Hospital Budgeting by Community
Community engagement is now a legislated feature of hospital governance in Ontario. What form that engagement takes is open to interpretation. For senior leaders of Northumberland Hills Hospital (NHH), based in Cobourg, Ontario, community engagement took the form of an ambitious Citizens’ Advisory Panel (CAP). Northumberland was coping with persistent budget shortfalls, so the panel’s task was to recommend possible changes to the hospital’s services.
To measure the success of CAP, the hospital asked The Monieson Centre for Business Research in Healthcare to conduct a review of the process; the review was carried out by a research team spearheaded by Yolande Chan, E. Marie Shantz Professor of MIS at Queen’s School of Business, and Leslie Benecki, now manager of quality improvement and integration at Kingston Community Health Centres.
In this conversation, Leslie Benecki discusses their conclusions and shares key success factors.
How the community engagement project worked at Northumberland Hills Hospital
Ontario’s Local Health Systems Integration Act (passed in 2006) requires the province’s hospitals to adopt a community engagement process as they move forward with institutional changes. That process is not defined, so it provides healthcare facilities with an opportunity to engage in a variety of ways. At Kingston General Hospital, for example, patients or family members of patients now provide input on an ongoing basis throughout the organization. Other hospitals may do things as simple as conducting client surveys
A Citizens’ Advisory Panel (CAP) is a one-time, intensive form of engagement, and that’s what Northumberland Hills Hospital used to get advice on budget and service provision decisions. Northumberland already had a couple of years of budget deficits and they were at risk, so they had to do something. Maintaining the status quo was not an option. The hospital’s board hoped the CAP process would result in more support for the decisions that had to be made, and would sustain, if not strengthen, bonds between the hospital and the communities it served.
The NHH board put out a call to the community for participants. From the 100 people who volunteered, 25 were selected to sit on the panel. Northumberland worked really hard to make sure they had a representative group of the population.
The panel was asked to consider which services were core and non-core, develop contingency plans, suggest new services the hospital could introduce, and advise on service integration strategies with other health service providers.
Panel members deliberated for five full Saturdays. Regional as well as local health system leaders were brought in to speak with them and answer questions. They were provided with background information and a tour of the hospital to understand the hospital’s services and the magnitude of the budget challenge. Each session was built on the previous one and members were given homework in the form of readings or a task that required getting input from family, friends, and neighbours.
What the CAP process provided that other consultations didn’t
The CAP was one form of input, but there were others as well. There were conversations with physicians who had privileges at the hospital, for example, and with the staff and the board. But the panel provided a different perspective because the participants didn’t have a vested interest in maintaining a particular service.
Panel members had the opportunity to take a broad look at what services were most needed in their community and what services could be provided by other organizations. They could conclude, for example, that palliative care was very important for the community but they could also question whether it needed to be provided by the hospital.
While the board and senior management provided information as requested, NHH leaders remained at arms’ length from the process to avoid leading, or being perceived to lead, the course of the discussions. Facilitation of the days was led by an external third party (MASS LBP), while a single board director served as moderator, auditing all of the sessions, answering questions on behalf of the board, and reporting back to the board on progress.
A key success factor is senior management buy-in
The CAP process cannot be successful without senior management commitment to take the recommendations seriously. Otherwise, it just looks like smoke and mirrors.
Northumberland was fortunate because President and CEO Robert Biron was very committed to being transparent, proactive, and inclusive. (Biron has since moved on to become President and CEO of The Scarborough Hospital.) Even if he wasn’t actively participating in sessions, he was there on all of those weekends to answer questions and demonstrate his support. Biron prepared the board as well, since the CAP process carries some risk. The panel could have come up with something that the board would have had difficulty accepting. In the end, most of the CAP’s recommendations were implemented.
The senior administrators at the hospital were also very engaged. They wanted to keep all stakeholders informed because these were high-impact decisions. Jennifer Gillard, Director, Communications and Community Engagement, played a key role. She developed a comprehensive communication strategy to keep internal and external audiences informed. External tactics included a website where all CAP materials were shared, e-bulletins as well as an advertising campaign. Internally, there was regular communication to the hospital staff and physicians.
As part of the CAP, there was an open meeting at which the entire community was invited to come and provide input. There were really strong efforts to try to make sure that people understood that this was not about putting 25 people in a room and inviting them to agree with management.
How panel participants viewed the process
You have to have a compelling reason to put a CAP together because it’s a very resource-intensive process. People aren’t going to invest the time unless it’s an important issue like a budget reduction or amalgamation of hospitals.
We conducted a follow-up survey that asked panel members what they thought of the experience. Overall, people thought it was an open and transparent process and that they had accomplished something of value to the community and the hospital. Some members thought a future community engagement process could be improved by having more opportunities to receive input from the broader community via social media, a web-based feedback forum, and more time between CAP sessions for members to obtain input from others.
Northumberland’s experience suggests that other health services providers would likely benefit from CAPs or similar activities to engage their communities in difficult budget and service provision decisions. An effective process would certainly require significant commitment and coordination, and could be complemented with social media and other online community engagement approaches.
— Interview by Alan Morantz