









































October 2017 Volume  2

HEALTH IMPACT ASSESSMENTS IN HOSPITAL COMMUNITY 
BENEFIT: A MULTIPLE CASE STUDY OF THE USE OF HIAs AT 

CHILDREN’S HOSPITAL COLORADO

Gregory Tung, PhD, MPH; Venice Williams, MPH

Abstract: 

Objective:  To explore the use of Health Impact Assessments (HIAs) within nonprofit hospital community benefit 
activities.

Methods:  We conducted case studies of three HIAs that were done in collaboration with Children’s Hospital 
Colorado as part of the hospital’s community benefit portfolio. We used data from key informant interviews and 
documents to construct individual explanatory case studies and we then conducted cross-case analysis to compare 
and contrast across cases. 

Results:  Hospital staff stated that HIAs provided Children’s Hospital Colorado with a transparent and systematic 
process for generating evidence-based recommendations with community and stakeholder feedback within the 
hospital’s community benefit activities. HIAs were used to generate recommendations to inform community ben-
efit planning activities and to generate public policy recommendations to enhance child health. The case studies 
highlighted several issues that need to be addressed in order to further explore and advance the use of HIAs within 
hospital community benefit activities including: use of HIAs on explicit health issues, hospital capacity for HIAs, 
potentially broadening the scope of HIA recommendations, and the use of HIAs to generate recommendations 
from broad priority areas.

Conclusion: HIAs have the potential to meet the need for established, evidence-based, and stakeholder respon-
sive tools and processes to be used within nonprofit hospital community benefit activities. In meeting this need, 
the non-profit hospital community benefit area can potentially serve as a major institutional home for the practice 
of HIAs. There is a need for additional research and practice innovation to further explore and refine the use of 
HIAs within nonprofit hospital community benefit activities. 

i 



The Use of  HIAs at Children’s Hospital Colorado Tucg; Williams

2

Introduction
The use of Health Impact Assessments (HIAs) in the 
United States (US) has grown rapidly over the last 
decade (Dannenberg, 2016). HIAs have been used in 
a broad range of sectors including built environment, 
transportation, housing, energy etc. (Dannenberg, 
2016). There is now growing evidence and consensus 
that HIAs are an important tool to introduce health op-
timizing recommendations in a variety of program and 
policy settings (National Research Council, 2011). The 
funding and creation of incentives and infrastructure 
or institutionalization of HIAs is now a major factor in 
the more widespread use of HIAs in the US (Morley, 
Lindberg, Rogerson, Bever, & Pollack, 2016).  

While a number of organizations such as the Na-
tional Research Council have highlighted HIAs as 
a valuable tool for “integrating health implications 
into decision-making” and as a tool that fits within 
the broader Health in All Policies (HiAP) movement, 
there has been limited institutionalization of HIAs in 
the US (National Research Council, 2011). There are, 
however, some examples of the HIA process being 
institutionalized on a small scale including legisla-
tion in Washington State that required an HIA to be 
conducted on a bridge replacement in Seattle (Seattle 
and King County Public Health, 2017). Two other 
interesting examples of HIA institutionalization are 
the Massachusetts Healthy Transportation Compact 
and the funding of HIAs in Alaska through the state’s 
natural resources permitting process (Anderson, Yoder, 
Fogels, Krieger, & McLaughlin, 2013; Massachusetts 
Department of Transportation, 2016). Both of these 
examples represent important advancements in the 
institutionalization of HIAs in the US. Additional 
avenues to institutionalize HIAs are needed in order to 
further advance the practice and realize the potential 
population health benefits of HIAs.  

The use of HIAs within nonprofit hospital community 
benefit activities holds promise for the more wide-
spread institutionalization of HIAs in the US (Tung 
& Williams, 2017). Nonprofit hospital community 

benefit activities are those that are required by the In-
ternal Revenue Service (IRS) of nonprofit hospitals to 
justify their nonprofit status (Rosenbaum & Margulies, 
2011). Nonprofit hospital community benefit activities 
have traditionally focused on the provision of chari-
ty care but a number of changes associated with the 
Patient Protection and Affordable Care Act (ACA) 
have pushed nonprofit hospitals to focus more on pop-
ulation and public health (Rosenbaum & Margulies, 
2011; Young, Chou, Alexander, Lee, & Raver, 2013). 

In 2012, nonprofit hospitals in the US reported spend-
ing more than $60 billion on community benefit 
(Leider et al., 2016). The redirection of even a small 
portion of this spending toward more population and 
public health oriented activities could have a signifi-
cant impact on the public’s health (Corrigan, Fisher, 
& Heiser, 2015). This shift in focus from charity care 
towards population health represents a tremendous 
opportunity for the integration of hospitals and public 
health systems, but what community benefit spending 
levels should be and what specific activities hospitals 
should engage in have yet to be established (Leider et 
al., 2016). This has created a need for additional tools 
and processes to guide nonprofit hospital investments 
and activities to enhance public health (Abbott, 2011).   

This need for tools and process to guide hospital com-
munity benefit activities can potentially be served in 
part by HIAs in at least two ways.  First, there is now a 
requirement for nonprofit hospitals to conduct commu-
nity health needs assessments (CHNAs) and develop 
corresponding implementation plans (Health Affairs, 
2016). Implementation plans are intended to guide and 
outline specific community benefit activities to address 
identified community health needs. HIAs can provide 
a transparent and systematic process and be used by 
nonprofit hospitals to generate recommendations to 
inform implementation plans. The HIA process is 
consistent with the IRS requirements that implemen-
tation plans (1) address priority areas identified in the 
CHNA, (2) be evidence informed, and (3) incorporate 
community and stakeholder feedback.



The Use of  HIAs at Children’s Hospital Colorado Tucg; Williams

3

Second, HIAs can provide a mechanism for hospitals 
to directly engage in policy and make recommenda-
tions to enhance population and public health.  An 
HIA used in this way would serve the role of an activ-
ity that directly benefits population health as opposed 
to a tool to guide community benefit planning and in-
vestment. HIAs used to generate policy recommenda-
tions can specifically address an identified community 
health need(s) and provide estimates of the anticipated 
population health impacts. 

To further explore the potential for the use of HIAs 
within hospital community benefit activities, we 
conducted a pilot consisting of three HIAs in col-
laboration with Children’s Hospital Colorado. These 
three HIAs were embedded within various aspects of 
Children’s Hospital Colorado’s community benefit 
activities and hospital staff were involved in various 
rules for all of the HIAs conducted. This pilot effort 
was supported with funding from the Health Impact 
Project, a collaboration of the Robert Wood Johnson 
Foundation and The Pew Charitable Trusts. 

The three HIAs conducted were: (1) the Colorado 
Marijuana and Child Abuse and Neglect HIA, (2) 
the Colorado Springs Pilot HIA, and (3) the Colora-
do Child and Adolescent Behavioral Health HIA. To 
explore the experience of using these HIAs within the 
context of nonprofit hospital community benefit activ-
ities, we conducted case studies informed primarily by 
key informant interviews of individuals who partic-
ipated in various aspects of the HIAs and our own 
experience as HIA practitioners/researchers. 

Methods
From December 2016 to March 2017, we conducted 
case studies with both explanatory and explorato-
ry components for each of the three HIAs that were 
conducted as part of this pilot (Yin, 2009). The focus 
of our case studies was to identify and explain the 
impacts from each HIA and explore the utility of each 
HIA within the hospital community benefits context. 
After all of the pilot HIAs were complete, we conduct-

ed a total of 17 key informant interviews with various 
stakeholders (e.g. HIA team members, hospital staff, 
community stakeholders, etc.) who participated in 
the HIAs. These interviews were guided by a theme-
based interview guide. Six key information interviews 
were conducted to inform the Colorado Marijuana and 
Child Abuse and Neglect HIA case study, seven key 
information interviews were conducted to inform the 
Colorado Springs Pilot HIA, and four key informant 
interviews were conducted to inform the Colorado 
Child and Adolescent Behavioral Health HIA. 

All interviews were audio recorded and memos were 
then written to synthesize information and abstract key 
themes from each interview by the interviewer. When 
appropriate and available, documents such as legis-
lative records were used as an additional data source 
for the cases. We used a data triangulation and expla-
nation building approach to synthesize the data from 
the interview memos and documents (Yin, 2009). This 
involved using multiple data sources (e.g. multiple 
interviewer perspectives) to explain and explore the 
phenomenon of interest and iteratively developing an 
explanation of key events and their linkages for each 
case (Yin, 2009). As an additional validation step, 
interview participants were given an opportunity to 
review the case studies and any statements attributed 
to them. The Institutional Review Board at the Univer-
sity of Colorado reviewed and approved our research 
protocol. 

Results
Here we report our results organized by case. Each 
case begins with a brief overview of the HIA, fol-
lowed by impacts, if any, from the recommendations. 
We then present perspectives of community stakehold-
ers shared on the HIA process, followed by perspec-
tives shared by Children’s Hospital Colorado staff on 
the utility of the specific HIA within the community 
benefit context.



The Use of  HIAs at Children’s Hospital Colorado Tucg; Williams

4

Colorado Marijuana and Child Abuse and Neglect 
Health Impact Assessment

This HIA was led by the Colorado School of Public 
Health and conducted in collaboration with Children’s 
Hospital Colorado and the Kempe Center for the 
Prevention and Treatment of Child Abuse and Neglect. 
The motivation for this HIA was to improve child 
and family health by generating recommendations on 
state policies surrounding how marijuana use should 
be handled in Child Welfare decision-making. More 
specifically, this HIA was scoped to generate recom-
mendations for mandatory reporting and Child Welfare 
screening decisions when marijuana is involved and 
improve consistency in practice across the state of 
Colorado, while reducing the number of families un-
necessarily interfacing with the Child Welfare system. 

Impacts

The HIA recommendations informed the develop-
ment of House Bill (HB) 16-1385, which updated and 
modernized the definition of child abuse or neglect in 
the Colorado Children’s Code as it relates to substanc-
es. During the 2016 legislative session this bill passed 
through the Colorado House of Representatives, but 
did not pass through the Colorado Senate before the 
close of that year’s legislative session. Although HB 
16-1385 did not pass in 2016, there is interest among 
stakeholders involved with the HIA to continue work 
in future legislative sessions. 

In addition, one of the key stakeholders involved with 
the HIA, the executive director of Illuminate Colorado 
– a strategic partnership of the established nonprofits: 
Colorado Alliance for Drug Endangered Children, Pre-
vent Child Abuse Colorado, Colorado Chapter of the 
National Organization on Fetal Alcohol Spectrum Dis-
order, and more recently Sexual Abuse Forever End-
ing – noted the potential for the HIA recommendations 
to inform future training and education for mandatory 
reporters as well as Child Welfare caseworkers. She 
develops and assists in the delivery of Child Welfare 

curriculum for the state of Colorado and expressed 
interest in using the HIA recommendations to develop 
new materials on marijuana/substance abuse training. 

Another key stakeholder, the state Child Welfare 
associate director stated that the state is embarking on 
modernizing the Trails database system, a statewide 
automated case management system that includes 
Child Welfare, Child Care, and Youth Corrections 
data, to better track substance use; which aligns with 
one of the HIA’s data recommendations. This change 
will help with aggregating data around when and 
where substance use occurs within the Child Welfare 
context, inform counties on how to target their ser-
vices and supports, and to develop prevention strate-
gies in the future. 

Despite the ongoing policy efforts, stakeholders that 
we interviewed said that practice among mandatory 
reporters and Child Welfare screeners in the state had 
not changed since the HIA recommendations were 
finalized.

Stakeholder perspectives

Interview participants for this HIA included two 
executive directors of institutional partners, two 
county-level human services division administrators, 
a state-level Child Welfare associate director, and the 
contracted meeting facilitator for the HIA. All partic-
ipants had no previous HIA experience.  There was 
consensus among the interviewees that the main ob-
jective of the HIA was achieved, which was to develop 
evidence-informed recommendations to assist man-
datory reporters and Child Welfare screeners in their 
decision-making when marijuana is involved.  

Relationship building among diverse stakeholders was 
expressed as one of the most effective elements of the 
HIA. Interview participants also stated that the stake-
holder engagement process in the HIA was effective: 
formal stakeholder meetings created a forum for 
different perspectives to be incorporated in interpret-



The Use of  HIAs at Children’s Hospital Colorado Tucg; Williams

5

ing the implications for the current state of science on 
the HIA recommendations. The perspectives included 
spanned the spectrum from child abuse pediatricians to 
marijuana patient advocates and child welfare workers 
at both the state and local levels.  

While interviewees agreed that the HIA produced 
valuable recommendations, some stated that the delin-
eation between developing the HIA recommendations 
and drafting policy language was unclear. This HIA 
developed two tiers of recommendations: the first tier 
focused on recommendations for actual practice and 
the second tier focused on updating legislation to be 
consistent with the practice recommendations. Many 
interviewees stated that they were uncertain as to 
where the HIA formally ended and policy and advoca-
cy efforts began. Furthermore, some participants felt 
that the policy efforts that came out of the HIA were 
beyond the original scope; such that a couple partic-
ipants stated that they were initially unaware that the 
HIA recommendations would lead to proposed legisla-
tion. 

Interviewees also stated that the HIA team could have 
improved on the dissemination of the HIA findings 
and recommendations. The final HIA report was 
shared with all stakeholders who participated in the 
process, but not formally shared with or presented to 
Colorado Department of Human Services, other coun-
ty Child Welfare departments, or mandatory reporters 
such as those in hospital systems. One county Child 
Welfare administrator added that there has been little 
discussion on the issue of marijuana once the HIA was 
completed, which she found disappointing, given the 
amount of time and energy she had dedicated to the 
work.

Children’s Hospital Colorado Perspectives

Leadership and staff at Children’s Hospital of Colora-
do stated that while they did view this HIA positively 
and as being consistent with the organization’s over-
all community benefit objective of improving child 

health, they ultimately viewed it as motivated more by 
opportunity and need than being clearly aligned with 
the hospital’s formal community benefit obligations. 
They noted that this HIA was not embedded within the 
hospital’s formal community benefit activities in that it 
was not used to inform implementation plans and was 
not directly aligned with community health priorities 
identified in the hospital’s formal CHNAs. Despite 
this, hospital representatives noted that HIAs could be 
used opportunistically like this in order to make policy 
recommendations to benefit public health and that 
HIAs used in this way fit within the larger umbrella of 
community benefit activities. 

Colorado Springs Pilot Health Impact Assessment

This HIA was conducted to generate recommenda-
tions to inform Children’s Hospital Colorado’s formal 
community benefit implementation plan in Colorado 
Springs, CO. This effort was led by the Colorado 
School of Public Health and conducted in collabora-
tion with Children’s Hospital Colorado’s Child Health 
Advocacy Institute. This HIA was scoped to address 
health priority areas identified in CHCO’s CHNA in El 
Paso County. More specifically, it focused on mental 
health and physical activity in school-aged children. 
This HIA generated recommendations for Children’s 
Hospital Colorado to invest in and advance school-
based health centers as part of the hospital’s future 
community benefit activities. 

Impacts

The HIA recommendations informed the development 
of Children’s Hospital Colorado’s 2016 Community 
Health Action Plan for El Paso County (Children’s 
Hospital Colorado, 2016). The report specifically 
highlights the school setting as a primary place for 
programming to address the top six health priorities 
for the region, particularly that “CHCO will spear-
head the creation of school resource centers that will 
provide: integrated primary care services, including 
mental and oral health; community support services; 



The Use of  HIAs at Children’s Hospital Colorado Tucg; Williams

6

professional development and technical assistance 
for school personnel; and will inform targeted policy 
initiatives” (Children’s Hospital Colorado, 2016).   

Stakeholder perspectives

Interview participants for this HIA included three 
representatives from Children’s Hospital Colorado, 
two school-based health center employees, a public 
health planner from the local health department, and 
the externally-contracted meeting facilitator. None of 
the interviewees had previous experience with HIAs. 
All interview participants stated that the HIA’s major 
objective was to determine CHCO’s role to address 
identified health priorities in the Colorado Springs 
region.

Non-hospital interview participants stated that the hos-
pital’s desire to collaborate with the community was 
evident. Participants shared that the HIA process also 
allowed for community voice and feedback to deter-
mine where the hospital’s community benefit invest-
ment should go. Regarding the development of new 
partnerships, many participants felt that the HIA gave 
the hospital good exposure to the Colorado Springs’ 
experience and the region’s uniqueness. 

The HIA’s stakeholder engagement process helped 
to build stronger relationships between the hospital 
and local community as well as between local stake-
holders. Interviewees stated that stakeholder meetings 
were productive with the right individuals represented; 
that the conversations facilitated a sharing of experi-
ences, ideas, and resources between groups; that good 
questions were asked; and appreciation among stake-
holders to be able to share their perspectives and have 
an open dialogue about the health priorities in their 
community. Several stakeholders stated that that they 
now wanted to become more involved in the health 
of the community and partake in more face to face 
interactions with other organizations that focused on 
the shared goal of improving child health. Ultimately, 
all participants shared that the HIA created a better 

understanding of the community in Colorado Springs 
and brought together a stakeholder group to discuss 
what role the hospital could play in the community. 

Despite these successes, there were several challeng-
es shared by participants. First, many stakeholders 
and even one of the hospital staff members who was 
a formal member of the HIA team were not aware of 
the impact of the HIA recommendations. They were 
not aware of how and if the recommendations were 
being adopted by the hospital and incorporated into 
its implementation plan. Several stakeholders stated 
that they received a draft report of the HIA, but did 
not realize that the process had been completed. In 
fact, many participants felt that the HIA process ended 
abruptly with no formal closure; a couple felt that 
there could have been a final group meeting to “wrap 
up loose ends” as there was lag time between the last 
meeting and the distribution of the draft report. 

Another challenge expressed by some participants 
related to the scope of the HIA. The scope of the 
HIA was refined and focused on school-based health 
centers based in large part on the perspectives and 
preferences of the hospital. A couple of participants 
expressed that although this narrowing of scope result-
ed in good recommendations that could be supported 
by the hospital, they would have appreciated a broader 
assessment of the priority areas and determination of 
scope with greater stakeholder input. 

Children’s Hospital Colorado Perspectives

Hospital representatives, some of whom directly en-
gaged as part of the HIA team, expressed enthusiasm 
for this HIA and stated that using the HIA process to 
inform implementation planning provided an estab-
lished and transparent process to make evidence-based 
recommendations with stakeholder and community 
input. They noted that many hospitals struggled to 
use information gathered from the community health 
needs assessment process to develop implementa-
tion plans and activities. Hospital representatives 



The Use of  HIAs at Children’s Hospital Colorado Tucg; Williams

7

stated that the HIA process validated the community 
health needs assessment findings and brought things 
into alignment with local stakeholders to inform the 
broader implementation plan. Hospital representatives 
noted that the HIA allowed the hospital to build new 
community partnerships and relationships including 
with those who were not directly involved in the HIA 
process.

Hospital staff also stated that the implementation 
of HIA recommendations has been difficult and not 
yet fully developed due to the lack of staff, a physi-
cal structure, experience, and hospital resources for 
execution. Some hospital representatives expressed 
concern that working with community stakeholders 
through the HIA process might create expectations 
that would be difficult for the hospital to meet. One 
hospital staff member felt that incorporating hospital 
employees responsible for developing the implementa-
tion plan in the HIA process from the beginning would 
be beneficial and that setting clear expectations and 
communication channels early on in the process would 
be helpful for future HIAs used in this manner. 

Children’s Hospital Colorado’s community benefit 
team also noted that the recommendations that came 
out of the HIA process were very detailed and spe-
cific and not necessarily calibrated well with the IRS 
community benefit implementation plan requirements. 
There were initial discussions that recommendations 
from the HIA might serve as the required imple-
mentation plan for the hospital in its entirety. As the 
HIA process progressed, hospital staff stated that the 
implementation plan needed to be broader in that it 
needed to address all of the identified community 
health priorities and outline more general strategies 
that would then need to be further refined when specif-
ic community benefit investments and activities would 
be decided on. As a result, recommendations from the 
HIA were broadened and made less specific when they 
were incorporated into the hospital’s implementation 
plan.  

Colorado Child and Adolescent Behavioral Health 
HIA

This HIA was policy focused and motivated by Chil-
dren’s Hospital Colorado’s implementation plan which 
stated that the hospital would utilize policy levers to 
address child and adolescent behavioral health – an 
identified community health priority area. This effort 
was initiated as a collaboration between the Colorado 
School of Public Health, Children’s Hospital Colora-
do’s Child Health Advocacy Institute, the University 
of Colorado’s Farley Health Policy Center, and the 
Keystone Policy Center. This HIA was intended to 
generate recommendations to the state of Colorado on 
how to implement an anticipated competitive grants 
program that would be made possible through a pro-
posed tobacco tax ballot initiative. The objective of 
this proposed competitive grants program was to en-
hance child and adolescent behavioral health services 
in the state of Colorado.

Impacts

This HIA was not completed as the tobacco tax ballot 
initiative intended to fund the proposed grants pro-
gram did not pass during the November 2016 elec-
tions. At the time the HIA was in the assessment phase 
and after consultation with the HIA and the stakehold-
er team, a collective decision was made to terminate 
the HIA as the decision point was longer present. 

Stakeholder perspectives

Interview participants for this HIA included a govern-
ment affairs specialist and the executive director for 
advocacy at Children’s Hospital Colorado, a policy 
director at the Farley Health Policy Center, and a 
senior policy analyst from the Keystone Policy Center. 
All but one had previous HIA experience. In addition, 
all interview participants were in agreement that the 
HIA’s major objective was to develop recommenda-
tions for a grants program targeted at enhancing child 
and behavioral health services in Colorado that was to 



The Use of  HIAs at Children’s Hospital Colorado Tucg; Williams

8

be funded by the proposed tobacco tax ballot initiative. 

This HIA was conceptualized as flowing directly from 
the hospital’s implementation plan which highlighted 
among other approaches, that child and adolescent 
behavioral health would be addressed through avail-
able policy approaches. As such, the initial scope of 
the HIA was very broad and was not initially specific 
to the tobacco tax funded grants program that became 
the eventual focus of the HIA. The initial broad scope 
was described both positively and negatively by many 
participants. The government affairs specialist felt that 
as collaboration between the different entities was still 
being built, the HIA seemed to move slowly initially. 
The Farley policy director agreed with this perspective 
and felt the scope of the HIA could have been refined 
earlier in the process. 

Ultimately, through an iterative screening and scop-
ing process, the HIA team assessed various potential 
policy approaches and eventually decided to focus 
the HIA on the tobacco tax initiative. The rationale 
was that it was likely the initiative would pass and 
that there was a real opportunity for evidence-based 
recommendations to be adopted in how the resulting 
program would be administered. In addition, the cam-
paign director for the tobacco tax initiative was also an 
HIA team member. The broader HIA team viewed this 
involvement as increasing the likelihood that HIA rec-
ommendations would be adopted. Despite this percep-
tion and consensus to focus on the tobacco tax initia-
tive, all interview participants shared that the HIA was 
inherently challenging, given that the outcome of the 
ballot initiative – that would fund and create the grants 
program – was uncertain. 

Interview participants stated that having an HIA team 
member who was well integrated into the tobacco tax 
campaign was essential to the process. It was also 
noted that this team member had the relationships with 
the key players statewide given her professional back-
ground and involvement in the tobacco tax initiative. 
This resulted in a stakeholder engagement process that 

members of the HIA team viewed as including most, if 
not all, of the politically influential organizations that 
are active in child and adolescent behavioral health in 
Colorado. These groups included: the state health de-
partment, major state foundations, and representatives 
from the governor’s office. 

However, the campaign director and HIA team mem-
ber stated that there was initial skepticism among 
stakeholders around the authenticity of the HIA pro-
cess and that some foundations wanted to complete 
this process separately and on their own. Overall, the 
political landscape along with relationships among 
stakeholders involved in the tobacco tax initiative and 
administering agencies were expressed as challenging 
for her to balance. 

All interview participants stated that if the tobacco 
tax initiative had passed, the recommendations from 
the HIA would have had an excellent chance of being 
adopted. Furthermore, all participants agreed that the 
right stakeholders were at the table and engaged in 
the HIA process. The ultimate failure of the tobac-
co tax initiative during the November 2016 election 
effectively made the HIA irrelevant. After prolonged 
discussions, the HIA team eventually made a decision 
to terminate the process. 

Children’s Hospital Colorado Perspectives

Leadership and staff at Children’s Hospital Colorado, 
who were directly involved as part of the HIA team, 
stated that they had high expectations for this HIA. 
They saw this opportunity as a proof of concept for the 
use of HIAs, as a tool that the hospital could use in the 
future to make recommendations and inform policy as 
part of the organization’s community benefit portfolio. 
They also stated that this HIA was a test for the hospi-
tal to take a more proactive role in policy engagement, 
as opposed to a more reactive stance that the hospital 
has adopted in the past. They also stated that they 
viewed this HIA as being very well aligned with the 
hospital’s CHNA priority areas and implementation 



The Use of  HIAs at Children’s Hospital Colorado Tucg; Williams

9

plan strategies. The defeat of the tobacco tax initiative 
was described by hospital representatives as unfortu-
nate, but they echoed the opinions of other stakehold-
ers and stated that in their opinion the recommenda-
tions that would have come out of the HIA process 
would have had a good chance of being adopted if the 
initiative had passed. 

Hospital representatives also stated that this HIA in 
particular gave them a greater appreciation for what 
was involved in conducting an HIA and the potential 
for the process in the future. The hospital’s govern-
ment affairs specialist stated that while he still viewed 
HIAs as a useful tool to make policy recommenda-
tions, he also now better understood how time and re-
source-intensive the process is. He noted that for much 
of the policy work that the hospital engages in an HIA 
is more than is necessary. He went on to state that an 
HIA would be most useful to make policy recommen-
dations when there was (1) a need for more rigorous 
assessment of scientific evidence and data and/or (2) 
the need for a very systematic and structured stake-
holder engagement process to build consensus among 
diverse participants.

Discussion
This pilot, the three HIAs that were conducted in 
collaboration with Children’s Hospital Colorado as 
part of the organization’s community benefit activities, 
has highlighted the potential, limitations, and oppor-
tunities for improvement in the ongoing use of HIAs 
within nonprofit hospital community benefit. There 
is a clear need for processes and tools to generate 
evidence-based recommendations to guide hospital 
community benefit activities in various ways. 

The focus of this work was to explore the use of HIAs 
within hospital community benefit. In many ways 
the lessons learned from previous HIA practice and 
evaluations were consistent and apply to our experi-
ence such as the importance of authentic stakeholder 
engagement and the challenges of timing and working 
on legislation (Dannenberg, 2016).  In other ways, the 

community benefit context created unique challenges 
and considerations.

Our experience reinforces the potential for HIAs to 
be used as a tool within hospital community benefit 
in at least two ways, (1) embedded within nonprofit 
hospitals’ formal community benefit assessment and 
planning activities and (2) to generate evidence-based 
policy and program recommendations to address iden-
tified community health priority areas. 

Our experience also highlights several issues that need 
to be addressed in order to further advance the use of 
HIA within hospital community benefit activities in-
cluding: use of HIA on explicit health issues, hospital 
capacity for HIA, potentially broadening the scope of 
HIA recommendations, and the use of HIA to generate 
recommendations from broad priority areas.

Nonprofit hospital community benefit activities have 
an explicit health focus and the HIA field has histori-
cally conceptualized the use of the tool as most ben-
eficial when used on topics and sectors where there 
is typically not an explicit health focus (The Pew 
Charitable Trusts, 2016). The rationale for this is that 
in these areas, there are important health implications 
that are not typically factored into decision making 
and HIAs can provide an avenue to include important 
health considerations that would not otherwise be in-
cluded. This is true, but HIAs can still provide signif-
icant benefits to important decisions in health explicit 
areas. All of the HIAs that we engaged in for this pilot 
were on health focused topics. The systematic HIA 
process provided structure that resulted in recom-
mendations developed based on more methodical and 
rational incorporation of scientific evidence and stake-
holder perspectives than if an HIA was not conducted. 
In addition, use of HIAs on health explicit topics could 
help to more systematically incorporate certain criteria 
that go beyond the total health impacts such as equity 
of anticipated impacts. 

Our pilot also highlights the need for capacity build-



The Use of  HIAs at Children’s Hospital Colorado Tucg; Williams

10

ing to conduct HIAs if there is additional growth in 
the use and institutionalization of HIAs within hos-
pital community benefit. This could take the form of 
training and capacity building among hospital staff 
involved with community benefit. The technical needs 
of hospitals could also be served by outside consul-
tants or via collaborations with health departments or 
other institutions with HIA knowledge and expertise. 
Given the potential for hospital community benefits 
to serve as a mechanism for enhancing hospital and 
public health collaboration, the potential use of HIAs 
collaboratively between hospitals and health depart-
ments could serve the technical needs of hospitals and 
help build collaborations in population heath efforts 
between hospitals and health departments (Abbott, 
2011). 

In our pilot, we found that the detailed and specific 
recommendations that were generated by the HIA 
process was not always well calibrated with the needs 
of community benefit planning activities such as IRS 
required implementation plans. In our experience, 
Children’s Hospital Colorado took the recommen-
dations from the HIAs we conducted in Colorado 
Springs, CO and broadened them to be incorporated 
into the hospital’s formal implementation plan in the 
region. Despite this, Children’s Hospital Colorado ex-
pressed enthusiasm for the HIA process and expressed 
that there was clear value in using HIAs in this way. 
Specific and actionable recommendations are consid-
ered best practice in HIA and are a great strength of 
the process but there might be utility in adapting the 
HIA process to generate broader recommendations for 
use by hospitals in their community benefit planning 
activities. This is an area where future research and 
practice innovation is needed. 

All of the HIAs used in this pilot generated recom-
mendations from broad priority areas and were not 
based on an already existing program or policy pro-
posal. Traditionally, HIAs have been used to generate 
health maximizing recommendations when an exist-
ing proposal has already been put forward (The Pew 

Charitable Trusts, 2016). Existing practice already 
has precedents for the use of HIA when there is not 
an existing proposal in place, but based on our pilot ef-
forts, HIAs used in this manner hold the most promise 
for use by nonprofit hospitals as part of their commu-
nity benefit activities given the need to address broad 
community health priorities. This does raise questions 
about adherence to best practices and whether or not 
these types of changes would make the process differ-
ent enough to no longer qualify as an HIA.  

Limitations
This pilot and the corresponding case studies included 
only three HIAs conducted in collaboration with one 
hospital. The stakeholders we interviewed were only 
a subset of all stakeholders involved in each HIA and 
there could have been different perspectives that we 
did not capture. What we learned from this pilot and 
the implications are related to context and may not be 
generalizable to other nonprofit hospitals with differ-
ent settings and circumstances. 

Conclusion
HIAs or HIA-like processes can potentially help 
meet the need for established, evidence-based, and 
stakeholder responsive tools and processes to be used 
within nonprofit hospital community benefit activities. 
In meeting this need, the nonprofit hospital commu-
nity benefit area could potentially serve as a major 
institutional home for the practice of HIA. There is a 
need for additional research and practice innovation to 
further explore and refine the use of HIA and/or HIA- 
like processes within nonprofit hospital community 
benefit activities.  



The Use of  HIAs at Children’s Hospital Colorado Tucg; Williams

11

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The Use of  HIAs at Children’s Hospital Colorado Tucg; Williams

12

CORRESPONDING AUTHOR
Gregory Tung, PhD, MPH
Assistant Professor
Department of  Health Systems, Management Policy
Program for Injury Prevention, Education and Research (PIPER)
Colorado School of  Public Health
13001 E. 17th Place, MS B119
Aurora, CO 80045
gregory.tung@ucdenver.edu

CHIA Staff:

Editor-in-Chief  
Cynthia Stone, DrPH, RN, Professor, Richard M. Fairbanks School of  Public Health, Indiana University-Purdue 
University Indianapolis

Journal Manager 
Angela Evertsen, BA, Richard M. Fairbanks School of  Public Health, Indiana University-Purdue University 
Indianapolis

Chronicles of  Health Impact Assessment Vol. 2 (2017) DOI: 10.18060/21517
© 2017 Author(s): Tung, G.; Williams, V.;
       This work is licensed under a Creative Commons Attribution 4.0 International License


