what we need to go forward with and what we can let go of in order to do the work that’s in front of us. I think we all know on a very intuitive level that we can’t maintain the commitment to the structures as the currently exist and continue the work that needs to be done going forward. But sometimes undoing structure is really hard,” reported Yant.
San Francisco’s Partnership also committed to another one of their values: community connection and engagement. “This is a town where you’re born with a right to participate; we have a very participatory community here, so we’ve been very conscious of that in every iteration,” said Yant. “I definitely think that the community aspect was a big piece to this process and a bigger piece than we’ve had in the past,” said Soos. The partners do not take the task of deepening community engagement lightly. “I think another key point of our success was that we agreed, worked hard, and learned a lot about how to engage community members in the process. I think that staying true to that commitment that we made with those community members is one of our large challenges moving forward,” added Yant. She went on to say, “I think it’s very important to recognize that these are very long term commitments. It is one of the trepidations I have with the three year cycle [for CHAs and CHIPs]. Three years goes by in a Nano-second and bringing in the community and engaging them in the process carries a huge responsibility to follow through on the commitment…If you over promise you lose the trust of the community forever”. “One of the challenges of the short, three-year time frame is looking for indicators that can actually change over three years; that can actually demonstrate that we’ve made a difference. For some of the indicators we’ve chosen in the past, there is just no way we are going to make a difference in three years on them,” added Soos. Community engagement will likely be a major theme in CHIP implementation as well. “I think…that the way this would roll out in various communities will look very different. So that something we do in Bayview, a historically African American neighborhood with a high degree of poverty and real community concerns about violence, will be different than the way we roll it out in a community like the Tenderloin, a downtown community, or even someplace like Noe Valley, a middle class community. I think that as we roll initiatives out and work with people actually doing the community work it will look different in different places”.
Although the details are still being determined and only the future can tell, Soos and Yant feel hopeful about the work moving forward, which is especially promising given the sheer numbers of participating partners. Soos and Yant both agree that looking at the areas in which interests of the participating organizations intersect is key when you have multiple partners with a large stake in the work involved. “So, our objectives and our goals don’t have to match entirely, but to the extent that they overlap and intersect I think is where we’ve found the most bang for our buck,” said Soos. Yant added, “I agree and I think that the other thing we’ve experienced over the years is that there is always tremendous need that far outstrips our ability to respond. Working together to narrow those interests is worthwhile and yet, hospitals and health departments for the most part are looking at the health needs from two very different lenses. I think what we’ve found over the years is that there is room to have us both, or anything in between, represented.” According to both Soos and Yant, trust is an important aspect of their partnership. Soos reported, “Regardless of where we sit, our vision is the same: we all want to live, work, and play in healthier communities. That sort of is the bottom line for all of us.”
For more information, please refer to the Q&A with Soos and Yant.