Summary
The Community Health Advisory Board (CHAB), Pierce County, WA, involves four healthcare systems — Franciscan Health System, MultiCare Medical Center, Group Health Cooperative of Puget Sound, and Good Samaritan Hospital — that have joined forces with other providers in an innovative attempt to better serve their community. An evaluation by representatives of New York University's Hospital Community Benefit Standard Program prompted St. Joseph Medical Center, Tacoma, WA, to bring major providers together in a coordinated effort that could reach community residents in need.
At their first meeting in November 1992, CHAB members agreed on a purpose: to facilitate collaboration between healthcare providers throughout the county to develop programs and services that improve the health status of community residents. In January 1993 CHAB members selected a "quick success" project: a program aimed at increasing immunization levels to 90 percent for two-year-old children in the county. In February 1993 CHAB members committed the "best and brightest" to the Immunization Task Force, naming experts in planning, nursing, community health, education, and marketing.
When the Immunization Task Force assessed the project, they realized that the "quick success" program would not be accomplished so quickly. CHAB has had to address underlying problems to make higher immunization levels sustainable. In March 1994 members will evaluate the immunization program's process, status, and structure; data on immunization levels; and the group's demonstrated ability to cooperate.
Cooperation is a fairly simple idea — people work together to accomplish a specific goal. But cooperation in a business world driven by competition is not always so simple. As healthcare reform rattles the traditional care delivery models, providers are reexamining how cooperation can work in community healthcare.
In Pierce County, WA, four healthcare systems — Franciscan Health System, MultiCare Medical Center, Group Health Cooperative of Puget Sound, and Good Samaritan Hospital — joined forces with other providers in an innovative attempt to better serve their community. This collaboration, though challenging, has succeeded and may serve as a model of cooperation.
The Advisory Board
The Community Health Advisory Board (CHAB) grew out of a 1991 visit to St. Joseph Medical Center, Tacoma, WA (sponsored by Franciscan Health System), from representatives of New York University's Hospital Community Benefits Standard Program. St. Joseph was 1 of 49 demonstration sites for the development of community benefit standards. Representatives visited St. Joseph to review and evaluate the hospital's progress in the program.
Although the researchers were pleased with St. Joseph's community health programs, they identified a need for a more systematic approach — a way to understand and prioritize the community's unmet healthcare needs and to evaluate and measure the impact of community health programs.
St. Joseph officials decided to bring major providers together in a coordinated effort that could reach more people. They hoped several organizations working together would have a more profound impact and be more effective than a single organization.
Believing that the effort would be better received if chaired by an individual not affiliated with a particular facility, St. Joseph President and Chief Executive Officer John Long approached Donald P. Sacco, a key healthcare leader in the community and president of Pierce County Medical (Blue Shield). Sacco agreed to chair the group.
Trying to assemble a group of people who had literally never sat down together was a challenge. Sacco, Long, and others lobbied behind the scenes with healthcare providers, the business community, and local politicians to gain support for the idea. "Community Health Advisory Board Relationship Model" illustrates the CHAB Relationship Model, describing the advisory group's and the planning and implementation groups' roles and tasks. "Community Health Advisory Board Relationship Model" also describes how the groups interact with each other and with community groups.
In addition to Sacco and Long, CHAB members now include top leaders from MultiCare Medical Center, Tacoma; Good Samaritan Hospital, Puyallup; Group Health Cooperative of Puget Sound, Seattle; Madigan Army Medical Center, Fort Lewis; Pierce County Dental Society, Tacoma; Pierce County Medical Society, Tacoma; and Tacoma-Pierce County Health Department, Tacoma.
CHAB's Purpose
At their first meeting in November 1992, the group agreed on a purpose: to facilitate collaboration between healthcare providers throughout the county to develop programs and services that improve the health status of community residents. They further agreed to:
- Identify unmet or underserved community health needs
- Seek ways to develop or encourage others to initiate programs and services designed to address those needs
- Report progress to the community
The members agreed to meet monthly for two hours for a minimum of 18 months. After the 18-month trial period, members will evaluate their progress and will continue to meet only if the group is actually improving the community's health status.
Unmet Needs Pierce County, located on the southeastern end of Puget Sound between the Olympic and Cascade mountain ranges, has numerous unmet health needs. The county, home to more than a half million diverse residents, is the second-most populous in the state. Tacoma, at the north end of the county, is Washington's second-largest metropolitan area. The county also has three military installations, a high growth rate, a higher-than-average cost of living, a lower-than-average per capita income, and a depressed economy. Pierce County has more single mothers than the national average; many of them live in poverty.
A Two-pronged Approach CHAB decided on two courses of action: Identify a broad-based health priority for long-term focus, and identify a "quick success" program to solidify the organization and build a strong team. The group agreed to avoid duplicating existing efforts and planned to coordinate with social services agencies in the area.
"We made a deliberate decision not to engage in a lot of study," said Sacco. "We wanted to do something." The group, therefore, used existing data from the Pierce County Health Department and the Washington State Hospital Association to assess and prioritize unmet county healthcare needs.
While continuing to seek a focus for a broad-based health priority, the group considered several healthcare projects for their "quick success" program. Possibilities included bike helmet safety programs, vision and dental care for the homeless, smoking cessation plans, playground safety, and childhood immunization.
The group used two criteria to evaluate projects: Will we be able to implement this project? And will it succeed? CHAB members also sought a project that would have universal appeal and minimal controversy so members could fully commit to it.
Quick Success: Immunization
In January 1993 CHAB members selected their "quick success" project: develop a program aimed at increasing immunization levels to 90 percent for two-year-old children in the county.
Statistics indicated that immunization rates for children in Pierce County fell far below the 90 percent level recommended by the Centers for Disease Control and Prevention. A September 1992 study of kindergartners, by the Tacoma-Pierce County Health Department, indicated that about half those children were not fully immunized at age two, although rates increased as children neared school age.
CHAB's vision was "a county of children free from vaccine-preventable disease." It was a challenging goal, and members realized the value of collaboration — what might have been impossible for a single organization became achievable as a group effort.
In February 1993 CHAB members committed their "best and brightest" to the Immunization Task Force, naming experts in planning, nursing, community health, education, and marketing. Top executives freed up the time of task force members, allowing them to make a real commitment to the project.
"There's a good mix of planners and program people," said Jane Shanaman, vice president of fund marketing and development for MultiCare. She agreed to chair the task force.
The task force's initial report reinforced the value of immunization, identified a number of reasons for the low rates, and profiled one group who had an unusually high immunization rate. The Puyallup Tribal Health Authority, representing Native Americans from a Pierce County reservation, reported a 95 percent immunization rate among two-year-old children. The high rate was due to several factors: a strong community orientation, an effective tracking system, and high motivation stemming from the memory of past epidemics.
Where immunization rates were lower, a number of causes were cited. Access was sometimes a problem — the bus did not go past the doctor's office, or office hours were not convenient for working parents. Cost barriers, real or perceived, were sometimes an issue. The county health department supplies vaccines to providers free of charge and limits what they can charge to no more than $10 per vaccine. For some parents, however, even a $10 charge is a hardship, and some providers linked immunizations to a regular office visit, for which there was an additional charge.
Other factors, such as language barriers, misperceptions, forgetfulness, and lack of a central tracking system, also contributed to lower immunization rates.
Last summer the Immunization Task Force recommended to CHAB an immunization program that was barrier free, community based, coordinated with parallel efforts, part of a larger approach to children's issues, and based on a thorough data analysis of needs.
The group started to identify pockets in the community where immunization rates were lower than the county average. They then worked to define and implement the best approach to increase rates in each area. By testing methods and using a systematic approach, the group worked to refine immunization delivery. Because low immunization rates resulted from a variety of factors, approaches to increasing rates had to be tailored to each community.
"There isn't one fix-it' that works for every area. You build the programs as you go," said Shanaman.
As the task force and CHAB members concentrated on the job at hand, rivalries and barriers fell away. "We're all focusing on the needs of the underserved now," said Sacco.
The Underlying Problems
Shortly after the project began, the Immunization Task Force realized that the "quick success" program selected by CHAB would not be accomplished so quickly. CHAB has had to address underlying problems to make higher immunization levels sustainable.
CHAB members have, therefore, postponed plans to seek a broad-based health priority and are instead focusing on completing the task before them.
"A flash in the pan just won't do it," Sacco said. "We've come to realize that immunization is our longer-term issue. It's likely to require continued attention from CHAB members. To do it right takes time. You have to have the right elements in place."
The group will probably not reach its goal by the 18-month deadline originally proposed for program evaluation. In March, members will evaluate the immunization program's process, status, and structure; data on immunization levels; and the group's demonstrated ability to cooperate. The evaluation will also include an examination of the community's response to CHAB: Was the concept embraced? Have social service agencies, the media, and others supported the group and their goals? Underlying the evaluation will be the recognition that CHAB, like any new effort, has had to evolve.
Lessons Learned
Those involved in creating CHAB learned some lessons along the way:
- It takes time to integrate a community health focus.
- They must go beyond medical intervention and eliminate the causes of poor health.
- Collaboration means giving up individual or organizational control. For example, St. Joseph administrators believed the CHAB project had a much better chance to succeed if it were headed by a neutral person. St. Joseph joined the project as a member. By giving up an element of control, St. Joseph saw group members cooperate better and have a stronger commitment to the project.
- CEOs and boards must now look beyond medical intervention (traditionally the task for hospitals) to examine the causes of poor health and then develop appropriate preventive interventions.
Looking to the future, Sacco identified his goals for CHAB: to increase immunization levels, to herald that success and broaden support, and, finally, to encourage other communities to pull major medical resources toward a common goal.
Pierce County is not unique. CHAB members believe the same effort could succeed in any community where healthcare providers will cooperate. Sacco noted that people with the personal and professional motivation to "do the right thing" can work toward such efforts collectively, not just as individuals. He acknowledged that long-time personal relationships among some of the CHAB members helped the process.
"Healthcare organizations will have to collaborate and leave their business perspectives behind in order to improve the health status of their communities," said Sara Lyon, vice president of marketing, Franciscan Health System. "There's a more powerful potential for healthy communities with groups like this than without them."
Ms. Lindsey is corporate communications manager, Franciscan Health System, Tacoma, WA.
