The Mission on the Wall and the Letter in the Mail: Assessing a Nonprofit Hospital's Culture Against Its Promise to the Poor
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Doctor of Nursing Practice Program, Aspen University
DNP855: Organizational Leadership and Systems-Based Practice
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Month Day, Year
The Mission on the Wall and the Letter in the Mail: Assessing a Nonprofit Hospital's Culture Against Its Promise to the Poor
An organization's mission statement describes what it says it values. Its culture, the shared assumptions that guide how people actually behave, may or may not match. The subject here is a composite nonprofit, faith-based community hospital, whose culture is tested against its own published mission using several sources of evidence, explains the gap with a framework for understanding organizational culture, and recommends steps a DNP-prepared nurse leader could take to bring practice closer to the promise.
The Mission
St. Brendan Medical Center, a composite 320-bed nonprofit hospital founded by a religious order, publishes the mission "to extend the healing ministry to all, with special concern for those who are poor and vulnerable." The mission appears in every lobby, in orientation, and on employee badges. The hospital is exempt from federal income and local property taxes on the basis of its community benefit.
Evidence From Practice
Four sources of evidence were examined. Financial data: charity care, the cost of care provided free or at reduced cost to patients who qualify, amounted to $1.40 of every $100 of total expenses last year. In a national analysis of 2018 Medicare cost reports, nonprofit hospitals spent on average $2.30 of every $100 of expenses on charity care, less than government hospitals ($4.10) or for-profit hospitals ($3.80), and the authors concluded that many nonprofit hospitals' charity care was not aligned with their favorable tax treatment (Bai et al., 2021). St. Brendan falls below even that nonprofit average.
Collections practices: a review of 50 accounts sent to an outside collection agency found that 19 belonged to patients whose recorded income would have qualified them for financial assistance. Front-line practice: in interviews, six of eight registration staff said they did not tell uninsured patients about financial assistance unless asked, because "that's the financial counselor's job," and the counselor works weekdays only. Clinical practice: nurses and chaplains described strong compassion for vulnerable patients at the bedside, including social work referrals and food vouchers.
Interpreting the Gap
Mannion and Davies (2018) describe organizational culture as the shared ways of thinking, feeling, and behaving in an organization, and they caution that culture is not uniform: organizations contain multiple subcultures, and what leaders espouse may differ from what staff experience. They also note that culture is shaped by what is measured, rewarded, and tolerated. St. Brendan illustrates each point. The clinical subculture enacts the mission at the bedside; the revenue cycle subculture enacts a different set of values, measured by days in accounts receivable and collection rates. Registration staff are rewarded for speed and accuracy of insurance data, not for connecting patients with assistance.
Schein and Schein (2017) describe the deepest level of culture as basic assumptions, beliefs so taken for granted that people do not question them. The assumption revealed here is that financial assistance is an exception to be applied for, rather than a right to be offered. The mission promises special concern for the poor; the collection letter tells the poor that the hospital's concern ends at discharge. Staff at every level believe in the mission; the systems they work within do not express it.
Why It Matters
The gap has consequences for patients, who may avoid needed care after receiving collection notices; for the organization, whose tax exemption depends on community benefit and whose reputation depends on trust; and for staff, whose sense of purpose is undermined when their work contradicts the mission they were hired to serve. For nurses in particular, seeing patients return sicker because they feared the bill is a source of moral distress. Several emergency nurses described patients who postponed follow-up for chest pain or diabetic wounds after receiving a collection letter from a previous visit, only to return by ambulance weeks later.
Where the Mission Is Alive
A fair assessment also records where culture and mission align, because those places show what the organization can build on. The emergency department's social worker keeps a small fund for bus passes and prescriptions, supported by staff donations. The oncology unit's nurses routinely connect patients with the drug manufacturer assistance programs that make treatment affordable. The chaplaincy service visits every patient without insurance within a day of admission. These practices share a feature the revenue cycle lacks: they were built by people who meet patients face to face and who see the consequences of cost. They also suggest a strategy. Pairing a registration supervisor with an emergency department social worker to redesign the first conversation about payment could carry the clinical subculture's assumption, that concern for the poor is part of care, into the part of the organization where it is currently missing. Culture change is more likely to succeed when it spreads a practice that already exists inside the organization than when it imports one from outside.
Recommendations for Nurse Leaders
A DNP-prepared nurse leader can help close the gap by working across subcultures. First, advocate for a presumptive eligibility process, using data already collected at registration to screen every uninsured or underinsured patient for financial assistance automatically. Second, propose that the hospital prohibit sending accounts to collections until assistance eligibility has been screened. Third, include a brief assistance script in registration training and add connection to assistance to registration staff performance measures. Fourth, bring nursing's bedside knowledge into the conversation by sharing cases of patients who delayed care. Fifth, recommend that charity care as a share of expenses be reported to the board alongside operating margin, so that the mission is measured as closely as finances.
Conclusion
St. Brendan's mission promises special concern for the poor, and its clinicians live that promise at the bedside. Its revenue systems, incentives, and measures, however, express a different assumption, leaving charity care below the national nonprofit average and sending eligible patients to collections. Assessing culture against the mission with evidence rather than impressions reveals the gap, and changing what the organization measures and rewards is the most direct way to close it.
References
Bai, G., Zare, H., Eisenberg, M. D., Polsky, D., & Anderson, G. F. (2021). Analysis suggests government and nonprofit hospitals' charity care is not aligned with their favorable tax treatment. Health Affairs, 40(4), 629-636. https://doi.org/10.1377/hlthaff.2020.01627
Mannion, R., & Davies, H. (2018). Understanding organisational culture for healthcare quality improvement. BMJ, 363, Article k4907. https://doi.org/10.1136/bmj.k4907
Schein, E. H., & Schein, P. A. (2017). Organizational culture and leadership (5th ed.). Wiley.
How this DNP 855 Module 3 example is structured
DNP855 Module 3 work often assesses culture against the mission the organization publishes. Aspen does not publish module deliverables, so check your classroom for the exact prompt. This example quotes the mission, gathers evidence from finances, records, interviews and clinical practice, interprets the gap with culture frameworks, states the consequences and recommends changes to measures and incentives.
DNP855 Module 3 questions, answered
What does DNP855 Module 3 usually ask for?
The module often asks you to assess an organization's culture against its published mission, using evidence rather than impressions. Aspen does not publish module deliverables, so your classroom's instructions govern.
How can culture be measured against a mission?
By comparing the mission's promises with evidence of actual practice: financial data, policies, records, interviews with staff at different levels and what the organization measures and rewards.
How much charity care do nonprofit hospitals provide?
A national analysis of 2018 Medicare cost reports found nonprofit hospitals spent on average $2.30 of every $100 of expenses on charity care, less than government ($4.10) or for-profit ($3.80) hospitals.
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