Federal government policy has increasingly required greater accountability from tax-exempt hospitals in demonstrating their contributions to the health of people in the communities they serve. In 2009, the internal revenue service added specific reporting requirements to Schedule H of Form 990 to promote uniform and comprehensive reporting of community benefit, so as to better assess the degree to which tax-exempt hospitals are providing appropriate levels of benefit to their communities.1,2 In addition to uncompensated care for indigent individuals, losses sustained in means-tested government programs, health professions' education, and research, the internal revenue service now stipulates the reporting of “community health improvement” and “community-building” activities (and requires hospitals to describe how these activities promote the health of their constituent communities).3 “Community health improvement” activities are non–revenue producing hospital efforts—primarily clinical and educational—that contribute to community health. “Community-building” activities are programs and investments hospitals make that are directed at broader health determinants, known to be powerful influences on the health of populations.4 Included here are activities such as economic development, environmental improvements, and coalition building.
The Affordable Care Act also requires increased hospital accountability to communities, carrying the requirement that nonprofit hospitals conduct a community health needs assessment (CHNA) with an implementation strategy that demonstrates the involvement of public health agencies, as well as a broad group of stakeholders.5,6 Singh et al have underscored the value of aligning community benefit activities with findings from CHNAs,7 but to date, there is scant evidence of the degree to which the views of local residents are incorporated into CHNAs. One review of CHNAs conducted by Texas nonprofit hospitals found that few engaged a broad array of community members in meaningful participation.8 Particularly problematic is the concern that hospitals are making choices regarding programs and activities without sufficient community input into decision-making processes.
Public deliberation is a promising approach to address the concern regarding insufficient community input. In wider use within the health sector in other countries,9,10 public deliberation is a method of community engagement that provides guidance to decision makers on value-laden issues when technical solutions alone are inadequate to provide direction or set priorities. Public deliberation includes educational components that are designed to provide balanced background information about divergent and/or competing approaches to a decision. Participants interact with facilitators, experts, and one another as they work through problems and case studies that are developed to lay out all sides of the question at hand and aid discussions that elicit information on the experiences and values of the group. The organization and facilitation of a public deliberation are directed toward generating reason-based discussion and debate, resulting in recommendations to the entity requesting the deliberation.11,12
Public deliberation has been gaining visibility in the United States as a mechanism for consulting the public about thorny health policy and programmatic issues. With roots in participatory democratic traditions,13–15 public deliberation practitioners endorse the view that important decisions, particularly where competing values and complex trade-offs are involved, are best made with guidance from an informed public that will bear the consequences of the decision. Deliberative processes pursue legitimacy, transparency, and accountability in decision making; participants who have a stake in the implementation of a decision, and who typically represent a wide swath of those who will be affected, are recruited to work with their peers to examine issues through the lens and values of their life experiences.
Public deliberation can use a continuum of methods and time frames, ranging from a half day to a week.16 Findings from a randomized controlled trial of 4 public deliberations approaches suggest that—for complex health issues—a citizen's panel approach is most likely to contribute to knowledge gains and typically leads to larger shifts in attitudes and perspectives.17 The citizen's panel model is a hybrid of deliberative polling18 (a 2-day deliberation typically involving a large and representative group of participants who interact with experts) and the Citizens' Jury method19–22 (an approach that typically involves 12-24 individuals from a cross section of the population who meet for 2-7 days to examine expert witnesses and deliberate on a policy-relevant question). In the randomized controlled trial of deliberative methods, African Americans, Latinos, and individuals with lower educational attainment reported more perceived impact from their participation than did whites and persons with higher educational attainment.23
Following on a 2014 CHNA—and in the context of emerging responsibilities related to community benefit—Maimonides Medical Center (MMC), in Brooklyn, New York, partnered with The New York Academy of Medicine (the Academy) to implement a series of public deliberations to elicit guidance from an informed cross section of Brooklyn residents regarding priorities for new hospital activities directed toward decreasing the burden of chronic disease, a major health concern identified in the CHNA. This article describes and reports on the results of these public deliberations, focusing on the issue of hospital role, 1 of 2 deliberative questions. Specifically, participants were asked to consider the following:
Should Maimonides' efforts to improve health focus primarily on the following:
- Improving prevention services delivered by medical staff in the hospital's clinics?
- Community interventions that decrease risk factors for disease?
- Working to change policies (eg, of the government, of employers, of schools) that make it easier for people to stay healthy?
After expedited approval from the Academy Institutional Review Board, study authors convened and facilitated three 2-day public deliberations in the fall of 2015. Extensive outreach was conducted to identify participants, including phone calls to community members who previously participated in MMC community programming; signs in libraries and other public places; engagement with local elected officials; announcements on social media; and outreach at health fairs and to community organizations serving diverse populations. Each deliberative session involved 21 to 24 participants who were selected from nearly 300 individuals who responded to outreach efforts. Demographic information was assessed through a screening form that potential participants could complete online or by phone. Eligibility criteria included Brooklyn residency, age 18 years or older, self-reported comfort with English, and a correct response to 1 numeracy item. Participants were purposefully selected from the larger sample to provide diversity according to age, race and ethnicity, languages spoken in the home, education, and neighborhood, as reported on the screening form. Informed consent was obtained from participating individuals.
In advance of each public deliberation, participants received background materials that provided context for their discussions. Each deliberation began with senior MMC leadership underscoring their interest in obtaining guidance from area residents on strategies the hospital should undertake to improve health outcomes in local communities. Facilitators oriented attendees to the ethos of a deliberation, including the importance of participation, respect for differing opinions, and the need to provide reasons when describing their perspectives.
Deliberative sessions featured educational presentations by team members and national and local experts. Topics included community-level health indicators and relevant risk factors; “evidence” in the context of health and medical research; and the contribution of social and environmental factors to chronic disease. Separate presentations provided concrete examples of clinical, community-based, and policy-based prevention interventions. To ensure that participants heard a balance of perspectives, these presentations were prepared and delivered by experts, each of whom provided rationales and evidence in support of the approach to prevention they championed. Participants interacted with experts, posing questions relevant to the deliberation.
Discussions and deliberations occurred within the larger group setting and in breakout groups of 7 to 8 participants. In each of 3 breakout sessions, participants examined exemplar case studies of clinical, community-based, and policy approaches to chronic disease prevention. Case studies included information on the effectiveness and cost-effectiveness of given interventions, as well as projected impact on the health of diverse Brooklyn residents in 10 and 30 years. All case studies were developed from evidence-based reviews conducted by the U.S. Preventive Services Task Force, the Community Guide to Prevention, and/or Cochrane reviews.24,25 To prepare participants for answering the overarching deliberative question regarding hospital role and approaches to preventing chronic illness, each small group shared its recommendations with the larger group following the breakout sessions. At the conclusion of the deliberation, participants were asked to make their final recommendations.
Data Collection, Management, and Analysis
Participants completed pre- and postsurveys that included questions on knowledge and attitudes related to areas that the public deliberation focused on: evidence; environmental, social, and behavioral risk factors for poor health; and prevention interventions. The postsurvey also included questions on perceptions of the public deliberation and its utility. Surveys were linked with a unique identifier, allowing analysis of both individual and group shifts in knowledge and attitudes. Descriptive statistics were used to characterize the participants at baseline; McNemar, Stuart-Maxwell, and paired t tests were used to examine shifts in knowledge and attitudes pre– and post–public deliberation. Regression analyses were used to examine whether increases in knowledge were associated with changes in attitude.
Qualitative data came from audio recordings of breakout sessions and phone interviews conducted with a sample of participants (n = 10) following the deliberative sessions. Interviewees were selected for diversity according to demographics and responses to the deliberative questions. Recordings were professionally transcribed; transcripts were managed using NVivo, a software package for qualitative analysis (NVivo11 QSR International, Victoria, Australia). Public deliberation discussions and interviews were coded for preidentified (eg, policy) and emergent (eg, feasibility) themes and analyzed using standard qualitative approaches, involving repeated reviews of the data by multiple members of the research team.
Characteristics of participants, and of the wider community, are described in Table 1.26 Sixty-four percent of participants were older than 50 years. Fifty-eight percent had at least a college degree, two-thirds were female, and just more than half (51.5%) were white. Approximately 20% were black/African American, approximately 10% were Latino, and 10% Asian.
TABLE 1 -
Prioritize Health! Participant Characteristics Compared With Brooklyn Total Population
||Prioritize Health (N = 66), n (%)
||Brooklyn, New York (N = 2 504 700), n (%)
||603 348 (24.1)
||505 656 (20.2)
||301 971 (12.1)
||279 801 (11.1)
||134 939 (5.4)
|Less than HS graduate
||360 662 (21.1)
|HS graduate or GED
||459 801 (26.9)
|Some college but no degree
||244 429 (14.3)
|College degree or higher
||644 405 (37.7)
||1 181 378 (47.2)
||1 323 322 (52.8)
||1 072 041 (42.8)
|Black or African American
||860 083 (34.3)
|American Indian/Native American
||13 524 (0.5)
||496 285 (19.8)
||262 276 (10.5)
At the beginning of the deliberations, participants answered on average 9 of 16 knowledge questions correctly. Postdeliberation, participants averaged close to 12 correct responses, a statistically significant increase (P < .001). In the postsurvey, 52% of participants correctly identified dropping out of high school as a risk factor for heart disease, compared with 21% in the presurvey (see Figure 1).
For the overarching deliberative question, there was an increase in the number of participants who prioritized community and policy interventions versus clinical interventions (see Figure 2). Although the presurveys indicated that many participants came to the deliberations preferring community (34.9%) or policy (50.8%) approaches, these numbers increased postdeliberation (39.7% and 57.1%, respectively). Qualitative findings were consistent with survey results. Participants emphasized the broad reach and implications of community and policy approaches.
If more resources [are] given to the hospital's traditional role, I think you're just continuing with the status quo. And I don't think it's gonna make much of an impact on changing the health outcomes of the people in the community.
I'm asking for hospitals to just be more mindful of all the different ways that we can increase health. It's not just one way.
If Maimonides were publicly rallying for different policies that would affect the community's health ... I feel like it would be a positive image for the hospital and it would also kind of show the community that the hospital is just not a place where you go when you're in dire need. It's a place that's focused on health on all levels.
When asked to rank the importance of each of the 9 exemplar interventions considered through the case studies, the highest-ranking intervention in both the pre- and the postsurvey was “community centers offering group exercise opportunities for older adults” (see Table 2), though there was a slight decrease in the postsurvey. The interventions that showed the greatest decreases in priority were “counseling on diet and physical activity within a clinical encounter” and “worksite wellness programs to improve diet and physical activity.” Interventions that showed the greatest increases in priority from pre- to postsurvey were those that focused on the importance of education, including “decreased class sizes to improve high school graduation” and “health care providers encouraging parents to read to their children.” Improvement in participants' knowledge about the connection between education and health was significantly associated with a higher prioritization of the smaller classroom size intervention (linear regression, β = .85, P = .0185, data not shown).
TABLE 2 -
Pre- and Postparticipant Prioritization of Interventions (Number and Percent That Ranked It as a High or Very High Priority)
||Pre, n (%)
||Post, n (%)
||Community centers offering group exercise opportunities for older adults.
||Implementing a policy that limits the amount of salt in processed foods.
||Decreasing elementary school class size to improve high school graduation rates.
||Schools creating vegetable gardens and scheduling time for students to garden during or after school, with guidance and support from school staff.
||Health care professionals working in teams to personalize care for people with high blood pressure according to their particular needs.
||Implementing a policy that assures all neighborhoods have streets that are safe for all users and have easy access to outdoor areas for exercise.
||Doctors encouraging parents to read to their children and providing them with an appropriate children's book at each checkup.
||One-on-one counseling by health professionals on how to eat better and be more physically active.
||Employers offering diet and/or exercise classes at the worksite.
Qualitative data gathered from participants indicate that, in addition to presenting information about the broader determinants of health, the public deliberation provided a framework for health that reflected and validated their own experiences. Responding to an interview question, “How did your understanding of social factors that impact chronic disease shift, if at all, during the public deliberation?” 1 participant noted,
It's something that I sort of thought anyway, but to see actual statistics on it that prove my gut feeling on the matter. And it just makes a lot of sense. If you're—if you didn't have the opportunity to have a good education, you're not going to have a good job, you're going to be much more stressed in life, you're going to have much less time to take care of yourself, you're going to have much fewer resources to eat properly.
When answering a question about dedicating resources to improve the health of people at high risk of disease because of social factors, another participant responded:
I think that would be at the top of the list, definitely, on things to pull resources for and to focus on because, mainly because it's hard for people to escape their environment. So, even if they're trying to make efforts themselves, the moment they walk out their door they're inundated with issues that are challenging or choices that might not be that easy to make for them.
Perceptions of the deliberative process
In the postdeliberation survey, all but 1 participant agreed or strongly agreed that they would participate in a process like this again, and 95% thought that hospitals should use this type of process to make decisions in the future (data not shown). As illustrated by the quotes later, participants saw community input in hospital decision making as important and had not known of opportunities to do so before the public deliberation. Participants also reflected that the public deliberation helped broaden their thinking about appropriate roles for hospitals.
I think if you want to affect the community, it is really important to get feedback from that community .... My thought of a hospital was when you need treatment, you go to a hospital. If you want to go beyond that, and have outreach programs like they're doing, I think the opinion of the community, that's super important.
How do you learn about the community or what the community needs or wants if not by gleaning information from actual residents and people who utilize the hospital facilities? So, yes, it's very important. It's something that I never even thought existed.
I think when I first filled out the [pre] survey I was more like clinical. But then after going through the two days, it broadened. My thinking wasn't so individual, it was thinking about everybody.... Because after being in a group you find out that there's a lot of different people with different situations. Not everyone is living like you, so ... you can't just think about yourself all the time.
In the public deliberations reported here, participants recommended that the sponsoring hospital should expand its activities to prevent chronic disease. Compared with a national sample, individuals taking part in the 3 deliberations came to the sessions with a greater understanding of the health impact of social and environmental factors.27 Nevertheless, in each of the public deliberations, participants' knowledge of the impact of socioeconomic factors on health increased. The final recommendations across all groups asked that the hospital take a larger role in community-based interventions, as well as in championing policies that would protect and promote their health. Review of the qualitative findings suggests that participants valued these expanded approaches to preventing disease because of their broad reach and ability to affect a range of factors related to health and quality of life more generally.
Output from public deliberations has been questioned, in that deliberations involve relatively small numbers and so are unable to represent the values and views of all who would be affected by the recommendations. In fact, the deliberations described here faced particular challenges in achieving representativeness because of the great diversity in Brooklyn, with respect to race, ethnicity, and socioeconomic status. Although the deliberations brought together a broad cross section of residents, participants were not representative of MMC's service area or of Brooklyn, overall (see Table 1). The groups, on average, were more highly educated than the overall population, which was in part a function of the need for participants in this public deliberation to have sufficient comfort with numeracy to allow them to engage in conversation around scientific evidence and cost-effectiveness. Furthermore, despite vigorous outreach efforts, there was minimal participation from members of the orthodox religious groups that are prevalent within the hospital's service area. Finally, we were unable to include community members who had limited English proficiency, because clear communication between participants is central to deliberative processes. To partially address this last limitation, we prioritized selection of participants who lived in households in which at least 1 member was not English-speaking.
Public deliberations, because of their limited size, do not achieve the representative sample that surveys do. Despite this limitation, public deliberations facilitate greater engagement and comprehension of any given topic, thereby prompting more informed recommendations. Ensuring that diverse populations are included remains an important challenge and likely requires additional resources to address (eg, for translation and interpretation). However, the heterogeneity of Brooklyn is unusual. Recruitment of a representation sample is likely to be less of a challenge elsewhere, particularly in rural and suburban areas, where there is greater racial, ethnic, and religious homogeneity.
Calls for nonprofit hospitals to shift their community benefit investments toward broader community needs and away from direct patient care are increasing.28,29 Yet despite the well-recognized association of social and environmental factors with the health of communities, a recent review of US hospitals' community benefit expenditures found that of the national median $130 per capita spent, less than 9% went toward community health improvement and community-building activities.2 A report of a sample of New York State hospitals found that less than 0.1% of total hospitals' expenses was directed at “community building” activities, such as housing and education that target root causes of health outcomes.30
The value to hospitals of their nonprofit status is estimated to have doubled between 2002 and 2011 from $12.6 billion to $24.6 billion.28 This benefit to hospitals is provided by taxpayers who, in foregoing access and alternative uses for this money, can reasonably claim a voice in hospital decisions regarding community benefit expenditures. Although the technical insights of clinicians, public health workers, administrators, and policy makers are essential to efforts to improve the health of populations, absent an understanding of the views of informed community members, opportunities to create a transformed system with an emphasis on health may fall by the wayside. In medicine, there has been increasing attention to “patient engagement,” which is now understood to be a critical component for a high-performing medical care delivery system. At the community level, engagement of residents by hospitals, public health agencies, and other entities with a stake in population health should be seen as an analogous and vital step in planning and decision making. Public deliberation is a tested methodology that can build the knowledge base among community members while at the same time providing guidance to health-promoting organizations.
Health systems are grappling with changes in reimbursement strategies that move away from fee-for-service toward value-based care31–33 and capitation. With that comes the concomitant need to promote and protect the health of populations in their service area. Although some systems have already assumed broader-based efforts to improve population health,3,30 reimbursement reform is still in its early days. For hospitals that principally serve economically disadvantaged communities and rely on public payers, it is likely that such a shift is difficult and that community benefit dollars will continue to support direct clinical services rather than moving toward a primary/primordial prevention model. However, findings from this work suggest that lay members of the public endorse a changing role for a hospital's approaches to health.
Implications for Policy & Practice
- Not-for-profit hospitals gain tax advantages. In communities where insurance coverage has increased, resources previously devoted to uncompensated care may become available for new initiatives that promote and support health more broadly.
- Priorities for the advantageous use of these resources can be vetted with an informed cross section of community members using the structured method of public deliberation.
- Community members who are familiarized with a range of strategies for prevention may be more likely to support innovations in how “health” dollars are expended, including population-based approaches.
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