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BY: JIM SPENCER, PharmD, and GORDON SELF, M.Div., D.Min.

Dr. Spencer is mission and ethics leader, Mercy Medical Center—North Iowa, Mason City, IA, and assistant professor, Creighton University School of Pharmacy and Health Professions, Omaha. Mr. Self, who is vice president, organizational advancement, Caritas Health Group, Edmonton, Alberta, was formerly at the Mason City facility, where he completed a mission fellowship.

An Iowa Facility Works to Involve Busy Employees in Community Benefit Reporting

Catholic health care is increasingly held accountable for tracking and reporting resources committed to community benefit. Today's health care organizations are expected to report back to the larger communities they serve. In response, Catholic organizations have developed software to help them gather such information in a standardized format and track their community benefit activity from year to year.*

*The Catholic Health Association; VHA, Inc.; and Lyon Associates, Inc., have developed a software program, Community Benefit Inventory for Social Accountability (CBISA). For information about it,access www.lyonsoftware.com.

However, organizations would do well, before tracking and reporting community benefit initiatives, to reflect on why doing so is important and to communicate a meaningful rationale for it to those who will be called on to report. Although Mercy Medical Center—North Iowa (MMC) has done much to support the poor and underserved in its community, we who are the facility's leaders understand that a good deal of this activity never gets reported. Several years ago, we realized that we must encourage staff members to list such activities so that we could compile a complete report.

Social Accountability
Catholic health care providers are accountable not only for their financial performance and investments but also for how well they demonstrate their mission and values. A Catholic hospital's mission should drive everything it does. The facility's stakeholders include government, insurers, sponsors, the church and local bishops, patients and residents (and their families), staff members, physicians, volunteers, and the members of its community. Among other things, a Catholic hospital must, to maintain its tax-exempt status as a not-for-profit organization, satisfy the Internal Revenue Service (IRS) that it contributes significantly to the welfare of its community. Doing so is usually not difficult because Catholic providers tend to be generous in their community benefit contributions.

Having Catholic hospitals in a community is a good thing, according to a study released a few years ago.1 Indeed, the numbers reported by Catholic health care systems are impressive, measured as they are in the millions of dollars of uncompensated care annually. The fact that such care is needed is a compelling argument for preserving the social "safety net" in the United States, in which Catholic hospitals play a major role.

However, we have found preservation of the safety net one of the less satisfactory incentives in persuading MMC staff members to report community benefit activities. The idea of a national safety net probably seems abstract to them. Also abstract is the notion of bringing together such information from Catholic and other not-for-profit providers across the nation to show lawmakers how badly health care reform is needed in the United States. And, finally, MMC staff members have little interest in the complexities of tax law and are therefore not inclined to gather community benefit data simply to support MMC's tax-exempt status.

So how were we to persuade MMC's staff, which was already burdened with increasing workloads, to report community benefit activities?

The Walking Nuns
One MMC staff member, thinking about the facility's mission, compared it to her own personal need to learn about her family's roots overseas. The best way to motivate staff, this person said, was to tell them about the life and spirit of Catherine McAuley, foundress of the Sisters of Mercy.

Mother McAuley was born in Dublin, Ireland, in 1778. Her father, James McAuley, was a wealthy man who reached out to the poor street children and invited them into the McAuley home. His generosity and compassion had a lasting influence on his daughter. However, James died when Catherine was only five, and, like many young children in America today, she grew up in a single-parent home. The family became impoverished because of Mrs. McAuley's inability to manage money. Catherine experienced grief, poverty, homelessness, and religious discrimination.

After her mother's death, Catherine was herself taken into the home of a wealthy Dublin family, where she lived for 20 years. In time, she inherited her benefactors' fortune, and she used it to build what she called the House of Mercy, a home and school for poor children. Other women joined her in this endeavor, and in 1831 they became the Sisters of Mercy.

In a sense, Catherine McAuley can be described as an originator of community needs assessment. Refusing to be cloistered, she spent much of her time traveling around the countryside looking for poor people to help—a practice that later caused her congregation to become known as the "walking nuns." Mother McAuley never forgot her own experience with poverty. She knew that the indignities suffered, not lack of money or food, were the worst thing about being poor. She believed in furnishing people with the skills they needed to help themselves—what we today call "empowerment."

Poverty of Spirit
It's easy to get into an "us and them" mentality when talking about community benefit ministry. We who are involved in the Catholic health ministry help "them," the poor. But, in seeing things that way, we overlook our own problems—rising costs, increased financial uncertainty, labor shortages, stress, burnout—which themselves amount to a kind of impoverishment. Being in touch with our own impoverishment, as Catherine McAuley was with hers, reminds us to minister with an authentic sense of caring. Getting in touch with our own "poverty of spirit" helps to break down those "us and them" dualities.

We need the stories of people like Catherine McAuley, and the founders and foundresses of other religious communities, both past and present, to continually inspire us. Shifting the focus from the individual to the larger community puts the need to report community benefit in a whole new light. At MMC, we decided that telling our staff about Mother McAuley might prove to be an effective, authentic way to solicit community benefit information. Helping staff members connect to their own "poverty of spirit" facilitates a greater commitment to reporting, as an expression of solidarity with the community—being at one with, not standing over, the people we serve.

The Categorical Imperative
The 18th-century philosopher Immanuel Kant argued that people should exercise good will not as a means to an end but because it is good in itself.2 The rightness of an act, he believed, is determined independently of a person's or organization's particular self-interest; any right action has inherent merit that can stand on its own. Kant called this the "categorical imperative." Following Kant, we who serve Catholic health care ought to report community benefit activities simply because doing so is right, regardless of the context or possible outcomes, either positive or negative. Reporting community benefit in this spirit expresses our intent to be guided by higher moral principles. Charity and service modeled by our corporate culture can inspire other forms of volunteer service that, although they will never be included in an official community benefit report, will nevertheless work toward the common good.3 Community and individuals grow and flourish collectively through expressions of charity, in keeping with the vision of Catherine McAuley.

At MMC, we asked ourselves: Are we advocating a Kantian approach because, in the long run, the message to staff will be more effective in soliciting community benefit reporting? Or should we simply drop all expectations, urge staff members' cooperation in reporting, and invite their responses? As we planned our staff education sessions, we debated this question, questioning our own motives.

We recognized both utilitarian and philosophical influences at play. Certainly we had a job to do and a responsibility to report the data to other stakeholders. We did, however, acknowledge a deeper sense of duty. Our intention to engage this activity, to stand before staff members and educate them about the value of community benefit, was guided more by a desire to be ethical—to be an ethical organization and to do the right thing.

There is, of course, a very practical reason for reporting community benefit—to allow more good to be done. This was the original purpose of the tax-exempt status. At MMC, we are certainly accountable to the IRS. But we are even more accountable to ourselves and our mission, and ultimately to God. As one writer has said, "Christians and moral theology must, however, live with an eschatological tension between the present time of redemption and the unrealized future of resurrection destiny. We are called to improve on and change what exists here and now but also to realize that our fullness of redemption will never be here."4 This "eschatological tension" calls us to do more than file a report. Our actions must be motivated by a higher reason.

Taking Action
In the summer of 2002, MCC launched a campaign to educate its staff about Catherine McAuley and the Sisters of Mercy. As a result of that campaign, we were able to persuade MMC staff to report community benefit activities. Our next question was: How do we make such reporting operational?

We soon realized that accomplishing that would require more than an educational blitz. In December 2002, MMC adopted a biannual reporting cycle for community benefit, in December and June (the end of the fiscal year). This frequency helps to keep staff members aware of the need to report. People get so busy that they simply forget to record community benefit activities. Having biannual (or, as in some health care organizations, quarterly) reporting, relieves one of the necessity to remember every activity. At MMC, we circulate "prompter lists" of community benefit programs and services undertaken in previous years, reminding staff of all we've been involved in. The prompter list is also a powerful educational tool because it points out the many good things done by the organization, clearly demonstrating how MMC lives its mission.

Electronic Reporting
At MMC, we are becoming more savvy about reporting community benefit electronically. We used to be a very paper-dependent culture. In those days, MMC's administration would mail out community benefit ministry (CBM) forms to each department, where they would be filled out and returned to the hospital's CBM coordinator. The CBM coordinator would then re-record the information on a computer, but frequently not before making several phone calls to clarify illegible handwriting. This process required hospital-wide mailing of forms, staff filling in the CBM reports and sending them to our CBM coordinator, who in turn had to re-record the information on the computer, sometimes not before several back-to-back phone calls to clarify illegible handwriting or to gather data inadvertently left off the form.

Paper forms added another, time-consuming layer of complexity to community benefit reporting, increasing the probability of a poor response. It was cumbersome, inconvenient, and viewed with suspicion by people who were privacy-conscious.

Online reporting has significantly improved our response, allowing staff members to quickly access the online CBM site from their desktop, in most cases without involving the CBM coordinator. However, our CBM coordinator is always available to help with electronic reporting, field inquiries, or process written forms submitted in paper format. Not every staff member has access to or proficiency with computers, and we do not want to inadvertently screen out submissions filed in the traditional way on paper forms.

There will always be some staff members who do not report, either with paper forms or electronically, no matter how persuasive and inviting the appeal. This is something we just accept, attempting to capture the data through other participants involved in the same community benefit initiative, or, if necessary, through anecdotal evidence.*

*The CBISA software accommodates the recording of both quantitative and qualitative data.

Information technology specialists at our facility conduct several training sessions a year to help staff acquire proficiency in using our online software. This training is part of a wider effort to promote an electronic reporting culture in the hospital. We are beginning to make some real progress in this area, but continual reinforcement and encouragement is required.

"Mission Moments"
Despite growing success with online community benefit reporting, we continue to hold face-to-face meetings with departments and service-line staff, often in conjunction with regular department and team meetings, so as not to burden staff with yet another mandatory meeting. The personal contact provides an opportunity not only to discuss reporting community benefit but also to praise staff members for the ways they are already living the mission, providing additional community benefit through their dedicated service.

We call such meetings "Mission Moments." Health care employees sometimes fail to see their work as mission related, especially if they are not involved in bedside care or work in clinical units. Our Mission Moments are opportunities to affirm and thank staff for their commitment in living the mission, as well as to educate them about our community benefit ministry and the need to tell the larger story.

We have come to realize that MMC's community benefit activities should be widely publicized—and as often as possible. Both staff members and the community need to be aware of the many good things the hospital does. Such publicity is not self-promotion—it is being accountable to our mission, as well as being good stewards of our reputation in the community. Reporting once in an annual report is an important first step. But it should not be the only time we tell our story.

Affirming the charitable role of our organizations encourages staff members to report on community benefit activities that their departments provide. Staff members should not feel admonished to give alms publicly. Rather, they should feel they are helping to demonstrate that the giving spirit is alive in their organizations.

NOTES

1. Alexandra E. Shields, Ellen O'Brien, and Darrell J. Gaskin, A Commitment to Caring: The Role of Catholic Hospitals in the Health Care Safety Net, Catholic Health Association, St. Louis, 2002.
2. Immanuel Kant, "Fundamental Principles of the Metaphysics of Morals," in Steven M. Cahn and Peter Markie, eds., Ethics: History, Theory, and Contemporary Issues, 2nd ed., Oxford University Press, New York City, 2002, p. 290.
3. "'Participation' is the voluntary and generous engagement of a person in social interchange. It is necessary that all participate, each according to his position and role, in promoting the common good. This obligation is inherent in the dignity of the human person" (Catechism of the Catholic Church, U.S. Catholic Conference, Washington, DC, 1994, article 2, para. 1913).
4. See Charles E. Curran, The Catholic Moral Tradition Today: A Synthesis, Georgetown University Press, Washington, DC, 1999, p. 34.

Copyright © 2005 by the Catholic Health Association of the United States
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