Using the ‘SMART’ Framework to Analyze Quality of Nonprofit Hospitals’ Implementation Plans

Background In 2010, the Affordable Care Act required nonprofit and government hospitals with 501(c)3 status to produce Community Health Needs Assessments (CHNA) and Implementation Plans (IP) detailing strategies to address community needs on a triennial basis. This rule was intended to redirect charity spending from individual patients toward community health. Internal Revenue Service (IRS) regulations simply require that IPs exist with few required stipulations. Analyses around the time the rule was enacted found implementation strategies, the individual components of the IP, to be of variable quality without concrete goals. Given the few specifications required by the IRS, we sought to assess the content and quality of IPs, for the most recent iteration of reports. Methods We randomly selected 2 nonprofit hospitals per state (including the District of Columbia) from a list of Medicare-participating hospitals in 2023. We reviewed their IPs and CHNAs dated 2021–2024. Using a framework for effective goal setting, we developed a codebook to assess the quality of implementation strategies based on Specificity, Measurability, Achievability, Relevance, and Timing (SMART).We assessed implementation strategies for identification of quantifiable metrics, novelty of activities, goal-setting, and activity evaluation over time. Results Of the 102 hospitals, 101 (99%) CHNAs and 97 (975) IPs were retrievable online. 47 IPs (48%) did not identify a single quantifiable metric to track progress and 63 (65%) did not establish a measurable goal. Only 41 (42%) articulated a commitment to creating or expanding existing initiatives. One-quarter did not recount progress made since the prior IP, despite a requirement to do so. Conclusions Hospitals largely published IPs, but their quality varied markedly. Implementation strategies were often too vague to be measurable, and the documents did not reliably report on progress made. The inability to enforce implementation strategies may undermine the policy’s intent.