Nonprofit hospitals and health systems spend more than $4 billion each year on community health improvement, yet little is known about the internal process that these organizations follow when implementing these efforts. Because of laws governing tax-exempt health care organizations, both the process these hospitals use to identify community health needs and their annual expenditure of community benefit dollars are known. Yet much else about the process of community health improvement is largely unknown. This study uses data from semi-structured interviews with 38 directors of community health efforts at nonprofit hospitals and health systems to describe the internal procedures that nonprofit hospitals and health systems follow when implementing community health efforts, with the goal of identifying both leading practices and areas in need of greater attention. Interviews were analyzed using open and axial coding. Results show hospitals' community health improvement efforts have 7 distinct stages: budgeting, assessing needs, developing strategy, allocating resources, implementing programs, evaluating, and communicating results. Two of these stages, assessing needs and communicating results, are similar across most organizations - most likely a result of federal regulations. Other stages, especially budgeting, allocating resources, and evaluating programs, show high variation across organizations and often lack a formal process. Several leading practices were identified for each stage, but community health efforts currently lack structure within many organizations and are not designed for improvement over time. To better leverage the resources available from nonprofit hospitals, the less public-facing aspects of community benefit will require more study and perhaps additional regulation.
Keywords: community benefit; community health improvement; nonprofit hospitals.