Commentary--Evaluating Community Partnerships: A Response

The article by Stephen M. Shortell et al. asserts that a community partnership with a common vision, strong governance, and effective management is more likely to succeed than one that lacks that vision, governance, and management. That assertion, however, does not answer the primary questions imbedded in the article, specifically:

• How do we know when a partnership in a community really exists? This is particularly important when there are great differences in the economic and political power of the potential partners as is the case with hospitals, government agencies, and community organizations.
• What are the critical features of that partnership that enable it to improve the community's health? Certainly, different kinds of problems may require very different kinds of partnerships and power-sharing arrangements. For example, you could hypothesize that working with the community to improve the immunization rates for childhood diseases would be a simpler task than working with the community to reduce the risk and transmission of AIDS if only because the former does not explicitly address issues of addiction and sexual practices. It would be useful to know whether there is a hierarchy of problems, some of which are very amenable to interventions from a wide assortment of community partnerships while others respond only to a smaller set of highly sophisticated partnerships.
• How do we assess the actual impact of that partnership on the community's health? We have a range of indicators that could assess whether the health care infrastructure changed (inputs), whether the appropriate services were delivered (process), and whether the health of the community improved (output). Given what we know about how rapidly or slowly different dimensions of health status change over time, what are the best indicators that we might use for the selected tasks to judge the impact of a community partnership?

While these questions are central to the article, they are not explicitly addressed. Indeed, the article does not explicitly evaluate community partnerships. It does not assess improvements in community health. And, while it may have assembled a montage of what many thought or perceived such evidence might look like, the article does not track a single observable footprint. There is very little objective analysis of process --midstream or otherwise--and very little quantitative analysis. The analysis is primarily a reliability test of the vision of the Community Care Network (CCN) sponsor--the American Hospital Association's Hospital and Research Education Trust. Even as a test to determine whether the CCN vision is perceived as hospitable or beneficial by the funded hospital-community demonstrations, the study is hampered by possible biases in how the perceptions were tested and the absence of any observable impact that the partnership process might have had. The central roles of the hospital in the demonstrations and as the provider association sponsoring this effort are also underplayed even though the world seen primarily through a hospital's lens is very different from that of other providers, residents, payers, or government officials. This does not mean that the authors' conclusions are erroneous. They may yet be proven to be true. Or not. Or other factors may be more important. At this point we do not know.

Our review of this article examines elements that we believe should be addressed in the evaluation of the CNN project, namely, sponsorship, community partnerships, potential biases, the quantitative analysis, and the guidance that the study offers for other community projects.

Sponsorship

"Tracking the Footprints" reviews the experience of twenty-five community partnerships in the American Hospital Association's CCN demonstration project. While the authors note the sponsorship, the issue of agency, that is, the identification of who is responsible for an action, is either ignored or downplayed so significantly that the reader can forget where the CCN project originated and what the project's focus is. CCN is a product of the American Hospital...