Hospitals are increasingly recognizing the importance of improving health by addressing complex and entrenched population-level issues that reach beyond traditional health care needs, and are working with non-health care organizations to tackle issues such as adverse childhood experiences (ACEs) and the social determinants of health (SDOH).
Measuring the impact of these partnerships, including health equity impacts, is vital. However, the ‘old way’ of measurement, where hospitals took a health care-centric approach and focused on clinical, financial, or service specific improvements, is unlikely to be appropriate or effective for this work.
Firstly, positive impacts likely won’t be seen in health care outcomes for many years. Secondly, a medical measurement model won’t accurately capture outcomes (positive or negative) accruing beyond hospital walls to other institutions or systems. Finally, a medicalized approach to determining outcomes can alienate non-hospital partners (such as social welfare, education or community-based organizations) or make it impossible for them to measure their impact.
In time, established methods and metrics for this work may emerge. In the interim, we suggest four foundational principles for a ‘new way’ of measuring complex partnership work.
- Agreement on shared goals
Complex partnership work, when done well, should involve multiple partners acting simultaneously for outcomes that don’t bring benefit to only their own organization – for example, improving the financial security of families living in poverty is likely to bring benefits to those families and to multiple organizations, including hospitals, through improved health. In this context, it is hard to attribute causality to any one actor or intervention, and partnership alignment is needed on a set of shared outcomes or single shared goal, recognizing that actions can (and should) benefit others within the system. This compares to the ‘old way’ of measurement, which focused more on institutional goals with partners often working towards different end results and outcomes.
Shared goals should be realistic, relevant, and proportionate to the size of the collaboration, while also being aspirational enough to provide motivation and unite partners in the longer term. For example, Cincinnati Children’s Hospital works with partners in the ‘All Children Thrive’ collaborative, united around long-term goals, including eliminating infant mortality and ensuring all children can read proficiently by third grade.
- An expansive and adaptive approach
The ‘old way’ of measurement often focused on immediate impacts, decided at the outset of a project, sourced from internal hospital data. A more expansive approach balances short term measures (what we can reasonably expect to see now) with longer-term impacts at patient, service, system, and population levels (while considering shared goals). Partners need to be nimble and open minded, adapting over time and ensuring they capture equity impacts. Trusting that measurement can be iteratively shaped enables partners to engage in conversation and collaboration as work evolves and matures. For example, a hospital may hear from local communities that a training intervention designed to help unemployed people access work in a hospital is not being accessed by parents of young children. Taking a flexible approach to measurement could allow the hospital to start to measure features of the program that may help to increase participation among this population (for example, supports such as providing childcare and more flexible approaches to attend training such as remote learning). In this way, using feedback loops, the intervention is more likely to reach a key population who could benefit, and improve health equity.
Partners may find they already have data sources which can be repurposed in creative ways to demonstrate progress, particularly if they look beyond their organization, to public health data or other metrics from non-health partners. For example, Nationwide Children’s Hospital works in partnership with a local school focused on STEM (science technology engineering and mathematics) to provide support for high school students, with a focus on those who have experienced ACEs. The program hopes to improve health, but in the meantime has measured increased graduation rates, fewer suspensions, and fewer missed classes.
- Centralising community
The ‘old way’ of measurement sometimes saw community members simply as sources of data or passive recipients of hospital communication on results and achievements. However, communities are critical partners in the measurement process, providing insight on expansive impacts across health and other areas, and centring equity by bringing understanding on who benefits and how.
The ‘old way’ of consulting communities tended to listen to those who spoke the loudest, whereas a ‘new way’ should focus on those most impacted, as they have the best understanding of the outcomes that matter to them. For example, Sinai Urban Health Institute works collaboratively with community members to design and evaluate community health interventions, including those seeking to improve SDOH among communities facing financial and social challenges. For example, SUHI recently evaluated a program to provide grant funding and technical assistance to small business owners on Chicago’s West Side. The evaluation included a focus on health equity by considering increased economic opportunity for Black and Latinx communities.
Engaging communities in co-production of measurement approaches means shifting power from the institution to the community. Hospital should be open to new ideas, embrace feedback, and share relevant data when possible. This is not a resource-light approach – it takes time, staff, and money. But when done well, it can result in significant rewards.
- Clear accountability
The ‘old way’ of measurement often failed to connect actions to responsibility, leaving partnerships without clear institutional accountability.
Within a context of shared outcomes and distributed leadership across a collective, partners should still be clear on their individual roles and responsibilities, outline what actions they are taking, how their actions are contributing to shared goals, and how their contribution can be measured. When partners are transparent about this, others can hold them to account, helping build trust across the partnership. Institutional accountability can also benefit from community involvement in governance or other structures. For example, Federally Qualified Health Center boards must have at least 51 percent consumer (patient) membership, which helps ensure progress on local priorities and provides a way for communities to hold them accountable for this progress. A similar requirement does not yet exist for hospitals.
We hope these principles enable hospitals and their partners to better understand their impacts on health and health inequities.
Authors note: Support for this research was provided by the Commonwealth Fund. The views presented here are those of the authors and should not be attributed to the Commonwealth Fund or its directors, officers, or staff.