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This article is the work of the Social Accountability Budget Task Force (see "Social Accountability Budget Task Force" at the end of this article), a group convened by CHA to examine how far the ministry has come since the association published the Social Accountability Budget 10 years ago. See the SAB section of CHA's Web site for materials mentioned in the notes. This column is the first of a series on the topic.

The mission dimension of our healing ministry can be demonstrated and measured to reveal how well an organization is delivering on its claim of being Catholic. The Catholic Health Association (CHA) is engaged in two efforts to examine the performance of Catholic-sponsored organizations as ministry.¹ The ultimate outcome of one of those efforts, a review of the ministry's 10-year experience with the social accountability process, will be the revision of the original social accountability budget document. This column summarizes the results of that review, emphasizing the need for an even greater community focus.

CHA broke new ground with its 1989 document, Social Accountability Budget: A Process for Planning and Reporting Community Service in a Time of Fiscal Constraint. The document provided guidelines for a community-based assessment of needs, for the planning and delivery of unreimbursed community services, and for the accounting and reporting of such services.

Since the introduction of the Social Accountability Budget, the healthcare environment has changed and much has been learned about responding to health challenges in communities. For that reason, a committee of CHA members with extensive social accountability experience has reviewed the ministry's implementation of the process. The committee identified attitudes, approaches, and skills organizations need to become more accountable to their communities.

Community Benefit Is a Mission Imperative
Catholic healthcare has its origins in a faith-based response to the health needs of poor and other vulnerable people. The social accountability process helps organizations quantify their care for uninsured and underinsured persons. The process also accounts for the cost of other initiatives that augment the financial value of the unreimbursed services we provide our communities. The ministry has provided these services with compassion and caring, but at times with insufficient attention to planning or evaluating their effectiveness. Community benefit services, for instance, need to be better connected to organizational efforts to establish a healthy community, thereby signaling the active, transformative nature of our mission and ministry.²

Jesus' mission, after all, was to promote God's reign of justice and peace here on earth. In his teaching, preaching, and healing, Jesus was attempting to create, in the community, the conditions for true health. Jesus wanted all people to be welcome and to participate in the community, to have the human goods necessary for full human flourishing. Hence, we promote the common good — the sum of those conditions (e.g., healthcare, employment, housing, political participation) necessary for a decent human life.

Because they are so often excluded from participation in the community and from its benefits, Jesus had a special affection for those on the margins of society. Indeed, a preferential option for the poor, of which charity care is an expression, is a prime mover of community benefit initiatives.³

Because Jesus was about such radical healing and relationships, so are we. Community initiatives are core to our ministry and should be included among our strategic initiatives. The healing ministry is not confined to ministry to the sick. It is fundamentally and essentially geared to building just, inclusive communities in which everyone's dignity is respected and supported. The social accountability process has helped us see more clearly that contributing to the conditions for true health requires partnering in the community to improve the environment and the conditions in which people live and work. Thus our accounting to the community for these initiatives takes on a significance similar to our financial accounting.

The past decade's experience with the Social Accountability Budget has been a catalyst, helping us appreciate that promoting healthier communities is part and parcel of our mission. We understand better now that:

• Our communities are the locus of our ministry every bit as much as are our healthcare campuses.
• Community benefit planning and social accountability must be integrated into our strategic planning and budgeting processes.
• Trustees and senior management must value and support community benefit initiatives.⁴

The social accountability process has launched us into promising new relationships with our communities, relationships central to both our integrity and our market success.⁵

New Models of Relationship with Community
The notion of stewardship reminds us that everything we have we possess as gift from a loving and gracious God for the good of the entire community. In the next generation of social accountability, understanding that the resources we steward are of and for the community will help us to better:

Work with the Community

• Engaging community in the assessment, planning, and evaluation of initiatives
• Building on community assets and capacity
• Listening to and learning from the community, hearing from its members what is valuable, then adding or discontinuing services as indicated

Build Partnerships

• Understanding that community participation in all aspects of our involvement is essential
• Strengthening our commitment to community coalitions, particularly with other ministry partners, including Catholic Charities, parishes, bishops, and dioceses
• Recognizing that mutuality and inclusivity build trust

Contribute to Healthy Communities⁶

• Broadening our notion of health and well-being and extending our efforts across and beyond the full continuum of care
• Solving complex problems by working with others and looking "upstream" to get at the source of these problems
• Coordinating all our community well-being initiatives (e.g., community benefit services, spiritual care, advocacy, mission-based investing, alternative investment, fund development)

Demonstrate to the Community the Value of the Services

• Setting annual community benefit objectives and evaluating our performance on the basis of their achievement⁷
• Moving toward outcome-based accountability in the community benefit arena, as we are in the clinical and financial arenas⁸
• Describing the value, often not wholly captured by the dollar amount, of our community benefit to various internal and external constituencies. We ought not be shy about telling our story!⁹

The social accountability process has made tangible the meaning and significance of Catholic social teaching. It makes concrete for leaders the call to act on our commitment to poor persons, to just social and economic relationships, and to the common good. It clarifies the assertion that "action on behalf of justice is not optional," even in economically challenging times. In the next generation of the social accountability process, community benefit will be regarded as a matter of integrity.¹⁰

Organizational Infrastructure Is Vital¹¹
Appreciation of the social accountability process has evolved with practice. It is now understood as far more than an inventory of the good we do in and for the community. Indeed, it is a set of attitudes, values, policies, and practices integral to the organization, and for that reason it should be better integrated into the organization's key structures and function. Ministry leaders in the next generation of social accountability will more intentionally:

Signal Leadership Commitment

• Recruiting board and senior management committed to community involvement
• Directing sufficient human and financial resources to a community benefit function that incorporates multidisciplinary perspectives
• Setting meaningful indicators for healthy community objectives and aligning incentives with those objectives¹²

Establish Policies and Procedures

• Identifying community benefit as a core business strategy for healthcare organizations throughout the continuum¹³
• Ensuring intentional, systematic, community-based collaboration with a view to building effective community relationships
• Calling for thorough and consistent reporting to pertinent constituencies, including government and taxing authorities,¹⁴ as well as to the community¹⁵

Integrate and Evaluate Community Benefit

• Tying it to the organization's strategic planning and budgeting and performance assessment processes
• Holding partners, vendors, and consultants accountable for community benefit activities
• Requiring outcome measurement and accountability

Organizations with effective community-based initiatives will translate their mission and vision statements into structural elements that, in turn, support new models of collaboration with their communities.

Special Competencies Are Required
Some are surprised to find as they move off the healthcare campus and out to the community that they are not "culturally competent" in that arena. One ought not to assume that institutionally oriented healthcare professionals, competent though they may be, have the skill sets to work with neighborhood groups, social agencies, parishes, or (given our intensely competitive posture) even other healthcare providers. Community organizations operate very differently from healthcare organizations. Healthcare executives' tendency to assume leadership (and take control) is often counterproductive in the community. Experience has shown us that the following skills serve an organization well in the community:

• A familiarity with the social service network and ethos
• Willingness to include and work patiently with all the parties that need to be "at the table"
• A listening, learning posture
• Knowledge of and appreciation for public health
• A genuinely collaborative working style
• An ability to communicate the community reality to different levels of the healthcare organization

Invigorating the Ministry
We invite all Catholic healthcare organizations to embrace the next generation of social accountability, making sure that the organization has both the infrastructure and competencies to support an effective community benefit program. We are confident that such community involvement will invigorate the ministry. To the extent that the ministry embraces such a commitment, our community benefit role will be greatly enhanced and the story we have to tell will be compelling.

NOTES

1. In addition to the social accountability process described here, CHA members are engaged in a benchmarking process that will help them measure and improve their organizations' overall performance as a ministry, building on the core values in the Ethical and Religious Directives for Catholic Health Care Services.
2. See Healthy People and Healthy Communities. A recent emphasis on economic growth and productivity, and the individual's role therein, has contributed to a decline in people's involvement in and contribution to community (social capital) so important to a well-working democracy. Community benefit efforts that mobilize and nurture the growth of individual and community capacities help restore a robust civic community, overcoming a prevalent individualism and social fragmentation.
3. The new healthcare landscape poses challenges to the imperative for community benefit activities. Because of the contemporary emphasis on disease prevention, health promotion, and reduced lengths of hospitalizations, many individuals have enrolled in managed care organizations. However, only a few of these are 501(c)(3) charitable entities. How this change affects healthcare organizations' responsibility to the community at large deserves further study.
4. Carolyn Lewis, then chairman-elect of the American Hospital Association (AHA), spoke about the importance of engaging the community in planning in real, ongoing, and innovative ways. See "The Chairman as Challenger," Hospitals and Health Networks, October 5, 1998, pp. 25-30.
5. See "A Community Benefit Primer" by Susan Patton, assistant corporate counsel, Mercy Health Services. This primer is a legal foundation document that conveys important information about not-for-profit status.
6. The healthy community movement recognizes that "people's health and quality of life are dependent on many community systems and factors — not simply a well-functioning health and medical care system." Healthy communities result from healthy choices and environments that support shared responsibility. They help unleash human potential, build trust and relationships, and mobilize the creativity and resources of the community toward a shared vision of the future. Healthy communities call for inspired leadership and action from every corner of the community. "Growing" a healthy community is a lifelong process requiring constant nurturing and vigilance. See the Coalition for Healthier Cities and Communities.
7. Lisbeth Schorr, in Common Purpose: Strengthening Families and Neighborhoods to Rebuild America, Anchor Books, New York City, 1997, urges the nation to move beyond limited social programs toward a more comprehensive long-term strategy "that could combat a wide range of social ills, including those that are separating the haves ever further from the have-nots." Chapter 5, "Finding Out What Works," develops what Schorr describes as "a new evaluation mind-set."
8. Some resources in outcomes measurement are Barry M. Kibel, What Is Outcome Engineering? Pacific Institute for Research and Evaluation, 121 West Rosemary St., Chapel Hill, NC 27516; Results Mapping Laboratory (919-967-8998); Measuring Program Outcomes: A Practical Approach, United Way of America, $5 (800-772-0008); Health Forum Outcomes ToolKit; and Lyon Software (419-882-7184).
9. See Telling Your Story: A Communications Resource for Catholic Healthcare, Catholic Health Association, St. Louis, 1999.
10. See CHA's Standards for Community Benefit.
11. See Kevin Barnett's "Elements of a Model Community Benefit Program"; his book, The Future of Community Benefit Programming, Berkeley, CA, 1997, is available from the Public Health Institute (510-644-8200).
12. Dick Davidson, AHA president, says: "If you reward a bigger bottom line, you're going to get one. If you reward improved market share, that's what you're going to get. But if that's the exclusive focus of your reward system, what won't you get? You probably won't get your mission." See Richard J. Bogue, "An Incentive for Community Health: Linking CEO Compensation to Community Goals," Trusteem, May 1999, pp. 15-19; and Linda Milstead, "The Pressure Is On: Tying Executive Pay to Community Benefits," Health Forum Journal, March-April 1999, pp. 47-49.
13. The Bogue article in note 12 lists 10 reasons for making community health improvement a core business strategy.
14. See the article for information about the final regulations on Public Disclosure of Forms 990. Completing and filing 990s is an opportunity to ensure that the information is comprehensive, since reporters, researchers, and others will use it. A Catholic healthcare organization should consider attaching its social accountability budget report to the 990 and even giving this report directly to the press.
15. Opportunities for "telling your story" — for articulating our values and faith-based approach to the healing ministry — include employee and community newsletters, regular board updates, and print and other public media.

PRACTICAL STEPS IN SOCIAL ACCOUNTABILITY

• Work with communities. Make your organization part of community-wide efforts to benefit your community. Listen to and learn from community members, especially those at risk.
• Build partnerships. Be a partner as well as a leader. Form collaborations with public and voluntary community organizations and businesses.
• Work with other Church ministries. Parishes, Catholic Charities, and other Church-related groups share our commitment to serving persons at risk and others in the community. Make friends with them.
• Build on community assets. Emphasizing the community's needs and problems can be counterproductive. The best way to tap its potential is by addressing its strengths.
• Work on improving health in the community. The focus of community benefit activities should be on improving the health of populations and the overall community.
• Use existing community assessments. Be especially quick to use information collected in conjunction with the Healthy People 2000/2010 goals. You may spend your time better working with others to understand community issues, rather than collecting primary information yourself.
• Consider "health" broadly. Healthcare organizations' community benefits extend beyond traditional health services to issues that strongly affect the health of persons and communities, such as housing, transportation, and education.
• Make your commitment to community benefit explicit. Your executives and trustees should be familiar with, and committed to, your organization's community benefit role. Accountability mechanisms should be built in.
• Integrate community benefit activities into other organizational priorities. Community benefits should be part of — not apart from — your organization's planning, budgeting, and operations.
• Examine the impact of community benefits. Set specific objectives for your community benefit programs and measure them against outcomes. Assess the impact of each community outreach activity, as well as that of the overall program.
• Assess the value of community benefits. Traditional reporting of community benefits has focused on program cost. Describing how individuals and populations have actually benefited will have a stronger impact. Be sure to use vivid narrative, as well as numbers, in your description.
• "Put your mission in the margins of your Form 990." Use this public document to demonstrate your organization's community benefit commitment.
• Tell your story. Employ all available media to make sure the community knows about your organization's community benefit activities. This is so important, it needs to be said twice: Tell your story.

WHAT DO YOU THINK?

We would like to have readers' responses to this first Social Accountability column. Which of the issues cited here should we emphasize in a future column? Do you have a relevant experience, practice, or tool that others in the ministry might find useful? Please fax or e-mail your responses to us.

1. I recommend that a future column focus on the following issue:
2. I urge the ministry to employ the following practice or tool:
3. I hope others in the ministry might make use of the following insight or lesson:

Please send your responses to Ann Neale, PhD, senior associate, Mission Services (fax: 314-427-0029).

Copyright © 1999 by the Catholic Health Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3477.