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ResourcesJULY 2004

Prepared for the Community Clinics Initiative

A Joint Project of Tides and The California Endowment

Assessing the Capacity of California’s Community Clinics:A Report on the Community Clinics Initiative’s

2003 Building Capacities Self-Assessment Survey

Report to the Field

Prepared by Stephanie Fuerstner Gillis,

Kendall Guthrie and Justin Louie

With assistance from Amy Luckey and Cory Sbarbaro

Blueprint Research & Design, Inc.

I. EXECUTIVE SUMMARY

KEY FINDINGS Capacity Strengths and WeaknessesFund DevelopmentAlternative Measures of Access

RECOMMENDATIONS

CONCLUSION

II. INTRODUCTION

III. METHODOLOGYSOME LIMITATIONS OF THE RESEARCH METHOD AND DATA

IV. FINDINGS: ASSESSING CLINICS’ OVERALL STRENGTHS AND WEAKNESSESA CLOSER LOOK AT THE MANAGEMENT TEAMCLINICS’ FINANCIAL SYSTEMS AND POSITIONCLINICS’ CONNECTIONS TO THE COMMUNITYA CLOSER LOOK AT MISSION, VISION AND PLANNINGEXAMINING BOARD LEADERSHIPUSING DATA TO INFORM CLINIC DECISION MAKINGA CLOSER LOOK AT CLINICS’ FUND DEVELOPMENT

Staff and Consultants Working on Fund DevelopmentBoard Involvement in Fund DevelopmentPrivate Fund Development Strategies

BENCHMARKING ACCESSLanguages in Which Services Are ProvidedTime to Get Appointments

V. RECOMMENDATIONS

VI. CONCLUSION

APPENDIX A. METHODOLOGYAPPENDIX B. RANKED ORDER OF CAPACITY ASSESSMENT ELEMENTS AND ITEMSAPPENDIX C. CO-LOCATED SERVICES AND WIC COORDINATIONAPPENDIX D. FUND DEVELOPMENT LEADERSAPPENDIX E. FUND DEVELOPMENT CAPACITY AND STRATEGIESAPPENDIX F. SELECTED INDICATORS OF ACCESSAPPENDIX G. BUILDING CAPACITIES SELF-ASSESSMENT SURVEY

CCI REPORT TO THE FIELD JULY 2004

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EXECUTIVE SUMMARY

For a generation, community health clinics have served as heath care providers to low-income, minority and immigrant communities. They have been a vital component in the safety net protecting California’sunderserved communities. As Californians face rising health insurance costs and decreasing access to health insurance, community clinics are poised to play an increasingly important role in California’s healthcare delivery system. These 700+ community-based primary care clinic sites in California serve more than2.8 million patients each year.1 Because they serve so many immigrants, community health centers are developing valuable expertise in providing culturally competent care to diverse populations. They also canserve as incubators for cost-effective chronic care management because they deal with a disproportionateshare of the state’s inhabitants who have chronic diseases such as diabetes and asthma.2

This report provides a snapshot of the organizational strength of these key institutions that support California’shealth care safety net. The Community Clinics Initiative (CCI), a unique collaboration between Tides and The California Endowment that supports community health clinics in California, is the largest grantmakingprogram of its kind in the U.S. CCI sponsored this research to inform the development of its own grantmaking program. The long-term goal of CCI is to strengthen California’s community clinic system in order to serve more patients and improve the quality of care, ultimately improving community health outcomes. In addition to the other activities CCI is pursuing to strengthen the clinic system, the programintends to strengthen the capacity of individual clinics. Improving the efficiency and effectiveness of individual clinics is a strategy to maintain and hopefully increase access to care for California’s uninsured and underinsured populations. CCI is sharing the results of this research with clinics to help them understand how they compare to their peers, and to help focus their organizational development efforts. In addition, clinicconsortia and funders can use this research to identify opportunities to strengthen key organizational capaci-ties of community clinics.

This report is based primarily on findings from CCI’s Building Capacities Self-Assessment Survey, which wassent to current and former CCI grantees in the early fall of 2003.3 The survey was originally conceived as a tool to assist clinics in determining their readiness to engage in capital campaigns, and focuses on thoseaspects of organizational capacity CCI believes are most vital to clinics in launching and implementing capital campaigns. The survey guided the clinic leadership through a self-assessment in the seven core areas of capacity that CCI chose to focus upon:

• Mission, Vision and Planning• Community Engagement and Collaboration• Leadership: Management Team• Leadership: Board of Directors• Financial Systems and Position• Fund Development• Data-Informed Decision Making

In addition, we collected some baseline information on various aspects of access to community clinic services.

“The process was indeed a significantlearning opportunity. We have found it to be a very useful tool.”

Jose Joel Garcia, CEOTiburcio Vasquez Health Center, Inc.

1. California Office of Statewide Health Planning and Development. Annual Utilization Report of Primary Care Clinics Data Profile, 2000.<http://www.oshpd.ca.gov/HQAD/reports.htm>.2. Bodenheimer, M.D., Thomas, Examining Chronic Care in California’s Safety Net, California HealthCare Foundation, July 2003. 3. We also include in this report “time to get appointment” data collected through phone calls and draw on data collected in previous years throughother CCI surveys for comparisons where appropriate.


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The survey was intended to provide clinics with a means for internal reflection on their strengths and weaknesses, as well as for internal and external benchmarking. The data also provide a baseline againstwhich Blueprint Research & Design, Inc. (Blueprint)4 can measure progress in the field and the impact ofCCI’s work. Furthermore, aggregated clinic data allows CCI and other clinic stakeholders to get a snapshot of the field to help with program development and planning for training and technical assistance.

The findings and recommendations have implications that go beyond the work of CCI and address the wholefield, including clinics, consortia, other regional and statewide clinic associations and funders interested incommunity health.

Key Findings

Capacity Strengths and Weaknesses

• Clinics consider their strongest areas of capacity to be Leadership: Management Team and FinancialSystems and Position.

• Clinics consider their weakest area of capacity to be Fund Development, followed by Data-InformedDecision Making and Leadership: Board of Directors.5

• California’s community clinics are in a fairly strong financial position. Nearly two-thirds of clinics report that they consider the strength of their financial position to be moderate or high (as measured by their bottom line over a three-year period). This self-reported data was also verified by objective data from clinics’ audited financial statements.

• Clinics feel they have a moderate level of capacity in the area of Community Engagement and Collaboration.The capacity assessment survey included three items that explore clinics’ external partnerships and relationships, their understanding of the local community’s needs and their presence and involvement in the local community. The relatively high ratings in this section of the survey contrast with the relativelylow level of actual coordination with community organizations and other health care partners that clinicsreported in a 2002 information management survey conducted in previous evaluation research,6 painting a mixed portrait of clinics’ engagement in their communities. This may imply that clinics have different definitions and expectations about coordination than CCI and other external observers.

• Most clinics possess limited staff capacity to take full advantage of the data they collect to inform their business and clinical decisions. The items designed to assess staff capacity for data analysis and the use of data in decision making received the lowest scores in the Data-Informed Decision Making section of the survey.

• Though clinics feel they have a moderate level of capacity overall in the area of Mission, Vision andPlanning, strategic planning and vision are considered to be weaknesses within this capacity area.

• Nearly 70% of clinics report that they provide space on-site for at least one of the following: the state’s WICprogram, California’s Medi-Cal program, outside pharmacies and community mental health providers.Providing space for these services is one measure of clinic collaboration with other health-related services.

4. Blueprint Research & Design, Inc. is a research, design, and strategy consulting firm serving philanthropic foundations. Blueprint has been CCI'sexternal evaluator since 2000.5. It is important to note that when a member of the board was included in the self-assessment process, the score for Board Leadership was higherthan when no board member participated. However, the difference was not statistically significant. 6. Community Clinic Information Technology Fact Book, prepared by Blueprint Research & Design, Inc. for the Community Clinics Initiative, SanFrancisco, August 2003, pages 38–39.


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• Federally Qualified Health Centers (FQHCs) report higher ratings across all capacity elements except funddevelopment. Since FQHC clinics are somewhat over-represented in the sample, it is likely that the surveyresults somewhat overstate the capacity of the field as a whole.7

Fund Development

• The typical community clinic raises 2% of its revenue from private sources other than foundations.8

However, there are FQHC and Look-Alike clinics that raise 6% to 10% of their revenue through private fundraising activities.

• Among clinics that are not Planned Parenthoods or free clinics, more than 65% reported that at least some of their board members contributed financially to their clinic during the most recently completed fiscal year, and 25% reported that all of their board members had made contributions. When asked whatproportion of their board actively assists in soliciting individual donations, 73% of these clinics reported that less than half of their board members help do this, and 34% get no help from their board in this area at all.

• On average, clinics have 1.65 full-time employees (FTE) working on fund development, which may includethe time of their executive directors and others who write grants for federal support. This number drops significantly (to 1.06 FTE) when Planned Parenthoods and free clinics are excluded, since these clinicsgenerally have higher fund development capacity.

• Clinics that do not have in-house fund development staff are no more likely to be working with consultantsthan clinics who do. On average, 38% of clinics report that they are working with at least one consultant onfund development activities.

• Most clinics are not pursuing even simple grassroots fundraising strategies. Almost half of typical community clinics do not send an appeal letter to their current donors, a low-cost strategy considered to be a basic one by fund development experts, and 55% do not solicit new donors through the mail.9

Alternative Measures of Access

• Ninety percent of clinics report that they are able to provide services in Spanish, 23% can provide servicesin Tagalog, followed closely by Vietnamese (20%).

• More than half of the clinics surveyed in a “secret shopper” survey could not provide an appointment fora sick person for at least three days, and 18% could not see the patient for three weeks or more. At 9% of clinics, only walk-in patients could be seen, and 30% were able to see the caller the same day.10

7. Federally Qualified Health Centers (FQHCs) are public or nonprofit health care corporations that provide care to medically underserved areas and populations. They are primarily health centers that are supported by federal grants under the U.S. Public Health Service Act. FQHCs must meetrigorous federal standards related to quality of care and services, cost and governance. The Social Security Act § 1905(l)(2))B) definition of an FQHCincluded an entity which is determined to meet the requirements of the section 330 grant program but does not receive the grant. This category ofhealth centers has been labeled FQHC Look-Alikes. The FQHC Look-Alikes receive no section 330 federal funding but are eligible for cost-basedreimbursement under Medicaid and Medicare and participate in the 340(b) Federal Drug Pricing program.8. This figure excludes Planned Parenthoods and free clinics that rely less on patient revenue or government funding sources and therefore need tobe more adept at private fundraising.9. These numbers exclude Planned Parenthoods and free clinics.10. For the “secret shopper” survey, a Blueprint staff person made anonymous calls to clinics posing as a sick person trying to get an appointment.For more details, see the Methodology section in Appendix A.


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Recommendations

• Public and private funders should support community clinics and feel confident that they are responsiblestewards for investments in community health. Funders, especially those in clinics' local communities, need to be educated about the financial stability of community clinics and the role that they play in improving overall community health. Through this survey and the work of Capital Link,11 CCI has documentedthat at least through 2002, California's community clinics were in a relatively strong financial position, especially when compared to clinics in other states.12 At the same time, demand for clinic services continues to outpace capacity, and recent shifts in public funding streams may significantly affect the funding environment for these organizations.

• Clinic funders and infrastructure groups could work together to develop a coordinated approach to strengthen the strategic planning, data-informed decision making and performance measurement skills of community clinics. These are key adaptive capacities that clinics need to navigate the rapid changes taking place in the health care field. Nearly one-third of clinics see themselves as relatively weak in thestrategic planning skills needed to fulfill their mission, and one-third also rate themselves as weak in data-informed decision making and the use of performance targets.

• Clinic funders and clinic infrastructure groups should work together on a strategy to support the clinics thathave the lowest overall capacity (approximately 20% of the clinics in this sample are relatively weak in allareas of capacity). This may require targeting assistance to strengthen organizational capacity, facilitatingthe sharing of services and resources or pushing them to merge with other clinics.

• FQHC and Look-Alike clinics would benefit from assistance to strengthen their fund development capacity,especially their ability to raise money from private sources such as individuals, corporations and local foundations. CCI hypothesizes that private fundraising: 1) diversifies the revenue streams for communityclinics, making them less subject to the political vicissitudes of government funding; 2) strengthens localcommunity buy-in to the clinic as a community organization; 3) helps clinics establish relationships withindividual donors that can be nurtured and relied upon in future fundraising campaigns and 4) helps clinics educate potential patients and other key players in their local communities about the role of community clinics, who can be mobilized for other health-related advocacy work.

• There are important lessons to be learned from examining the fundraising successes of the free andPlanned Parenthood clinics. For example, though Planned Parenthood clinics do not get any financial support from the national office, they benefit tremendously from the branding and public relations workconducted by the national office. To support their local fundraising efforts, California clinics could jointogether (on a regional or statewide basis) and share the costs of raising the public’s awareness of the role of community clinics in public health care. FQHC clinics should also look to their peers for successfulfundraising strategies and develop an FQHC model for fundraising from private sources, one that works for clinics with community boards.

11. Capital Link is a nonprofit consulting firm that connects community health centers to capital resources. 12. Based on presentations prepared and delivered by Allison Coleman, CEO of Capital Link, to the CCI Steering Committee and to the CPCAVentures Board on July 16, 2003, and January 16, 2004, respectively. These presentations, which were supported by CCI, included financial trenddata from FY99–FY02 for a cohort of California clinics and provided comparative data compiled by Capital Link on national health center financialtrends over the same period.


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• Clinic leaders and external community clinic stakeholders need to reach agreement on how much community engagement is happening and how much is ideal for community clinics. There is a need to invest in independent research to more closely examine the types of collaboration that clinics areengaged in; ascertain the benefits and costs of collaboration with other clinics, health care players, andcommunity organizations; and identify best practices. This could be used to jumpstart a conversationamong all key stakeholders to set some standards for the field.

• Nearly one-third of clinics see themselves as relatively weak in the strategic planning skills needed to fulfilltheir mission. One-third also rate themselves weak in data-informed decision making and performance targets. These are key adaptive capacity skills that will be critical for clinics in navigating the rapid changesin the health care field over the coming years. Clinics funders and infrastructure groups could work togetherto develop a systematic approach to strengthening these critical skills.

• Clinics could use help strengthening their board leadership. Board management is a particular challenge at FQHC clinics, which are required to have consumers fill half their board slots. Clinics need research andnew models that highlight effective ways to manage these types of boards. Because CCI is not currentlyplanning to focus on boards, there is an opportunity for new funders to take a leadership role in this area.

Conclusion

The findings from CCI’s capacity assessment survey can be used to guide funders who are interested ininvesting in community health. The overall strength of the leadership in these organizations and their generalfinancial stability bode well for the future of California’s clinics, which are likely to be facing challenging timesin the near future as government budget shortfalls trigger reduced public spending. While CCI will continue tosupport clinics on strengthening their technology and fund development capacity, many opportunities exist forother partners to help strengthen clinics’ ability to improve public health outcomes. There is an urgent needto explore new models for clinic governance that can maintain the grassroots nature of community boards butalso support fundraising and policy work. The field also needs to agree upon standards for collaboration andcoordination. Finally, there is more work to be done in the areas of fund development and data-informed decisionmaking than CCI alone can undertake. CCI will need to work in close partnership with other stakeholders andsupporters of community clinics to ensure that California’s underinsured populations will be able to accessthe care that they need.


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II. INTRODUCTION

The Community Clinics Initiative (CCI), a unique collaboration between Tides and The California Endowmentand the largest grantmaking program of its kind in the U.S., began in 1999 to provide resources, evidence-based programming and evaluation, education and training to support community health centers and clinics.Through information sharing and major grants, CCI acts as a catalyst to strengthen California's communityclinics and health centers to improve health outcomes in underserved communities. The state's communityclinics offer high-quality, low- and no-cost care, often in rural and inner-city areas, providing a lifeline for millions of uninsured and underinsured Californians.

Through information sharing and grants in technology, capacity building and leadership, CCI advances thecommunity health care system by enabling clinics and their associations to deliver high-quality care for all patients and ensures that clinics remain vital partners in building healthier communities. Grantees encompass 90% of California's community clinics and regional consortia, securing CCI's role as a major player in the field. Individual awards enable clinics to pursue activities such as converting to electronic medical recordkeeping, improving or expanding patient facilities, using software to share data among clinicsin a network or training staff members in fundraising strategies. These enhanced capabilities allow clinics tobetter track health status, care for more patients, achieve diverse revenue sources, reduce administrativecosts, expand opportunities for shared learning and collaboration and advocate for community health needs.

The long-term goal of CCI is to strengthen California’s community clinic system in order to serve more patients and strengthen the quality of care, ultimately improving community health outcomes. In addition to improving the clinic system, CCI strives to strengthen the capacity of individual clinics to maintain and, ultimately, increase access to care for California’s uninsured and underinsured populations.

This report provides a snapshot of the organizational strength of California’s community clinics. CCI is sharingthe results of this research with clinics to help them understand how they compare to their peers and focustheir own organizational development efforts. In addition, clinic consortia and funders can use this research toidentify opportunities to strengthen key organizational capacities of community clinics.

III. METHODOLOGY13

CCI originally asked Blueprint Research & Design, Inc. (Blueprint)14 to develop the Building Capacities Self-Assessment Survey as a tool to assist clinics in determining their readiness to engage in capital campaigns. CCIintended for clinics to use the survey as a tool for internal reflection on their own strengths and weaknesses, as well as for internal and external benchmarking. CCI also needed baseline data for Blueprint to track progress in the field and measure the impact of the CCI’s work. Furthermore, aggregated clinic data allows CCI to get a snapshot of the field to help with program development and planning for training and technical assistance.15

“We have made discussion andreview (of this tool) part of ourmonthly senior management teammeetings and board meetings.”

Debra A. Farmer President/CEOWestside Family Health Center

13. For more details on the study’s methodology, please see Appendix A.14. Blueprint Research & Design, Inc. is a research, design and strategy consulting firm serving philanthropic foundations. Blueprint has been CCI'sexternal evaluator since 2000.15. CCI’s Building Capacities Self-Assessment Survey is based on the Capacity Assessment Tool created by McKinsey & Company for VenturePhilanthropy Partners (www.vppartners.org), published in Effective Capacity Building in Nonprofit Organizations (2001).


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The survey guided the clinic leadership through a self-assessment in the seven core areas of capacity uponwhich CCI chose to focus:


Within the seven broad areas of capacity, clinics were given a number of specific items to reflect upon. Clinics assessedthemselves on each item using a scale that ranged from Level One (clear need for increased capacity) to Level Four(high level of capacity in place), and were given clear descriptions of the characteristics of a clinic at each of theselevels. In addition to the capacity assessment portion of the survey, clinics were asked a number of questions focusedupon fund development strategies and access to services.

The analysis that follows is based on the 90 surveys that were returned, an 82% response rate among CCI’s2003 Building Capacities grantees and a 60% response rate overall. The 90 survey respondents did not differ significantly from the other clinics in California, except in the percentage of Federally Qualified Health Centers (FQHCs)16 and American Indian Health Centers that completed surveys. FQHCs were more likely than non-FQHCs to have completed a survey, and American Indian Health Centers were less likely than non-Indianhealth centers to have completed a survey.17

Some Limitations of the Research Method and Data

The survey method and data set have a few limitations that should be noted.

• The sample somewhat over-represents the proportion of FQHC clinics in the field. Because FQHC clinics tend to have higher capacity than non-FQHC clinics in all areas except fundraising, the data may somewhat overstate the capacity of the entire field.

• The data come from a self-assessment, which contributes bias, although several steps were taken to reduce this bias. CCI understood the trade-off between the enhanced organizational learning from the self-assessment process and the objectivity of the scores, and chose to invest in organizational learning.Compared to other self-assessments, this survey minimized subjectivity in several ways.

– The survey used a defined rating scale with detailed definitions of what an organization at each level of capacity looks like. This method helps individuals within an organization ensure that their ratings

Level

LevelOne

LevelTwo

LevelThree

LevelFour

Description

Clear need forincreased capacity

Basic level of capacity in place

Moderate level ofcapacity in place

High level of capacityin place

Score

1

2

3

4

16. Federally Qualified Health Centers (FQHCs) are public or nonprofit health care corporations that provide care to medically underserved areas andpopulations. They are primarily health centers that are supported by federal grants under the U.S. Public Health Service Act. FQHCs must meet rigor-ous federal standards related to quality of care and services, cost and governance.17. Interestingly, FQHCs were more likely to have completed a survey because they were more likely to be CCI grantees. In other words, out of allthe clinics who have applied for funding from CCI, FQHCs have been more likely to be given grants. Since only grantees received surveys, FQHCswere overrepresented in the population surveyed. On the other hand, American Indian Health Centers were just as likely as other clinics to receiveCCI funding, but their response rate to the survey was lower.


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are aligned. It also increases the accuracy of comparing scores across organizations. Other capacityassessment instruments tend to be simple lists with check boxes, or use numerical rating scales without common definitions of what each numerical level means.

– Multiple people were involved in the self-assessment process.Blueprint recommended that clinics include their management teams and board members in the process. This approach alsoincreased organizational learning. More than half of the clinics involved at least four people in their self-assessment process and more than a third included at least one board member. (See Table 1.) This does not eliminate the possibility of bias, however, when management team members are assessing their own performance or board performance without board input, for example.18

Given the self-reported nature of the data, it is more appropriate to focus on looking across all of the capacity elements in order to see clinics’ perceptions of their relative strengths and weaknesses. Scores on any single item should not be viewed as an objective measure of a clinic’s capacity along that capacity dimension.

• The survey only examines select aspects of capacity and is not a comprehensive capacity assessment, in contrast to the original McKinsey Capacity Assessment Grid upon which the CCI survey is based. CCI chose to assess specifically the capacities that are most associated with the objectives of the program’sBuilding Capacities grants, which were designed to increase clinics’ ability to conduct capital campaigns.Individual items were written to assess progress towards CCI’s objectives, which also contributes some bias.

Because of the level of sensitivity of the tool, the challenges of self-assessment and the complexity of the concepts that the tool attempts to assess, it is unrealistic to expect that this tool will pick up changes on an annual basis. The tool can provide a strong initial portrait of capacity in the field, but it is best used tomeasure long-term change. The data also provide a baseline against which the field can be measured in several years.

Table 1. Clinic Involvement in the Assessment

% of clinics indicating at least two people involved with assessment (n=90) 84.4%% of clinics indicating at least three people involved with assessment (n=90) 71.1%% of clinics indicating at least four people involved with assessment (n=90) 56.7%% of clinics indicating at least one board member involved with assessment (n=90) 32.2%

“This is a good tool and we will beincorporating it into our prestrategicplanning session analysis.”

Christine NogueraCEOSequoia Community Health Foundation

18. We compared the board capacity rankings of clinics that included board members in their process with those that did not, and the results areinconclusive. There is a trend showing that clinics that included board members ranked board capacity higher than those clinics with no boardinvolvement, but the differences are not large enough to be able to say with confidence that the trend is not a random occurrence.


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IV. FINDINGS: ASSESSING CLINICS’ OVERALL STRENGTHS AND WEAKNESSES

The clinics consider their strongest areas of capacity to be Leadership: Management Team and FinancialSystems and Position. They feel they have moderate capacity in the areas of Community Engagement andCollaboration, and Mission, Vision and Planning. They consider their weakest areas of capacity to be FundDevelopment, followed by Data-Informed Decision Making and Leadership: Board of Directors.19 (See Chart1.) More detailed information on capacity ratings can be found in Appendix B.

Chart 1. Overall Assessment of Clinics’ Strengths and Weaknesses

We divided the clinics into several groups in order to explore whether or not a clinic’s FQHC status affected itscapacity assessment scores: we separated FQHC clinics from FQHC Look-Alikes, Planned Parenthoods andother non-FQHC clinics. Not surprisingly, clinics with FQHC status ranked themselves higher than non-FQHCclinics on all elements of capacity, except for Fund Development. Clinics need to be strong in order to achieveFQHC status, due to the regulatory, oversight and reporting requirements tied to federal funds. However, oncethey become FQHC clinics, they are likely to get a very large proportion of their funding from governmentsources, which explains their lower scores regarding the diversity of funding sources that contribute to clinicrevenue. Planned Parenthood clinics ranked higher than Look-Alikes and other non-Look-Alike clinics in all seven areas of capacity. Because Planned Parenthoods receive support as part of a national network ofclinics and need to raise money from a wide array of funding sources (since they cannot rely on governmentfunding), we would expect to see differences in organizational capacity. They are in some ways more similarto other types of community-based nonprofits than to community health clinics.

3.15

3.13

3.04

3.01

2.79

2.73

2.55

1.00 1.25 1.50 1.75 2.00 2.25 2.50 2.75 3.00 3.25 3.50 3.75 4.00Low Basic Moderate High

Elements of Organizational Capacity

Leadership: Management Team

Financial Systems & Position

Collaboration

Mission, Vision, & Planning

Leadership: Board of Directors

Data-Informed Decision Making

Fund Development

Average Score for Each Capacity Element

19. It is important to note that when a member of the board was included in the self-assessment process, the score for Board Leadership was higherthan when no board member participated. However, the difference was not statistically significant.


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We also checked to see if clinics in urban environments assessed themselves differently from clinics in rural settings. Though there were some differences in the area of Fund Development (discussed later in this report), clinics’ settings did not seem to play a significant role in their capacity assessments.

Finally, we analyzed whether or not clinic size (as defined by their budget size) affected their capacity assessment scores. We found that clinic size is strongly correlated with six of the seven organizational capacity elements, with larger clinics reporting scores that were significantly higher in the areas of Mission,Vision and Planning, Community Engagement, Leadership: Management Team, Leadership: Board ofDirectors, Financial Systems and Position and Data-Informed Decision Making. There were no significant differences in Fund Development scores based on clinic size. Clinics with larger budgets are expected to havestronger organizational capacity, especially in financial management, since they need to be able to managethe funds. They are also likely to offer more programs and services, requiring more sophisticated management.

A Closer Look at the Management Team

When considering the clinics’ scores in the area of Leadership: Management Team, it is important to note that this is the capacity area in which the bias of the self-assessment tool is most likely to play a role, as weasked management teams to assess their own performance. Management teams feel they are strongest in the overall experience and expertise of team members, and intra-team communication and coordination (bothhave a mean score of 3.22). They assign themselves a moderate level of capacity (mean score of 3.21) in the area of Composition, which was designed to assess the interdisciplinary nature of management teams and medical director participation in particular. The weakest areas of management team work are considered to be Leadership and Collaboration (which is designed to capture the team’s sense of purpose and responsibility, team members’ trust and respect for one another and the efficiency of the team’s work) and Decision Making (which assesses both decision-making processes and follow-through on team decisions). Both of these items were given a mean score of 3.06. (See Chart 2.)

Chart 2. Assessing the Management Team

43%

36%

43%

25%

28%

42%

50%

38%

56%

52%

11%

13%

17%

19%

18%

4%

1%

2%

0%

2%

0% 10% 20% 30% 40% 50% 60% 70%

Management Experience &

Expertise (mean=3.22)

Management Communication(mean=3.22)

Management TeamComposition (mean=3.21)

Management Team

Collaboration & Leadership(mean=3.06)

Management Decision Making(mean=3.06)

LEVEL FOUR(high)

LEVEL THREE(moderate)

LEVEL TWO(basic)

LEVEL ONE(low)

Leadership: Management Team N = 88

Percentage of Clinics Scoring at Each Capacity Level


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Clinics’ Financial Systems and Position

This section of the survey tool was designed to capture the level of sophistication of clinics’ financial management systems and the overall strength of their financial position at the end of their most recently completed fiscal year. Clinics feel that they are particularly adept in their Use of Financial and OperationsData, an item which gauges the types of financial reports produced, how frequently these reports arereviewed by clinic leadership and how the reports inform planning and operations. This was the highest rated item in this capacity area, with a mean score of 3.21. (See Chart 3.) This finding highlights one aspect of successful data-informed decision making, a practice CCI’s Information Technology (IT) grants and activities from 1999–2002 have been working to strengthen.20

Clinics also feel they are in a fairly strong overall financial position (Bottom Line is given a mean score of3.19). We were able to cross-reference clinics’ self-reported assessments of their financial position with objective data collected by the CCI’s partner, Capital Link, who has collected and is analyzing data from clinics’ audited financial statements for fiscal years 2000, 2001 and 2002.21 Comparing the self-assessmentdata with the objective financial data collected by Capital Link, it was clear that clinics were very honest and accurate in their self-assessments: with very few exceptions, the clinics assessed themselves in the appropriate level of capacity for their financial position. Clinics in Levels One and Two generally retained 1% of their overall revenue as profit, while clinics in Level Three retained 8% and those in Level Four heldonto 11% as profit.

Financial Planning and Budgeting is considered to be an area where clinics have “moderate” capacity (mean of 3.11). This is in line with findings in the area of Mission, Vision and Planning that show clinics facechallenges in operational planning, strategic planning and visioning (to be discussed later) – these activitiesrequire similar skills as needed for budgeting and financial planning. It is not surprising that Cash Flow isassessed at a lower level than other items (mean of 3.08), because of the challenges related to billing and collecting from the many different insurance providers and funding sources. We also expected to see relatively low scores on Diversity of Funding Sources (mean of 3.05), since CCI has heard from clinics thatdiversifying their funding base has not been a priority and may not be the most efficient way to strengthentheir financial sustainability.22

20. The section of the survey that assesses data-informed decision making currently focuses on the use of clinical data and benchmarking data indecision making, but will be expanded to include some items about the use of financial data in the future. 21. Capital Link was able to provide us with at least some financial data for 74 of the 90 clinics that filled out the Building Capacities Self-AssessmentSurvey.22. CCI supports the diversification of funding sources (raising funds from private sources in particular) as a way to strengthen clinics’ connections totheir local communities, and secondarily as a strategy for promoting sustainability.


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Chart 3. Financial Systems and Position

Clinics’ Connections to the Community

Clinics report that they have a moderate level of capacity in the area of Community Engagement andCollaboration, which includes three items that explore clinics’ external partnerships and relationships, their understanding of the local community’s needs and their presence and involvement in the local community. (See Chart 4.) Of these three, clinics feel they are strongest in their ability to build external relationships (mean of 3.14), which includes crafting partnerships and collaborating with other – primarilyhealth-related – organizations. They give themselves slightly lower scores (mean of 3.01) in the area of Community Presence and Involvement, which assesses both the clinics’ presence and participation in the broader community and the involvement of community members in the clinic (as board members, for example). And more than 60% of the clinics gave themselves a score of “3” when assessing their ability to work with community leaders and use community data to assess community needs (mean of 2.97).

It should be noted that in previous evaluation studies conducted by Blueprint, clinics reported a less robustportrait of their coordination with other health care agencies and community actors.23 The 2002 InformationManagement Assessment Survey requested more detailed information about which organizations clinics coordinate with on a range of activities. In 2002, clinics reported their highest level of collaboration with community-based organizations, yet only one-third of clinics surveyed said that they formally coordinated with these organizations. A little less than one-third also reported working with county health departments or hospitals to coordinate patient care or understand community health status.

Financial Systems & PositionN = 87

43%

52%

40%

44%

41%

38%

22%

34%

26%

28%

16%

18%

22%

25%

25%

3%

8%

3%

6%

6%

0% 10% 20% 30% 40% 50% 60% 70%

Use of Financial & Operations

Data (mean=3.21)

Bottom Line (mean=3.19)

Financial Planning & Budgeting(mean=3.11)

Cash Flow (mean=3.08)

Diversity of Revenue Sources(mean=3.05)


LEVEL FOUR(high)


LEVEL TWO(basic)

LEVEL ONE(low)

23. K. Guthrie and A. Luckey, Getting Beyond Information Technology Basics: An Update on the Evolving Information Management Capacity ofCalifornia’s Community Clinics, prepared by Blueprint Research & Design, Inc. for the Community Clinics Initiative, San Francisco, June 2003. Also,Community Clinic Information Technology Fact Book, prepared by Blueprint Research & Design, Inc. for the Community Clinics Initiative, SanFrancisco, August 2003.

The apparent contrast between the current survey results of relatively high scores on collaboration and the2002 findings, which show more limited actual coordination with community organizations and other healthcare partners, may reflect that clinics’ definition of and expectations about coordination differ from those ofCCI and other external observers. For example, in interviews with key community clinic stakeholders andobservers conducted as part of CCI’s evaluation in the summer of 2003, stakeholders who did not work in clinics cited disappointment in the limited level of coordination between clinics and other health care partners.24 In contrast, when talking with clinic leadership, most felt that clinics’ coordination with other players had improved, and did not see collaboration as an area of concern.

Chart 4. Community Engagement and Collaboration

Another section of the survey also collected information about how closely community clinics collaborate withcertain specific health care programs or organizations that serve the same patient base as clinics: the State of California’s Women, Infants, and Children (WIC), Healthy Families and Medi-Cal programs, as well as outside pharmacies and community mental health providers. Nearly 70% of clinics reported that they provide space for one or more of these programs, making it easier to coordinate care. We looked at clinics’coordination with WIC as an example of how closely clinics connect their services with other programs: 41% of clinics reported that they refer eligible patients to WIC services and 24% follow up on those referrals.Approximately one-third of clinics reported that they share written information about the benefits of WIC witheligible patients, and the same proportion give eligible patients written information about WIC locations andtimes that WIC services are available. (See Appendix C.)


14

Community Engagement & CollaborationN = 90

34%

27%

18%

48%

49%

61%

16%

23%

21%

2%

1%

0%

0% 10% 20% 30% 40% 50% 60% 70%

External Relationship Building(mean=3.14)

Local Community Presence &Involvement (mean=3.01)

Assessment of CommunityNeeds & Clinic Environment

(mean=2.97)


LEVEL FOUR(high)


LEVEL TWO(basic)

LEVEL ONE(low)

24. Internal CCI memo, “Stakeholder Assessments of the Community Clinic Initiative’s Impact,” November 2003. Stakeholders interviewed for thisresearch included 15 CCI Steering Committee members, 12 other clinic leaders, 8 funders of community clinics and 11 observers of the field (countyhealth officials, health care safety net experts and potential health care partners).


15

A Closer Look at Mission, Vision and Planning

This section of the survey examines mission-based management practices in clinics, the clarity of their vision,the presence of a strategic plan and strategic planning skills and the use of performance targets, new program development and operational planning practices. (See Chart 5.) Clinics give themselves high scores(mean of 3.41) on the item that assesses the relevance of their mission and their reliance on the mission to guide their work. They also feel that they do a good job developing new programs that are responsive tocommunity needs (mean score of 3.13). They feel moderately comfortable with the clarity of their vision and their ability to plan operations (both are assigned a mean of 3.02). They are a little less confident in therelevance (or presence) of their strategic plans (mean of 2.97) and feel they could strengthen their strategicplanning skills (mean of 2.78). They also see room for improvement in the use of clearly defined targets tomeasure their overall performance (mean of 2.70), which is again related to the lower level of confidence they have in the area of Data-Informed Decision Making (as reflected in Chart 1).

Chart 5. Mission, Vision, and Planning

Examining Board Leadership

The items in this section of the survey examine the composition and commitment of the board, members’understanding of the governance responsibilities of the board, orientation and training practices, committeestructures and participation and the level of board involvement in fundraising and strategic planning. (See Chart 6.) Overall, clinics are less confident in the capacity of their boards than they are in other

Mission, Vision & PlanningN = 88

58%

34%

23%

26%

31%

19%

16%

29%

50%

57%

53%

42%

45%

41%

10%

10%

19%

19%

19%

30%

41%

3%

6%

1%

2%

8%

6%

2%

0% 10% 20% 30% 40% 50% 60% 70%

Mission (mean=3.41)

New Program Development

(mean=3.13)

Clarity of Vision (mean=3.02)

Operational Planning(mean=3.02)

Strategic Plan (mean=2.97)

Strategic Planning Skills(mean=2.78)

Performance Targets

(mean=2.70)


LEVEL FOUR(high)


LEVEL TWO(basic)

LEVEL ONE(low)

organizational competencies. The mean score for this section of the survey is below the “moderate” level of capacity (mean of 2.97), and five of the six items are rated below the “moderate” level, Level Three. (See Chart 1 and Appendix B.) The one item that defies this trend is Board Governance (mean of 3.14), anitem that assesses the overall efficiency and effectiveness of the board, particularly in the areas of fiduciaryresponsibility and performance monitoring. The lowest score is for board involvement in fundraising (mean of 2.08), which is not surprising given the challenges of engaging board members in fundraising while meeting the consumer-board requirements imposed upon some community clinics.25 The remaining items –Board Composition and Commitment (mean of 2.84), Board Training and Orientation (mean of 2.81),Strategic Planning Role (mean of 2.79) and Committee Structure and Participation (mean of 2.77) – fallbetween these two.

There are some differences in the overall assessment of Board Leadership by type of clinic. PlannedParenthoods and other family planning clinics generally give their boards higher scores in this area. Theseclinics require strong board leadership and board involvement in fundraising since they're less reliant on government funds and need to raise money from more diverse funding sources, and because they are ofteninvolved in contentious political debates.

Chart 6. Leadership: Board of Directors


16

Leadership: Board of DirectorsN = 84

42%

20%

11%

23%

18%

14%

35%

47%

60%

40%

48%

26%

16%

29%

26%

29%

27%

43%

6%

4%

2%

8%

7%

17%

0% 10% 20% 30% 40% 50% 60% 70%

Board Governance

(mean=3.14)

Board Composition &

Commitment (mean=2.84)

Board Training & Orientation

(mean=2.81)

Strategic Planning Role(mean=2.79)

Committee Structure &Participation (mean=2.77)

Board Fundraising (mean=2.38)


LEVEL FOUR(high)


LEVEL TWO(basic)

LEVEL ONE(low)

25. Fifty-one percent of the board members of FQHC and FQHC Look-Alike clinics must be actual users of the clinics and must represent the racialand ethnic diversity of the clinics’ patient base.


17

Using Data to Inform Clinic Decision Making

CCI began with a focus on strengthening the information technology (IT) capacity of community clinics inthree stages: 1) automation and data collection, 2) data analysis and 3) data-informed decision making.26

CCI posits that strengthening IT capacity, which allows clinics to both improve efficiencies and to collect data that can be used to improve effectiveness, is one route to reaching more underserved patients and to improving the quality of clinic services, ultimately improving community health outcomes. The link betweencollecting the data and the longer-term goal of improving the efficiency and effectiveness of community clinicsis getting clinics to use the data they have collected to inform both operational and clinical decisions. Clinics’movement along this progression was explored in the Data-Informed Decision Making section of the survey.As demonstrated by clinics’ self-assessments in this section (overall mean of 2.73), significant attention willneed to be paid to this set of competencies if CCI is to achieve its ultimate objectives. Although there wereonly three items assessed, all three have mean scores between Level Two (basic level of capacity in place)and Level Three (moderate level of capacity in place). (See Chart 7.) In other words, very few clinics considerthis to be an area of strength, and roughly one-third consider this to be an area where they have minimal oronly basic capacity.

Clinics are slightly better able to use clinical data (mean of 2.78) such as patient demographics, patient diseases and patterns in patient health challenges than they are in using data from other clinics or objectivesources such as local, regional or federal primary care standards to benchmark their performance (mean of2.70). The results of the items in this section of the survey also suggest that clinics first need to develop and cultivate staff expertise in data collection and analysis. The item that received the lowest scores in this sectionof the survey (mean of 2.70) assessed the amount of staff time dedicated to data collection and analysis andthe data analysis skills of those who are responsible.

These findings are consistent with earlier evaluation findings. In earlier surveys, most clinics reported thatthey had established basic IT systems to collect their data, but fewer were analyzing the data and only a handful were systematically using their data to support decision making. For example, in 2002, about two-thirds of clinics said that their management team regularly reviewed data on administrative issues (e.g.,budget variance and provider productivity). However, clinical data was much less accessible. Less than half of the medical directors regularly reviewed service utilization reports or data on patients with specific chronicdiseases.27 Moreover, less than half of the clinics said that their regular management reports compared current data to previous time periods. Finally, less than half compared their financial, utilization or patienthealth-status data to other clinics in their consortia or to federal or statewide standards.

26. Wiring California’s Health Care Safety Net: How Community Health Centers Are Using Information Technology to Improve Their Services, prepared by Blueprint Research & Design, Inc. for the Community Clinics Initiative, San Francisco, February 2002.27. K. Guthrie and A. Luckey, Getting Beyond Information Technology Basics: An Update on the Evolving Information Management Capacity ofCalifornia’s Community Clinics, prepared by Blueprint Research & Design, Inc. for the Community Clinics Initiative, San Francisco, June 2003. Also,Community Clinic Information Technology Fact Book, prepared by Blueprint Research & Design, Inc. for the Community Clinics Initiative, SanFrancisco, August 2003.

Chart 7. Data-Informed Decision Making

A Closer Look at Clinics’ Fund Development

Diversifying funding sources is a strategy often promoted by funders to insulate nonprofit organizations fromsudden downturns in any one funding source, thereby increasing their sustainability. CCI, however, has a different theory about why diverse funding sources are important to community clinics. CCI is particularlyinterested in clinics’ ability to raise funds from private sources other than foundations. CCI theorizes that by raising funds from local individuals and corporations, clinics can strengthen their connections to their communities and build relationships that can be leveraged over time for many different purposes. The items in this section of the survey are written to assess this particular theory, and lean heavily toward assessing clinics’ ability to raise funds from private sources, in addition to their overall fund developmentstrategies, activities and staff capacity.

Because private fundraising has not been a priority for the community clinic field overall, it is not surprisingthat this area of capacity has the lowest overall mean score of all of the competencies assessed by the survey(mean of 2.55). In addition, it is not unexpected that the capacity to raise money from private sources, andthe actual proportion of clinics’ revenue that comes from private sources, is the item with the lowest score(mean of 2.28), both within this section (see Chart 8) and compared to all of the other individual items in thesurvey. (See Appendix B.) The Fund Development Strategy and Activities item assesses the diversity of clinics’funding base and the priority placed on diversifying funding sources by the executive director and board.Therefore, it makes sense that this item is also scored at a low level (mean of 2.62). The mean score for this


18

Data-Informed Decision MakingN = 86

10%

14%

6%

59%

49%

62%

28%

33%

29%

2%

5%

3%

0% 10% 20% 30% 40% 50% 60% 70%

Use of Clinical Data(mean=2.78)

Performance Management:Benchmarking (mean=2.72)

Data Analysis Skills & Staff

(mean=2.70)


LEVEL FOUR(high)


LEVEL TWO(basic)

LEVEL ONE(low)


19

item is significantly higher than the item on Private Funding Sources, however, which suggests that clinicleadership recognizes the importance of this area of clinic management. The highest score in this section ofthe survey – assessing staff capacity in the area of fundraising – is still relatively low (mean of 2.76). This itemasks about the resources allocated to fund development, both financial and human, and access to externalexpertise such as consultants.

There are some variations in this section of the survey based upon the type of clinic. Free clinics are strongerat fund development, as are Planned Parenthoods and other family planning clinics. These types of clinicseither see more uninsured patients for free, including patients not covered by Medicare or Medi-Cal, orreceive less government funding due to political reasons. As a result, they need to raise funds to subsidizecare, which explains their more diverse funding bases. We also found that clinics in rural settings were significantly less able to raise funds than urban clinics, which is explained by the relative isolation of ruralclinics. There are both fewer individuals and fewer foundations to draw upon in rural areas.

Chart 8. Fund Development

Because this is an area of particular interest to CCI, a number of other questions were included in the surveyto assess overall fund development capacity. The survey collected detailed revenue and expense data thatallowed us to identify those clinics that excel at raising funds from private sources (other than foundations).The clinics at the top of this list are almost all Planned Parenthoods or free clinics, and raise more than 20%of their revenue from private (non-foundation) sources. There may be strategies relied upon by these clinicsthat could be adapted for other clinics.

Fund DevelopmentN = 88

23%

16%

13%

38%

38%

25%

33%

38%

38%

7%

8%

24%

0% 10% 20% 30% 40% 50% 60% 70%

Fund Development Staff,Budget & Skills (mean=2.76)

Fund Development Strategy &Activities (mean=2.62)

Private Revenue Sources

(mean=2.28)


LEVEL FOUR(high)


LEVEL TWO(basic)

LEVEL ONE(low)

When Planned Parenthoods and free clinics are removed from the data set, the average clinic raises 2% of its revenue from private sources other than foundations. The leaders in private fundraising among FQHCand Look-Alike clinics raise between 6% and 10% of their revenue from private sources and may be willing to serve as resources for other clinics interested in strengthening their own private fundraising efforts.28 (SeeAppendix D.)

Staff and Consultants Working on Fund Development

The survey also asked about the amount of staff and consultant time dedicated to fund development at clinics. On average, clinics have 1.65 FTE staff working on fund development, which may include the time oftheir executive directors and others who write grants for federal support. This number drops significantly (to1.06 FTE) when Planned Parenthoods and free clinics are excluded, since these clinics generally have higherfund development capacity. Clinics that do not have in-house fund development staff are no more likely to beworking with consultants than clinics who do. On average, 38% of clinics report that they are working with atleast one consultant on fund development activities. (See Appendix E.)

Board Involvement in Fund Development

A board’s credibility in fundraising can be affected by board members’ own willingness to “walk the talk” and make contributions themselves to the organizations for which they are seeking support. Among clinicsthat are not Planned Parenthoods or free clinics, more than 65% reported that at least some of their boardmembers contributed financially to their clinic during the most recently completed fiscal year, and 25%reported that all of the members of their board had made contributions. When asked what proportions of their boards actively assist in soliciting individual donations, 73% of these clinics reported that less than half of their boards help do this, and 34% get no help from their board members in this area at all.

Private Fund Development Strategies

The most popular fundraising strategy to help clinics raise private dollars is producing fundraising events and soliciting corporate sponsorship for those events. Soliciting individual donors and board members arealso strategies that are commonly pursued by more than 60% of clinics. The least popular strategies are selling products, collecting donations online and soliciting patients. (See Appendix E.) In general, PlannedParenthoods and free clinics are more likely to engage in a broader range of private fundraising activities thanother clinics. One activity that Planned Parenthoods and free clinics engage in much more than other clinicsis direct mail appeals. More than 94% of Planned Parenthoods and free clinics solicit both existing and new donors for money this way. In contrast, almost half of other clinics do not send an appeal letter to theircurrent donors, a low-cost strategy considered to be a basic one by fund development experts, and 55% donot solicit new donors through the mail.

Benchmarking Access

Strengthening individual clinics is one of the strategies CCI is pursuing to at least maintain and hopefullyincrease access to care for California’s uninsured and underinsured populations in the face of other pressures on the health care delivery system. Therefore, one of the measures of success for CCI’s capacity-


20

28. Of the leaders among FQHC and Look-Alike clinics listed in Appendix D, three (Marin Community Clinic, Haight-Ashbury Free Clinics and ImperialBeach Health Center) used to be free clinics.


21

building activities will be changes in access to care over time. Measuring access goes beyond simply tracking changes in the number of patients that are served by clinics. Indicators also include reaching new populations with services, providing new types of services that meet critical patient needs and providing services in a time and place that is convenient for patients. Blueprint’s survey included a number of questions designed to benchmark these different elements of access at community clinics. Some of this data, specifically that which concerns the range of services provided in Appendix F, are not new to the fieldand are tracked by the state. Blueprint collected this data to serve as baseline data for measuring howstrengthened organizational capacity of clinics affects access to clinic services.29 We focus in this report onthose pieces of data that may be new information for the field: collaboration with other programs and organizations in the provision of services (discussed earlier in the section on Community Engagement andCollaboration), information about the languages in which services are provided and time to get appointments.

Languages in Which Services Are Provided

Clinics were asked in which languages other than English they are able to provide services at least 80% of the time without accessing outside translation services. As might be expected, Spanish was the most widelyused language, with 90% of clinics reporting that they are able to offer services to Spanish-speaking patients.The next most frequently used language in clinics is Tagalog, with roughly one-quarter of the clinics reportingthat they can provide services in this language, followed closely by Vietnamese (20%). Other languages thatclinics report using to provide services include Mandarin (13%), Cantonese (11%), Hmong (9%) andCambodian (8%). (See Table 2.)

Table 2. Languages at Clinics

SpanishTagalogVietnameseMandarinCantoneseHmongCambodianKoreanLaotianMienMixtecoPortugueseRussianFarsiFrenchHindi

Percentage of clinicsthat provide servicesin the language

90%23%20%13%11%9%8%6%3%3%3%3%3%2%2%2%

Language

PunjabiThaiZapotecAmerican Sign Language AmharicArabicArmenianDariDutchJapaneseKanjobalPashtoQuicheTigrinyaTriquiUrdu

Percentage of clinicsthat provide servicesin the language

2%2%2%1%1%1%1%1%1%1%1%1%1%1%1%1%

Language

29. One piece of data, the proportion of clinics that owns buildings versus the proportion that leases, was included in the survey to assess readinessfor capital campaigns. (See Appendix E.) Future surveys will instead track the total amount of physical space available to provide services.

Time to Get Appointments

As one way to gauge how accessible clinic services are to new, uninsured patients, Blueprint engaged in a “secret shopper” survey. We made anonymous calls to clinics posing as sick, uninsured community members seeking appointments.30 The purpose of the calls was to track the amount of time new, uninsuredpatients have to wait to access care when they are sick.

As the results in Table 3 show, a large percentage of clinics (30%) had appointments available the same dayas the call. Another 13% could provide an appointment the next day. But more than half of the clinics couldnot provide an appointment for a sick person for at least three days. At 9% of clinics, only walk-in patientscould be seen.

Table 3. Time to Appointment (n=135)

Nine of the clinics that offered appointments suggested that the patient walk in for more prompt service, andfive noted that their wait time for an appointment would be shorter if the patient were a registered patient andnot a new patient. There were no noticeable variations in the length of time to appointment based on cliniccharacteristics such as FQHC status, rural or urban, or geographic location.

Table 4 shows additional data that was gathered on how long the caller had to wait on the phone to speak tosomeone. Of the 163 clinics contacted, 58% had a wait of less than a minute on the phone. Another 25%had a wait of one to four minutes. Only 7% had a wait of eight minutes or more. At 4% of clinics, the callerwas not able to speak to a person and was asked to leave a voicemail message.

Table 4. Phone Wait Time (n=163)


22

30. From mid-October to mid-December, two female staff members made anonymous calls to 166 community clinics around the state to ask for anappointment. Calls were made on Tuesday through Thursday, generally in the morning hours from 8:00 am until noon. An appointment was requestedfor a sick person with no insurance. In the end, 163 clinics were contacted, with appointment time information collected from 135. Some clinics wereunreachable and others were not taking new patients.

Length of Timeto AppointmentSame day Next day3–7 days1–3 weeksOver 3 weeksWalk-in only

Percentage of Clinics 30%13%13%17%18%9%

Length of Wait on the PhoneLess than 1 minute1 to 4 minutes5 to 7 minutes 8 or more minutes Asked to leave a voicemail message

Percentage of Clinics 58%25%6%7%4%


23

V. RECOMMENDATIONS

• Public and private funders should support community clinics and feel confident that they are responsiblestewards for investments in community health. Funders, especially those in clinics' local communities, need to be educated about the financial stability of community clinics and the role that they play in improving overall community health. Through this survey and the work of Capital Link, CCI has documentedthat at least through 2002, California's community clinics were in a relatively strong financial position, especially when compared to clinics in other states.31 At the same time, demand for clinic services contin-ues to outpace capacity, and recent shifts in public funding streams may significantly affect the funding environment for these organizations.

• Clinic funders and infrastructure groups could work together to develop a coordinated approach to strengthen the strategic planning, data-informed decision making and performance measurement skills of community clinics. These are key adaptive capacities that clinics need to navigate the rapid changes taking place in the health care field. Nearly one-third of clinics see themselves as relatively weak in thestrategic planning skills needed to fulfill their mission, and one-third also rate themselves as weak in data-informed decision making and the use of performance targets.

• Clinic funders and clinic infrastructure groups should work together on a strategy to support the clinics thathave the lowest overall capacity (approximately 20% of the clinics in this sample are relatively weak in allareas of capacity). This may require targeting assistance to strengthen organizational capacity, facilitatingthe sharing of services and resources or pushing them to merge with other clinics.

• FQHC and Look-Alike clinics would benefit from assistance to strengthen their fund development capacity,especially their ability to raise money from private sources such as individuals, corporations and local foundations. CCI hypothesizes that private fundraising: 1) diversifies the revenue streams for communityclinics, making them less subject to the political vicissitudes of government funding; 2) strengthens localcommunity buy-in to the clinic as a community organization; 3) helps clinics establish relationships withindividual donors that can be nurtured and relied upon in future fundraising campaigns and 4) helps clinics educate potential patients and other key players in their local communities about the role of community clinics, who can be mobilized for other health-related advocacy work.

• There are important lessons to be learned from examining the fundraising successes of the free andPlanned Parenthood clinics. For example, though Planned Parenthood clinics do not get any financial support from the national office, they benefit tremendously from the branding and public relations workconducted by the national office. To support their local fundraising efforts, California clinics could jointogether (on a regional or statewide basis) and share the costs of raising the public’s awareness of the role of community clinics in public health care. FQHC clinics should also look to their peers for successfulfundraising strategies and develop an FQHC model for fundraising from private sources, one that works for clinics with community boards.

• Clinic leaders and external community clinic stakeholders need to reach agreement on how much community engagement is happening and how much is ideal for community clinics. There is a need to invest in independent research to more closely examine the types of collaboration that clinics areengaged in; ascertain the benefits and costs of collaboration with other clinics, health care players, andcommunity organizations; and identify best practices. This could be used to jumpstart a conversationamong all key stakeholders to set some standards for the field.

31. Based on presentations prepared and delivered by Allison Coleman, CEO of Capital Link, to the CCI Steering Committee and to the CPCAVentures Board on July 16, 2003, and January 16, 2004, respectively. Capital Link is a nonprofit consulting firm that connects community health centers to capital resources. These presentations, which were supported by CCI, included financial trend data from FY99–FY02 for a cohort ofCalifornia clinics and provided comparative data compiled by Capital Link on national health center financial trends over the same period.

• Nearly one-third of clinics see themselves as relatively weak in the strategic planning skills needed to fulfilltheir mission. One-third also rate themselves weak in data-informed decision making and performance targets. These are key adaptive capacity skills that will be critical for clinics in navigating the rapid changesin the health care field over the coming years. Clinics funders and infrastructure groups could work togetherto develop a systematic approach to strengthening these critical skills.

• Clinics could use help strengthening their board leadership. Board management is a particular challenge at FQHC clinics, which are required to have consumers fill half their board slots. Clinics need research andnew models that highlight effective ways to manage these types of boards. Because CCI is not currentlyplanning to focus on boards, there is an opportunity for new funders to take a leadership role in this area.

VI. CONCLUSION

The findings from CCI’s capacity assessment survey present an initial portrait of the state of California’s community clinics. This information can be used to guide funders who are interested in investing in community health. The overall strength of the leadership in these organizations and their general financialstability bode well for the future of California’s clinics, which are likely to be facing challenging times in thenear future as government budget shortfalls trigger reduced public spending. Informed by research, CCI haschosen to focus on specific elements of capacity in community clinics. CCI will continue to build upon itswork in the area of IT by supporting clinics to strengthen their analytical capacity and ability to use the datathey are collecting to inform clinical and business decisions. CCI also will focus explicitly on strengtheningfund development capacity, an area where there is great opportunity for growth. Finally, CCI will devoteresources to increasing the medical directors’ participation in overall clinic management and to building apipeline of new leaders for the field.

There are many opportunities for other partners to help strengthen clinics’ ability to improve public health outcomes. Clinics are clearly struggling with board management, and there is an urgent need to explore newmodels and structures for clinic governance that can maintain the grassroots nature of community boards,but also support fundraising and policy work. There are opportunities to strengthen board training and toenhance the executive directors’ skills in board management. In addition, the field needs to agree upon standards for collaboration and coordination. A good starting point would be to support research on howmuch and what kinds of collaboration clinics are involved in, which could jumpstart a conversation amongkey stakeholders. Finally, there is more work to be done in the areas of fund development and data-informed decision making than CCI can take on alone – CCI will need to work in close partnership with other stakeholders and supporters of community clinics to ensure that California’s underinsured populations will be able to access the care that they need. Investing in primary care for these populations is extremely cost-effective and has tremendous benefits for all Californians.


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APPENDIX A. METHODOLOGY

CCI’s Building Capacities Self-Assessment Survey is based on the Capacity Assessment Tool created byMcKinsey & Company for Venture Philanthropy Partners (www.vppartners.org), published in Effective CapacityBuilding in Nonprofit Organizations (2001). We are grateful to Venture Philanthropy Partners for sharing thetool with us: we recognize the significant contribution their work has made to the field of capacity buildingand nonprofit management. The McKinsey tool was modified by Blueprint in both language and content foruse with community clinics. In particular, CCI’s version focuses on the capacity areas that CCI believes aremost vital to clinics in launching and implementing capital campaigns. In addition, Blueprint added items tothe survey to collect some baseline information on various aspects of access to community clinic services.

Six questions (numbers 4.1, 4.2, 4.3, 4.4, 4.6, and 5.2) have been reprinted directly from the McKinsey tool,with the permission of Venture Philanthropy Partners. In addition, Blueprint redesigned the format of the survey, creating a Microsoft Excel workbook to be distributed, completed and collected electronically. Theelectronic format contains a summary sheet that automatically tallies clinics’ self-assessment scores in eacharea of capacity so that clinics can immediately see the results of their assessment and their own strengthsand weaknesses. Collecting the data electronically was also more efficient for Blueprint, saving time andreducing errors that can happen in data entry.

The CCI survey was first reviewed by a small set of clinic leaders, and was refined before it was pilot tested by close to ten clinics. Once the feedback from the pilot test was incorporated, the survey was administeredvia email to 151 current and former CCI grantees.32 The 87 grantees who received funding in 2003 through CCI’s Building Capacities program, which focuses on organizational development, were required to return the survey as part of their grant agreement, while participation was voluntary for previous grantees. The clinics were asked to include their management team members and at least one board member in the self-assessment process, and they were given six weeks to complete the recommended process. The survey guided the clinic leadership through a self-assessment in the seven core areas of capacity that CCI chose to focus upon:


Within the seven broad areas of capacity, clinics were given a number of specific items to reflect upon. For example, in the Leadership: Management Team section of the survey, clinics were asked to assess the management team’s composition, communication and coordination, decision-making processes, collaborationand leadership and members’ experience and expertise. Clinics assessed themselves on each item using ascale that ranged from Level One (clear need for increased capacity) to Level Four (high level of capacity inplace), and were given clear descriptions of the characteristics of a clinic at each of these levels. In additionto the capacity assessment portion of the survey, clinics were asked a number of questions focused uponfund development strategies and access to services.

32. The survey was sent in July of 2003. The survey was not sent to nine of CCI’s 160 current and former grantees because there was either noavailable contact information, clinics had closed or clinics had merged.


26

APPENDIX B. RANKED ORDER OF CAPACITY ASSESSMENT ELEMENTS AND ITEMS 33

Table 1. RANKED ORDER OF CAPACITY ASSESSMENT ELEMENT MEANSLeadership: Management Team


Community Engagement & Collaboration

Mission, Vision & Planning



Fund Development

Table 2. RANKED ORDER OF CAPACITY ASSESSMENT ITEM MEANSMission, Vision & Planning - Mission (clinic's reason for existence)

Leadership: Management Team - Management Experience & Expertise

Leadership: Management Team - Management Communication

Leadership: Management Team - Management Team Composition

Financial Systems & Position - Use of Financial & Operations Data

Financial Systems & Position - Bottom Line

Community Engagement & Collaboration - External Relationship Building (partnerships & collaboration)

Leadership: Board of Directors - Board Governance

Mission, Vision & Planning - New Program Development

Financial Systems & Position - Financial Planning & Budgeting

Financial Systems & Position - Cash Flow

Leadership: Management Team - Management Team Collaboration & Leadership

Leadership: Management Team - Management Decision Making

Financial Systems & Position - Diversity of Revenue Sources

Mission, Vision & Planning - Clarity of Vision (clinic's long-term goals for itself & its community)

Mission, Vision & Planning - Operational Planning

Community Engagement & Collaboration - Local Community Presence & Involvement

Community Engagement & Collaboration - Assessment of Community Needs & Clinic Environment

Mission, Vision & Planning - Strategic Plan

Leadership: Board of Directors - Board Composition & Commitment

Leadership: Board of Directors - Board Training & Orientation

Leadership: Board of Directors - Strategic Planning Role

Mission, Vision & Planning - Strategic Planning Skills

Data-Informed Decision Making - Use of Clinical Data

Leadership: Board of Directors - Committee Structure & Participation

Fund Development - Fund Development Staff, Budget, & Skills

Data-Informed Decision Making - Performance Management: Benchmarking

Mission, Vision & Planning - Performance Targets

Data-Informed Decision Making - Data Analysis Skills & Staff

Fund Development - Fund Development Strategy & Activities

Leadership: Board of Directors - Board Fundraising

Fund Development - Private Revenue Sources (non-foundation or contract)

3.153.133.043.012.792.732.55

3.413.223.223.213.213.193.143.143.133.113.083.063.063.053.023.023.012.972.972.842.812.792.782.782.772.762.722.702.702.622.382.28


27

Table 3. RANKED PERCENTAGE OF CLINICS AT CAPACITY LEVELS 3 OR 4Mission, Vision & Planning - Mission (clinic's reason for existence)

Leadership: Management Team - Management Communication

Leadership: Management Team - Management Experience & Expertise

Mission, Vision & Planning - New Program Development

Community Engagement & Collaboration - External Relationship Building (partnerships & collaboration)

Leadership: Management Team - Management Team Composition

Leadership: Management Team - Management Team Collaboration & Leadership

Financial Systems & Position - Use of Financial & Operations Data

Leadership: Management Team - Management Decision Making

Mission, Vision & Planning - Clarity of Vision (clinic's long-term goals for itself & its community)

Community Engagement & Collaboration - Assessment of Community Needs & Clinic Environment

Mission, Vision & Planning - Operational Planning

Leadership: Board of Directors - Board Governance

Community Engagement & Collaboration - Local Community Presence & Involvement

Financial Systems & Position - Bottom Line

Financial Systems & Position - Financial Planning & Budgeting

Mission, Vision & Planning - Strategic Plan

Leadership: Board of Directors - Board Training & Orientation

Financial Systems & Position - Cash Flow

Financial Systems & Position - Diversity of Revenue Sources

Data-Informed Decision Making - Use of Clinical Data

Data-Informed Decision Making - Data Analysis Skills & Staff

Leadership: Board of Directors - Board Composition & Commitment

Leadership: Board of Directors - Committee Structure & Participation

Mission, Vision & Planning - Strategic Planning Skills

Leadership: Board of Directors - Strategic Planning Role

Data-Informed Decision Making - Performance Management: Benchmarking

Fund Development - Fund Development Staff, Budget, & Skills

Mission, Vision & Planning - Performance Targets

Fund Development - Fund Development Strategy & Activities

Leadership: Board of Directors - Board Fundraising

Fund Development - Private Revenue Sources (non-foundation or contract)

87%86%85%84%82%81%81%81%80%80%79%79%77%76%74%74%73%71%70%69%69%68%67%66%64%63%63%61%57%54%40%38%

33. The items that are bolded in Table 2 are those that fall below a mean score of 3.00. These same items are bolded in Table 3 to show how therank changes when using the proportion of clinics that score themselves at a “3” or a “4” instead of the mean to rank the items.


28

APPENDIX C. CO-LOCATED SERVICES AND WIC COORDINATION

Table 1. CO-LOCATED SERVICES

Percentage of clinics that provide space for any other organizations or programs that provide services for their clients, such as Women, Infants and Children (WIC); Medi-Cal; outside pharmacy; or community mental health services. (N=74)

Percentage of clinics that offer on-site enrollment for Healthy Families. (N=87)

Percentage of clinics that offer on-site enrollment for Medi-Cal. (N=84)

68%

82%

74%

Table 2. WOMEN, INFANTS & CHILDREN (WIC) SERVICES

How often does each client eligible for WIC services receive written information about the benefits of WIC? N=74

How often does each client eligible for WIC services receive referrals to WIC sites? N=74

How often does each client eligible for WIC services receive written information on the location and times of WIC services? N=73

How often does each client eligible for WIC services receive follow-up on WIC referrals? N=74

% OF CLINICS INDICATING "ALWAYS"

34%

41%

32%

24%

% OF CLINICS INDICATING

"OFTEN"

43%

43%

40%

28%


"OCCASIONALLY"

18%

14%

22%

31%


"NEVER”

5%

3%

7%

16%


29

APPENDIX D. FUND DEVELOPMENT LEADERS

Table 2. TOP 10 FQHC/FQHC LOOK-ALIKES – % OF TOTAL REVENUE FROM FUNDRAISING

La Clinica De La Raza—Fruitvale Health Center

Coastal Health Alliance

Redwood Coast Medical Services

Marin Community Clinic*

Shasta Community Health Center

Northeast Valley Health Corporation

Haight Ashbury Free Clinics*

Imperial Beach Health Center*

Southwest Community Health Center

Sierra Family Medical Clinic

* These clinics used to be free clinics

% OF TOTAL REVENUE FROM FUNDRAISING

(N=87)

% OF TOTAL REVENUE FROM

NET PATIENT SERVICE REVENUE

(N=87)

% OF TOTAL REVENUE FROM FOUNDATIONS AND GRANTS

(N=87)

TOTAL OPERATING EXPENSES

(N=78)TOTAL REVENUE

(N=87)

% OF TOTAL REVENUE FROM GOVERNMENT CONTRACTS

(N=87)

10.0%

8.7%

8.4%

7.7%

6.4%

3.8%

3.7%

3.3%

2.7%

2.4%

50.4%

35.7%

61.5%

54.7%

69.9%

37.6%

1.3%

75.2%

56.8%

83.9%

1.7%

10.4%

8.6%

7.0%

17.9%

0.4%

3.6%

0.0%

14.3%

12.6%

36.1%

44.5%

19.9%

25.4%

2.7%

57.4%

87.7%

21.5%

18.6%

0.0%

$30,678,084

$2,060,557

$3,116,381

$5,744,730

$13,777,875

$32,030,000

$15,191,129

$1,847,264

$3,486,727

$743,629

$27,830,799

$2,019,844

$2,781,238

$5,513,177

$13,272,964

$31,612,000

$15,180,438

$1,771,399

$3,410,336

$714,544

Table 1. TOP 10 CLINICS – ALL CLINICS% OF TOTAL REVENUE FROMFUNDRAISING

Share Our Selves Free Medical Clinic #

Samaritan House Free Medical Clinic #

Planned Parenthood Golden Gate*

St. Anthony Free Medical Clinic #

Planned Parenthood of Santa Barbara, Ventura and San Luis Obispo Counties*

Venice Family Clinic #

Planned Parenthood of Orange and San Bernardino Counties*

Roseland Children's Health Center

Planned Parenthood of San Diego and Riverside Counties*

Six Rivers Planned Parenthood*

# Indicates free clinic * Indicates Planned Parenthood affiliate

% OF TOTAL REVENUE FROM FUNDRAISING

(N=87)

% OF TOTAL REVENUE FROM

NET PATIENT SERVICE REVENUE

(N=87)

% OF TOTAL REVENUE FROM FOUNDATIONS AND GRANTS

(N=87)

TOTAL OPERATING EXPENSES

(N=78)TOTAL REVENUE

(N=87)

% OF TOTAL REVENUE FROM GOVERNMENT CONTRACTS

(N=87)

77.9%

36.0%

22.7%

20.0%

17.0%

16.3%

15.5%

14.3%

12.4%

11.4%

0.0%

0.2%

70.3%

0.0%

73.5%

19.3%

60.4%

37.5%

82.8%

84.2%

22.1%

32.1%

4.9%

78.9%

0.0%

13.7%

5.0%

4.7%

3.3%

2.1%

0.0%

23.2%

0.5%

0.0%

10.6%

50%

18.5%

28.5%

1.4%

0.0%

$3,850,000

$3,575,848

$14,610,299

$95,000

$6,091,889

$12,667,411

$13,165,951

$424,882

$24,883,304

$2,245,771

Not available

$3,165,908

$17,430,918

Not available

$5,911,256

$12,272,049

$12,264,638

$405,168

$22,496,121

$2,049,821


30

APPENDIX E. FUND DEVELOPMENT CAPACITY AND STRATEGIES

Table 1. FUNDRAISING STAFF

% OF CLINICS W/LESS THAN 1.0 FTE DOING FUND DEV.*

% OF CLINICS W/1.0–2.0 FTE DOING FUND DEV.

% OF CLINICS W/MORE THAN 2.0 FTE DOING FUND DEV.

MEAN—NUMBER OF FTE PER CLINIC

*Nine clinics reported zero FTE doing fund dev.

ALL CLINICS (N=89) P.P. & FREE CLINICS (N=17)ALL CLINICS EXCEPT P.P. &

FREE (N=72)

37.1%

41.6%

21.3%

1.65

5.9%

29.4%

64.7%

4.14

44.4%

44.4%

11.1%

1.06

Table 2. FUNDRAISING CONSULTANTS

% OF CLINICS THAT ARE NOT WORKING WITH A CONSULTANT

% OF CLINICS THAT ARE WORKING WITH AT LEAST ONE CONSULTANT

ALL CLINICS EXCEPT P.P. & FREE (N=71)

ALL CLINICS EXCEPT P.P. & FREE W/LESS THAN 1.0 FTE DOING FUND DEV. (N=31)

ALL CLINICS EXCEPT P.P. & FREE W/AT LEAST 1.0 FTE DOING FUND DEV. (N=48)

62.0%

38.0%

64.5%

35.5%

59.0%

41.0%

Table 3. PLANNED PARENTHOOD & FREE CLINICS—BOARD FUNDRAISING

What proportion of your board made an individual contribution to the clinic during the last fiscal year? (N=17)

What proportion of your board actively assists in soliciting individual donations? (N=17)


“NONE”

5.9%

5.9%

% OF CLINICS INDICATING “LESS

THAN HALF”

17.6%

52.9%

% OF CLINICS INDICATING “MORE

THAN HALF”

23.5%

23.5%

% OF CLINICS INDICATING “ALL”

52.9%

17.6%


“DON'T KNOW”

0.0%

0.0%

Table 4. ALL CLINICS EXCEPT P.P. & FREE—BOARD FUNDRAISING

What proportion of your board made an individual contribution to the clinic during the last fiscal year? (N=17)

What proportion of your board actively assists in soliciting individual donations? (N=17)


“NONE”

33.3%

33.8%

% OF CLINICS INDICATING “LESS

THAN HALF”

20.8%

39.4%

% OF CLINICS INDICATING “MORE

THAN HALF”

19.4%

19.7%

% OF CLINICS INDICATING “ALL”

25.0%

4.2%


“DON'T KNOW”

1.4%

2.8%


31

APPENDIX E. FUND DEVELOPMENT CAPACITY AND STRATEGIES (CONT.)

Table 5. BOARD FUNDRAISING COMMITTEE

Percentage of ALL CLINICS that have a board with a standing fundraising committee (N=89)

Percentage of PLANNED PARENTHOOD & FREE CLINICS that have a board with a standing fundraising committee (N=17)

Percentage of ALL CLINICS EXCEPT PLANNED PARENTHOOD & FREE that have a board with a standing fundraising committee (N=72)

60.7%

88.2%

54.2%

% OF CLINICS THAT NEVER ENGAGE IN

ACTIVITY

25.6%

26.7%

38.9%

38.9%

41.1%

41.1%

45.6%

45.6%

55.6%

56.7%

66.7%

71.1%

% OF CLINICS THAT ENGAGE IN ACTIVITY OCCASIONALLY (LESS

THAN ANNUALLY)

22.2%

30.0%

26.7%

11.1%

14.4%

31.1%

22.2%

27.8%

12.2%

27.8%

10.0%

16.7%

% OF CLINICS THAT ENGAGE IN

ACTIVITY AT LEAST ANNUALLY

52.2%

43.3%

34.4%

50.0%

44.4%

27.8%

32.2%

26.7%

32.2%

15.6%

23.3%

12.2%

TOTAL % OF CLINICS THAT

ENGAGE IN ACTIVITY

74.4%

73.3%

61.1%

61.1%

58.9%

58.9%

54.4%

54.4%

44.4%

43.3%

33.3%

28.9%

Table 6. ALL CLINICS’ FUNDRAISING ACTIVITIES

Fundraising event to raise money and/or to strengthen relationships with current and prospective donors (N=83)

Solicitation of corporate sponsors for special events or for a special campaign or initiative (N=83)

Board and/or staff personal solicitations of existing individual donors (N=83)

Solicitation of board members for donations (N=83)

Direct mail appeal to current donors—those who have contributed to your clinic during the last fiscal year for general operating support (N=83)

Direct mail campaign for a special program or initiative (as opposed to general operating support) (N=83)

Direct mail appeal to prospective new donors for general operating support (N=83)

Concluding speaking engagements to community groups with a pitch for donations (N=83)

Solicitation of donations through United Way campaign (N=83)

Solicitation of patients for donations (N=83)

Collecting online donations via a website (N=83)

Sales of products (such as t-shirts) (N=83)


32

APPENDIX F. SELECTED INDICATORS OF ACCESS

Table 1. ALL CLINIC SERVICES PROVIDED

Health education (N=90)

Family planning services (N=89)

Primary care for adults (N=89)

Primary care for children (N=89)

Chronic disease care management (N=88)

Nutrition (N=90)

Prenatal care (N=89)

Mental health services for adults (N=89)

Dental care for adults (N=88)

Specialty medical services (N=89)

Dental care for children (N=89)

Mental health services for children (N=89)

On-site pharmacy (N=89)

Substance abuse services (N=89)

On-site radiology (N=89)

Optometry (N=88)

OB deliveries (N=89)

% OF CLINICS PROVIDING

SERVICE AT NO SITES

3%

4%

7%

10%

13%

17%

22%

34%

38%

39%

40%

43%

44%

62%

71%

78%

79%

% OF CLINICS PROVIDING SERVICE

AT SOME SITES

12%

24%

26%

27%

26%

28%

40%

29%

40%

38%

39%

26%

30%

19%

24%

17%

13%

% OF CLINICS PROVIDING

SERVICE AT ALL SITES

84%

72%

67%

63%

61%

56%

37%

37%

23%

22%

20%

31%

26%

19%

6%

5%

8%

TOTAL % OF CLINICS THAT

PROVIDE SERVICE

97%

96%

93%

90%

88%

83%

78%

66%

63%

61%

60%

57%

56%

38%

29%

22%

21%

Table 2. SITE OWNERSHIP

% of clinics that "own all buildings"

% of clinics that "own some & lease some"

% of clinics that "lease all buildings"

ALL CLINICS (N=87)

PLANNED PARENTHOOD CLINICS (N=6)

FREE CLINICS (N=9)

LARGE CLINICS (REVENUES =/>

$12M) EXCEPT P.P. AND FREE CLINICS

(N=17)

SMALL CLINICS (REVENUES </= $1.6M) EXCEPT P.P. AND FREE

CLINICS (N=14)

ALL CLINICS EXCEPT P.P. AND FREE CLINICS

(N=72)

24.1%

55.2%

20.7%

0.0%

100.0%

0.0%

33.3%

44.4%

22.2%

25.0%

52.8%

22.2%

71.4%

14.3%

14.3%

5.9%

94.1%

0.0%

CCI REPORT TO THE FIELD JULY 2004 APPENDIX G. BUILDING CAPACITIES SELF-ASSESSMENT SURVEY

Mission, Vision & Planning

AssessmentCategories (7 questions)

LEVEL ONE:Clear need

for increased capacity

LEVEL TWO:Basic level

of capacity in place

LEVEL THREE:Moderate level


LEVEL FOUR:High level


1. Mission (clinic’s reason for existence)

Mission not revisited recently and may not be as relevant today; Very few staff can articulate the mission and it is rarely referred to

Mission refl ects clinic’s values and purpose, but may lack clarity or currency; Few staff, primarily those with long tenure, are familiar with it; Lacks broad agreement and is rarely referred to

Mission is a clear expression of clinic’s reason for existence that refl ects its values and purpose; Held by many within clinic and often referred to

Mission is a clear expression of clinic’s reason for existence that describes an enduring reality and refl ects clinic’s values and purpose; Broadly held within clinic and frequently referred to; Used to prioritize programs

a. Level Oneb. Level Two

c. Level Threed. Level Four

e. N/A

2. Clarity of Vision (clinic’s long-term goals for itself & its community)

Little shared understanding, even among top management, of what organization aspires to become or achieve beyond the stated mission

Somewhat clear understanding of what clinic aspires to become or achieve; Held only by top management or “on the wall,” but rarely used to direct actions or set priorities

Clear and specifi c understanding of what clinic aspires to become or achieve; Held by top management and many others within the clinic and often used to direct actions and set priorities

Clear, specifi c, and compelling understanding of what clinic aspires to become or achieve; Held by most to all staff and consistently used to direct actions and set priorities



e. N/A

3. Strategic Plan

Medium- to long-term strategic plan either non-existent, unclear, or incoherent (largely a set of scattered initiatives); Strategy has no infl uence over management decisions.

Medium- to long-term strategic plan exists but is either not clearly linked to mission, vision, and overarching goals, lacks coherence, or is not easily actionable; Strategy is not broadly known and has limited infl uence over management decisions

Coherent medium- to long-term strategic plan has been developed and is linked to mission and vision and a clear timeframe but is not fully ready to be acted upon; Strategy is mostly known and management decisions partly guided by it

Clear, coherent medium- to long-term strategic plan that is actionable and linked to overall mission, vision, and overarching goals in a clearly defi ned timeframe; Strategy is broadly known and consistently helps guide decisions at all levels of organization



e. N/A

4. Strategic Planning Skills

Limited ability and tendency to develop strategic plan, either internally or via external assistance; If strategic plan exists, it is not used

Some ability and tendency to develop strategic plan either internally or via external assistance; Strategic plan roughly directs management decisions

Ability and tendency to develop and refi ne concrete, realistic strategic plan; Some internal expertise in strategic planning or access to relevant external assistance; Strategic planning carried out on a near-regular basis; Strategic plan used to guide management decisions

Ability to develop and refi ne concrete, realistic and detailed strategic plan; Critical mass of internal expertise in strategic planning, or effi cient use of external, sustainable, highly qualifi ed resources; Strategic planning exercise carried out regularly; Strategic plan used extensively to guide management decisions



e. N/A

5. Performance Targets

Targets are non-existent or few; Existing targets are vague or either too easy or impossible to achieve; Not clearly linked to aspirations and strategic plan; Targets largely unknown or ignored by staff and board

Realistic targets exist in some key areas, and are mostly aligned with aspirations and strategic plan; May lack milestones, or mostly focused on “inputs” (things to do right), or often renegotiated; Staff and board may or may not know and adopt targets

Performance targets in most areas; Linked to aspirations and strategic plan; Mainly focused on “outputs/outcomes” (results of doing things right) with some “inputs”; Typically multiyear targets, though may lack milestones; Targets are known and adopted by most staff who usually use them to broadly guide work; Board evaluates performance based on targets

Limited set of quantifi ed, demanding performance targets in all areas; Targets are tightly linked to aspirations and strategy, output/outcome-focused (e.g., results of doing things right, as opposed to inputs, things to do right), have annual milestones, and are long-term nature; Staff consistently adopts targets and works diligently to achieve them; Board evaluates performance based on targets



e. N/A

6. New Program Development

No assessment of gaps in ability of current program to meet recipient needs; Limited ability to create new programs; New programs created largely in response to funding availability

Limited assessment of gaps in ability of existing program to meet recipient needs, with little or limited action taken; Some ability to modify existing programs and create new programs

Occasional assessment of gaps in ability of existing program to meet recipient needs, with some adjustments made; Demonstrated ability to modify and fi ne-tune existing programs and create new programs

Continual assessment of gaps in ability of existing programs to meet recipient needs and adjustments always made; Ability and tendency to create new, highly innovative and effective programs to meet the needs of potential service recipients in local area or other geographies; Continuous pipeline of new ideas



e. N/A

7. Operational Planning

Organization runs operations purely on day-to-day basis with no short- or longer-term planning activities; No ability or experience to conduct data-based operational planning

Some ability and tendency to develop operational plan either internally or via external assistance; Operational plan loosely linked to strategic planning activities and used roughly to guide operations; Operational planning not based on trend data

Ability and tendency to develop and refi ne concrete, realistic operational plan, linked to annual budget and trend data; Some internal expertise in operational planning; Operational planning carried out on a regular basis; Operational plan linked to strategic planning activities and used to guide operations

Clinic develops and refi nes concrete, realistic, and detailed operational plan linked to annual budget and trend data; Has critical mass of internal expertise in operational planning; Operational planning exercise carried out regularly; Operational plan tightly linked to strategic planning activities and systematically used to direct operations



e. N/A

Comments:


34

Community Engagement & Collaboration

AssessmentCategories

(3 questions)









1. Assessment of Community Needs & Clinic Environment

Planning is not supported by systematically collected data about community needs or clinic’s external opportunities and threats; Clinic has very few connections to community members and opinion leaders that could help clinic leaders understand evolving community needs

Clinic uses some data about community needs, opportunities, or external threats to inform planning although collection is haphazard; Clinic has some connections to community members and opinion leaders who inform clinic leaders about evolving community needs

Clinic uses some data about community needs and clinic’s external opportunities and threats to inform planning; Data collected and used systematically to support planning effort and improve it; Clinic has multiple connections to community members and opinion leaders with whom clinic leaders regularly communicate about the evolving community needs

Clinic has clear, formal systems for assessing community needs and external opportunities and threats; Data used systematically to support planning and improve it; Clinic has many connections to community members and opinion leaders with whom clinic leaders regularly communicate about the evolving community needs; Communication is two way (community leaders often initiate communication)



e. N/A

2. Local Community Presence & Involvement

Clinic’s community presence either not recognized or generally not regarded as positive; Few members of local community (e.g., patients, business leaders, other nonprofi t leaders) constructively involved in the organization

Clinic’s presence somewhat recognized and generally regarded as positive within the immediate community (e.g., potential patients); Some members of larger community (e.g., business, civic, and/or other nonprofi t leaders) constructively involved with the organization

Clinic reasonably well-known within community beyond just potential patients, and perceived as open and responsive to community needs; Members of larger community (e.g., business, civic, and/or other nonprofi t leaders) constructively involved in organization

Clinic widely known within larger community and perceived as actively engaged with and extremely responsive to it; Many members of the larger community (e.g., business, civic, and/or other nonprofi t leaders) actively and constructively engaged with organization (e.g., board, fund-raising)



e. N/A

3. External Relationship Building (partnerships & collaboration)

Limited use of partnerships and alliances; Some coordination with other clinics in areas such as resource development, but few or no formal relationships

Early stages of building relationships and collaborating with other stakeholders; Coordinates primarily with other clinics but also is working to build relationships with other community-based organizations; Coordination focused primarily on infl uencing public policy and/or resource development, but also is beginning to discuss coordinating things such as patient care, staff training, etc.; May belong to clinic consortium, but activities focused primarily on information sharing as opposed to collaborative work

Effectively built and leveraged some key relationships with several types of relevant parties (for-profi t, public health, and nonprofi t sector entities); Belongs to a clinic consortium and actively coordinates work with other clinics; Coordination happens in areas such as business/operations, patient care, advocacy, and public policy, understanding patient populations, population health, and clinical issues; Contributes disease registry data to a disease collaborative; Recognized for effective alliances

Built, leverages, and maintains strong relationships with variety of relevant parties (local, state, and federal government entities as well as for-profi t, other nonprofi t, and community agencies), including membership in a consortium and disease collaborative; Relationships anchored in stable, long-term, mutually benefi cial collaboration; Integrates/shares some business operations to take advantage of economies of scale Coordination exists around understanding patient populations and population health, improving individual patient care, infl uencing public policy, and resource development



e. N/A

Comments:


35

Leadership: Management Team


(5 questions)









1. Management Team Composition

Senior management responsibilities concentrated primarily in Executive Director position; Some functions (e.g., operations, development, fi nance, IT, personnel, community outreach, patient services including dental and/or mental health) outsourced; Medical Director is uninvolved in management

Senior management responsibilities shared by a management team that is interdisciplinary; Members of the team represent different areas of the organization (e.g., operations, development, fi nance, IT, personnel, community outreach, patient services including dental and mental health); Medical Director is relatively uninvolved in clinic management

Senior management responsibilities shared by a management team that is interdisciplinary; Most areas of the organization (e.g., operations, development, fi nance, IT, personnel, community outreach, patient services including dental and mental health) are represented on the team; Medical Director actively participates as member of management team

Management team is interdisciplinary; All areas of the organization are represented (e.g., operations, development, fi nance, IT, personnel, community outreach, patient services including dental and mental health), including active participation and leadership of the Medical Director and other appropriate clinical managers



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2. Management Communication & Coordination

Executive Director and senior managers meet infrequently and irregularly; Management team members know almost nothing about the priorities and activities in departments beyond their own

Management team meets as needed on an infrequent and irregular basis; Team members communicate individually between meetings; Members know what the most urgent issues are in all departments but not other department’s goals and priorities

Management team meets on a regular basis; Frequent communication among members between meetings; Members know key issues and goals of other departments and how they affect their own work

Management team meets frequently and regularly; Frequent and open communication between meetings; Members have strong understanding of issues, future plans, and goals in each department and how they affect the whole organization, as well as their own department



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3. Management Decision Making

Decisions made largely on an ad hoc basis by the Executive Director and/or whomever is accessible; Virtually all decision- making authority is centralized in one or two people; Divisions of roles and responsibilities among team members are neither formalized nor clear

Process for management team’s decision making often breaks down and not always inclusive; Management team authorized, but unlikely to make key decisions in Executive Director’s absence; Most roles and responsibilities among team members are not formalized

Clear, inclusive systems for team decision making but decisions are not always appropriately implemented or followed; All roles and responsibilities among team members are formalized, but may not refl ect organizational realities

Clear, formal lines/systems for decision making that draw upon expertise and input of all team members; Roles and responsibilities among team members are formalized, clear and compliment each other



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4. Management Experience & Expertise

Senior managers have very limited experience in clinic or other health-related organizations; Managers have very limited capabilities or track record of managing large-scale projects (e.g., IT, capital, medical record system conversion, implementation of pharmacy or dental services); Limited track record of learning and personal development; Combined length of service at clinic less than 5 years

Senior managers have some experience in clinic or other health related organizations; Some managers have limited capabilities and track records of managing large-scale projects (e.g., IT, capital, medical record system conversion, implementation of pharmacy or dental services); Good track record of learning and personal development; Combined length of service around 5 years

Management team has signifi cant experience in clinic or other health related organizations; Team members have relevant capabilities and track records of managing large-scale projects (e.g., IT, capital, medical record system conversion, implementation of pharmacy or dental services); Good track record of learning and personal development; Combined length of service more than 10 years

Management team highly experienced in clinic and other health related organizations; Team members have outstanding capabilities and track records of managing large-scale projects (e.g., IT, capital, medical record system conversion, implementation of pharmacy or dental services); Outstanding track record of learning and personal development; Combined length of service more than 15 years



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5. Management Team Collaboration & Leadership

Management team members work independently more than together; Little trust among team members and team members sometimes undermine team decisions; Meetings are ineffi cient

Management team members have built some trust and respect for each other; Sense of their role as a part of a team is still in development; Team meetings often have a simple agenda and are reasonably effi cient but lack clear facilitation; Follow-up action items aren’t always clear; Other staff are unfamiliar with or indifferent to the role of the management team

Management team members trust and respect one another and understand their responsibilities as a team; Meetings are well-planned and effi cient and often have assignment of action items and responsibilities at the end, and team processes are still evolving and improving; Other staff recognize individual team members as leaders, but are unclear on the role of the management team

Management team members function well as a team and respect and trust one another; Team meetings are well-planned, effi cient, and effectively facilitated; Each meeting ends with clear assignment of action items and responsibilities; All team members stand by team decisions; Management team members are respected by staff and board as organizational leaders and all understand the role the management team plays in organizational leadership



e. N/A

Comments:




(6 questions)









1. Board Composition & Commitment

Consumer members are not fully utilized or integrated; Membership drawn from a narrow spectrum of constituencies; Little or no relevant experience; Low commitment to organization’s success, vision, and mission; Meetings infrequent and/or poorly attended

Consumer members not fully utilized or integrated; Membership represents a few different constituencies (e.g., attorneys, accountants, community-based organization leaders, faith-based organization leaders, other health care providers, local business owners); Moderate commitment to organization’s success, vision, and mission; Regular, purposeful meetings are well-planned and attendance is good overall

Consumer members well-integrated and remaining members come from diverse fi elds of practice and expertise (e.g., attorneys, accountants, community-based organization leaders, faith-based organization leaders, other health care providers, local business owners); Membership represents most constituencies; Good commitment to organization’s success, vision, and mission; Regular, purposeful meetings are well-planned and attendance is consistently good

Consumer members well-integrated and remaining members come from broad variety of fi elds of practice and expertise (e.g., attorneys, accountants, community-based organization leaders, faith-based organization leaders, other health care providers, local business owners); Strong commitment and proven track record of investing in learning about the organization and addressing its issues; Outstanding commitment to the organization’s success, mission, and vision; Regular, purposeful meetings are well-planned and full-attendance is the norm rather than the exception



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2. Board Governance

Board roles and responsibilities are not clearly understood by members; Board does not review budgets, audits or regulatory and licensing reviews, does not set performance targets and hold CEO/ED accountable, or does not operate according to formal procedures

Understanding of roles and responsibilities of board and management varies; Board functions according to by-laws, reviews budgets, and occasionally sets organizational direction and targets, but does not review CEO/ED performance or its own functioning; Does not review audit or regulatory and licensing reviews comprehensively

Roles and responsibilities of board and management are clear and function well; Board reviews budgets, audits, regulatory and licensing reviews; Size of board set for maximum effectiveness with rigorous nomination process; Board sets performance targets, but does not regularly monitor them; Board does not systematically review CEO/ED’s or their own performance

Board and management work well together from clear roles; Board fully understands and fulfi lls fi duciary duties; Size of board set for maximum effectiveness with rigorous nomination process; Board actively sets performance targets and regularly monitors performance; Periodically evaluates itself and formally evaluates CEO/ED on an annual basis



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3. Board Training & Orientation

No plans for board recruitment, orientation, or training; No formal training available and no new board member orientations

No plans for board recruitment; Board training occurs “on the job” rather than through any formal training sessions; Some formal training provided on an ad hoc basis upon request; Limited orientation for new members

Board recruitment and training plans developed; Some formal training for all board members loosely based upon a curriculum; Orientation for new members occurs and is supported by written materials

Board recruitment occurs according to plan; All board members receive formal training; Board training needs assessed annually and training plan and curriculum developed annually; Comprehensive board orientation for all new board members occurs and is supported by written materials



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4. Committee Structure & Participation

Generally, board members do not contribute additional time to participate in committees; Most standing committees are inactive and lack relevant expertise; Standing fund development committee does not exist

Most standing board committees have some activity, although with varying levels of effectiveness; Some committees include members with relevant expertise to help inform decision making; Standing fund development committee does not exist

Board functions through stable and active standing as well as ad hoc committees meeting regularly and reporting to board; Most committees include some members with relevant expertise to help inform decision making; Standing fund development committee is active and includes members with some expertise in raising funds from private sources

Board functions through stable and active standing as well as ad hoc committees charged with clear roles and responsibilities; All committees include members with relevant expertise necessary to fulfi ll responsibilities and make sound decisions; All committees meet regularly and present reports to the board; Fund development committee active and expert in all types of fundraising, including raising funds from private sources



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5. Board Fundraising

Most members do not recognize fundraising as one of the board’s roles and responsibilities; No goals or plans for board-driven fundraising activities exist

Members accept that the board has some fundraising responsibilities, but concerns exist regarding ability of consumer boards to be successful in this area; One or two members have fi nancially contributed to the clinic; Board fundraising activities not yet underway

Many members embrace fundraising as one of the board’s core roles and responsibilities; Core group of board members consistently participates in fundraising; Realistic and appropriate board fundraising goals and plans exist; Majority of members have made fi nancial contributions; Fundraising activities are underway

Majority of members embrace fundraising as a core board role and responsibility; Most board members have made fi nancial contributions to the organization; Realistic and appropriate board fundraising goals and plans are in place; Board is actively fundraising and has achieved measurable progress towards goals



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6. Strategic Planning Role

Plans to address community needs are developed by clinic staff, without a structured process for board input; Insights about the community’s current and future needs are not solicited by clinic staff or offered by board members during planning process; Board’s strategic planning role limited to ratifying staff’s plans; No process for board’s regular review and updating of plan

Structured process for community-based board to have input and approve clinic’s strategic plan exists, but is not always followed; Board members’ insights about community’s needs and strategies to address them are drawn upon informally, often on an individual basis, for planning purposes; No process exists for board’s regular review and updating of plan

Clinic follows a structured process for community-based board to have input and approve clinic’s strategic plan; Process includes solicitation of members’ insights about the community’s needs to inform develop of clinic’s goals and plans; Board regularly reviews and updates strategic plan

Clinic follows a structured process for community-based board to have signifi cant input and approve clinic’s strategic plan; Process includes solicitation of members’ insights about the community’s current and future needs to inform develop of clinic’s goals and plans; Board utilizes data about the community’s health status in planning process; Board regularly reviews and updates strategic plan



e. N/A

Comments:


37



(5 questions)









1. Bottom Line Revenues have exceeded expenses in zero or one of the past 3 years

(Positive operating margin in 0–1 of the last 3 years)

Revenues have narrowly exceeded expenses in two of the past 3 years

(Slightly positive operating margin in 2 of the last 3 years)

Revenues have exceeded expenses in two of the past 3 years

(Positive operating margin in 2 of the last 3 years)

Revenues have exceeded expenses in all of the past 3 years

(Positive operating margin in 3 of the last 3 years)



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2. Cash Flow On average, clinic does not have enough cash available to pay all of its monthly bills

(Approximately <30 days cash on hand)

On average, clinic has just enough cash available to pay its monthly bills, but not enough to cover any unforeseen expenses

(Approximately 30–45 days cash on hand)

On average, clinic has enough cash available to pay its bills, and enough additional cash on hand to cover modest unforeseen expenses

(Approximately 46–60 days cash on hand)

On average, clinic has enough cash available to pay its bills, and enough additional cash on hand to cover signifi cant unforeseen expenses

(Approximately >60 days cash on hand)



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3. Diversity of Revenue Sources

Clinic highly dependent on a few government grants and contracts, which make up over 50% of clinic revenue; Remainder of budget derived from foundations and a limited amount of patient revenue; Clinic highly vulnerable to fl uctuations in government funding priorities

Clinic’s revenue primarily derived from government and foundation grants and contracts (over 50% of revenue from these two types of sources); Remainder of budget derived from patient revenue; Clinic vulnerable to fl uctuations in government and foundation funding priorities; Clinic aware of need to diversify funding but lacks understanding and skills to do so

Clinic has grants and contracts from a variety of government and foundation sources, which together account for less than 50% of its revenues; Just under half of its revenue is derived from patient revenue (approx. 40%); Successful efforts are underway to develop private sources

Clinic has grants and contracts from a variety of government and foundation sources, which together account for less than 50% of its revenues; Half or more of its budget is derived from patient revenues (50%); A growing portion is derived from private sources other than foundations (about 5%); Diversity of funding sources provides insulation from fl uctuations in government and foundation funding priorities



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4. Financial Planning & Budgeting

Very limited fi nancial forecasting; General budget developed and approved by board of directors; Performance against budget loosely or poorly monitored

Limited fi nancial forecasting, ad hoc update; Annual budget utilized as operational tool; Used to guide/assess fi nancial activities; Some attempt to isolate divisional (program or geographical) budgets within central budget; Performance-to-budget monitored periodically

Solid fi nancial forecasts, updated at least semi-annually and discussed with management team, staff, and board; Annual budget utilized in operations; Refl ects organizational needs; Solid efforts made to isolate divisional (program or geographical) budgets within central budget; Performance-to-budget monitored at least quarterly

Very solid fi nancial forecasts, continuously updated; Annual budget updated regularly, reviewed monthly by management team and board, and utilized in daily operations; As strategic tool, it develops from process that incorporates and refl ects organizational needs and objectives; Well-understood divisional (program or geographical) budgets within overall central budget; Performance-to-budget monitored on a monthly basis



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5. Use of Financial & Operations Data

Occasionally produces some basic fi nancial management reports, such as budget-to-actual fi nancial reports, cash fl ow, and/or accounts payable/accounts receivable; Reports produced upon request, rather than at any regular time interval, and primarily reviewed by Executive Director

Regularly produces basic fi nancial management reports, such as budget-to-actual fi nancial reports, cash fl ow, and/or accounts payable/accounts receivable; Occasionally produces more sophisticated fi nancial reports on request such as cost center reports, administrative/overhead, and/or cost reporting/FQHC/cost reconciliation; Financial reports reviewed by Executive Director at least quarterly and by the board at least twice per year

At least quarterly, produces basic fi nancial management reports, such as budget-to-actual fi nancial reports, cash fl ow, and/or accounts payable/accounts receivable; Produces some more sophisticated fi nancial/operations reports such as cost center reports, administrative/overhead, cost reporting/FQHC/cost reconciliation, inventory, and/or personnel tracking; Reports include data from previous time period for comparison; Financial reports reviewed by Executive Director monthly, and by the management team and board at least twice per year

Produces comprehensive fi nancial management reports (budget-to-actual fi nancial reports, cash fl ow, and/or accounts payable/accounts receivable, cost center reports, administrative/overhead, cost reporting/FQHC/cost reconciliation, inventory, and/or personnel tracking) with trends information that are reviewed and discussed by management team on a monthly basis and shared with the board at least quarterly; Information from the reports feeds directly into planning, decision-making, and adjustments in operations



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Comments:


38

Fund Development


(3 questions)









1. Fund Development Strategy & Activities

Board leadership and Executive Director not focused on diversifying revenue sources; Fund development strategy not well articulated and focuses on one type of development such as grant writing

Board leadership and Executive Director recognize need to achieve a diverse balance of revenue sources; Fund development activities somewhat opportunistic, not organized in a coherent strategy; Activities go beyond grant writing to include marketing and communications, direct mail, personal solicitation or planned giving efforts; Clinic does not strategically target new revenue sources

Board leadership and Executive Director are committed to diversifying revenue sources; Fund development strategy includes multiple components (e.g., grant writing, marketing and communications, direct mail, personal solicitation, planned giving); Clinic is actively identifying and pursuing new revenue sources, including targeting private funding sources (other than foundations and contracts); Has a short, but good track record of successful fundraising from private sources

Board leadership and Executive Director are committed to maintaining a diverse revenue base; Well-developed fundraising strategy and systems to achieve and maintain a diverse balance of revenue sources; Fund development strategy includes several complimentary components (e.g., marketing and communications, direct mail, personal solicitation, planned giving); Strategy includes identifying and pursuing new revenue sources, including signifi cant effort to target private funding sources (other than foundations and contracts); Proven activities and skills for generating funding from private sources



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2. Fund Development Staff, Budget, & Skills

No dedicated fund development staff and no budget for development; Generally weak grantwriting and fundraising skills and lack of expertise (either internal or access to external expertise)

Some staff time and budget dedicated to fund development; Regular development needs covered by internal staff, who also do other jobs, but have some experience/training in grantwriting; Occasional access to some external grant writing and fundraising expertise

Some dedicated fund development staff who have professional training/experience in grantwriting and fundraising; Main development needs covered by some combination of internal skills and expertise, and access to some external grantwriting and fundraising expertise

Fully staffed professional fund development team with development budget; Highly developed internal grantwriting and fundraising skills and expertise in all funding source types to cover all regular needs; Access to external expertise for additional extraordinary development needs



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3. Private Revenue Sources (non-foundation or contract)

Clinic has no experience with or commitment to raising funds from private sources such as individuals and/or corporations; Less than 2% of the clinic’s annual revenue comes from private charitable donations (other than from philanthropic foundations)

Board leadership and ED do not put high priority on private fundraising; Clinic does not have an annual fundraising campaign; Solicitation of private contributions is infrequent and somewhat haphazard; Between 2% and 3% of the clinic’s annual revenue comes from private charitable donations (other than from philanthropic foundations); The amount of revenue from private sources is inconsistent from year to year

Board leadership and ED prioritize private fundraising; Clinic consistently has annual fundraising campaigns; Development team includes staff experienced in individual donor relations; Between 3% to 5% of the clinic’s annual revenue comes from private charitable donations (other than from philanthropic foundations); The amount of revenue from private sources is consistent, but not increasing year to year

Board leadership and ED put high priority on private fundraising; Clinic has ongoing strategies and systems for soliciting private donations and communicating with donors; Development staff are expert at relations with individual donors; More than 5% of the clinic’s annual revenue has come from private charitable donations (other than from philanthropic foundations) for at least three years; The amount of revenue from private sources has consistently increased year to year



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Comments:




(3 questions)









1. Data Analysis Skills & Staff

Limited capacity to work with research data; Only sporadically uses data from outside sources to support proposals or program decisions; Little understanding of where to fi nd useful data or how to assess its quality

Often uses simple data from internal or outside sources to support fund development and/or advocacy; Can read research reports and evaluate the quality of data but does not rely on data as part of regular decision making; Familiar with one or two sources of public health data especially relevant to community clinics; Little capacity to analyze raw data or present it in graphical, engaging ways

Familiar with relevant sources for public health data that are regularly consulted to support decisions, proposals, or advocacy; Can determine data quality, manipulate data from existing data sets, and make generalizations about the validity of fi ndings for community clinics and/or the local population; Some staff members have research and data analysis skills, though this may be only part of their job descriptions; Some staff capacity to conduct basic primary research such as surveys; Can effectively present data using charts, tables, and graphics for a variety of audiences

Respected by peers as both a consumer and producer of research data; Staff positions are dedicated to research and data analysis; Regularly scans public health research for relevant and valid data to support program planning and advocacy; Regularly works with management staff to identify important organizational questions and answer them through research, either collecting data from outside sources or conducting primary research; Strong relationships with other researchers in the public health arena, and/or at other clinics



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2. Use of Clinical Data

Minimal and haphazard tracking of basic clinic management data such as patient demographics; Reports can be produced upon request, are produced irregularly and reviewed by the Medical Director; Cannot identify patients by different types of diseases

Tracks basic clinic management data such as patient demographics, utilization of different services and/or provider productivity; Produce reports at least twice a year that are reviewed by the Medical Director; Reports do not include trend information comparing current data to previous time periods

Regularly tracks clinic management data such as patient demographics and provider productivity, and maintains at least one disease registry; Reports are produced at least quarterly and are reviewed and discussed by the Medical Director, Executive Director, and management team; Can identify patients by different diseases and Medical Director requests this data on an occasional basis, but not regularly; Has occasionally conducted some small analyses of patterns in patients’ health but does not do so on a regular basis

Tracks clinical data such as service utilization by different demographics, quality assurance, and/or utilization reports with trend information; Small number of clear, measurable, and meaningful key performance indicators; Reports are produced at least quarterly and are reviewed and discussed by the Medical Director, Executive Director, and management team; Program planning and/or adjustments are made based upon information from the reports and impact of changes is also tracked by reviewing changes in these data; Maintains multiple disease registries; Can conduct sophisticated analysis of patient population health and chronic disease management and adjust services appropriately



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3. Performance Management: Benchmarking

Rarely compares performance data such as fi nancial performance, patient demographics, service utilization, or population health status to other clinics or any objective standards

Some efforts made to benchmark performance against the outside world; Compares fi nancial performance, patient demographics, and/or service utilization with local clinics and/or consortia members on an irregular basis but at least once per year; No comparisons made to any objective standards, such as federal or local/regional primary care standards

Benchmarking of fi nancial performance, patient demographics, and/or service utilization occurs at least once per year, but driven largely by top management; Comparisons made to local/regional clinics as well as to other clinics statewide, but no comparisons made to any objective external standards (e.g., federal benchmarks, local/regional primary care standards, MGMA standards, etc.); Learnings from these activities shared with all staff and often used to make adjustments and improvements

Comprehensive external benchmarking part of the culture and takes place up to four times per year; Performance compared to objective external standards (e.g., federal benchmarks, local/regional primary care standards, MGMA standards, etc.) as well as to other clinics; Benchmarking used by staff in target-setting and daily operations; High awareness of how all activities rate against internal and external best-in-class benchmarks; Systematic practice of making adjustments and improvements on basis of benchmarking



e. N/A

Comments:

39

Action

Community Clinics InitiativeA Joint Project of Tides and The California Endowment

P.O. Box 29907

San Francisco, CA 94129-0903

(415) 561-6400

www.communityclinics.org

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