Communities and hospitals: social capital, community accountability, and service provision in U.S. community hospitals

Health Services Research, Oct, 2004 by Shoou-Yih D. Lee, Wendy L. Chen, Bryan J. Weiner

Finally, we anticipated that system and network membership would temper community hospitals' response to social capital in implementing accountability mechanisms and provision of community-oriented health services (H7 and H8). Results indicated that hospitals with system/network membership did not differ in their response to community social capital when it came to their provision of community-oriented services (Table 4). However, hospitals with system membership were more likely to implement community accountability mechanisms in relation to a greater level of community participation among community residents. The interactions between network membership and social capital indices were not statistically significant.

DISCUSSION

As organizational changes sweeping through the health care sector gradually undermine the historic accountability mechanisms employed by community hospitals (Emanuel and Emanuel 1997; Proenca, Rosko, and Zinn 2000), questions have been raised about how to hold hospitals accountable to local communities and how to guarantee their involvement in community health services. In a departure from most existing research that focused on the organizational determinants of community accountability in hospitals (e.g., Lee, Alexander, and Bazzoli 2003; Procenca, Rosko, and Zinn 2000), we examined whether a prominent feature of community structure--that is, social capital--might be related to hospital accountability, as evidenced in their employment of community accountability mechanisms and provision of community-oriented health services. We also examined the contingencies based on hospital attributes so as to identify opportunities and barriers to improving hospitals' contribution to community health.

Although most of the hypotheses were not supported in the analysis, several of the specific findings are worth noting. First of all, contrary to Hendryx et al.'s (2002) prediction, neither of the two social capital indicators--community participation and voting participation--was associated with hospitals' community accountability. In fact, results indicated that the level of community accountability, or the collaboration of hospitals with other community groups in gathering, using, and disseminating health information, reflected more what the hospitals were (e.g., nonprofit hospitals), whom they were affiliated with (e.g., healthcare systems), and how competitive the local hospital market was, rather than the sociopolitical milieu within which they operated (e.g., communities with high social capital). It could be that hospital involvement in health information collection and usage was widely expected across communities, hence the existence of limited geographic variation. Whether a hospital was willing to, or could, live up to that expectation depended, instead, on their mission, their slack resources, their access to the required know-how and suitable partner organizations through interorganizational linkages, as well as the pressure they faced in competing for patients. However, it is important to note that the absence of a direct relationship in the analysis does not necessarily preclude the indirect association of social capital with hospitals' community accountability through the distribution of different types of hospitals. For example, we found a significant correlation between voting participation and nonprofit hospital ownership (r = 0.14, p<0.0001). Thus, in communities where the residents were more politically active, there might be a greater presence of nonprofit hospitals and a higher level of community accountability.