Ascension Columbia St. Mary's Hospital Ozaukee

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Community Benefit Reports

Learn how our programs and services help improve the overall health of the communities we serve, and provide quality healthcare to all who need it.

Community Health Needs Assessment (CHNA) Overview

The Community Health Needs Assessment for Ascension Columbia St. Mary’s Hospital Ozaukee represents analysis for the primary service area of the hospital, which is defined as the Ozaukee County area. The demographics for the area are described in the Ozaukee County Secondary Data Report on pages 1 and 2.

This geographic area is served by two health systems: Ascension Columbia St. Mary’s (CSM) and Aurora Health Care. Children’s Hospital of Wisconsin serves as a secondary and tertiary resource for the county. These health systems, along with Wheaton Health Care and Froedtert Health System are part of the Milwaukee Health Care Partnership (MHCP), a collaborative to improve health care for underserved people.

Community Health Needs Assessment Process

Representatives from the Milwaukee Health Care Partnership (MHCP) had collaborated to develop a process for the Community Health Needs Assessment (CHNA) of Milwaukee. The process was also used in the assessment of Ozaukee County. The Ozaukee County Health Department was an important participant in the Ozaukee CHNA process. The Ozaukee CHNA used the same multi-level assessment process from the Milwaukee experience. The first level consisted of a survey of county residents regarding their health status, health access and perception of community needs. The survey questions developed for Milwaukee were used for the Ozaukee process. A consultant was contracted to perform the survey using techniques that the consultant had used in similar surveys over ten years. The survey process has been reviewed for scientific reliability. The survey was conducted over the telephone to cell phone owners and “land-line” telephone owners. The survey received input from 400 people. Survey results were reported in the CHNA Ozaukee County Community Health Survey Report and the CHNA Ozaukee County Community Health Survey Summary.

The second level of data gathering was performed by the Center for Urban Population Health (CUPH) as secondary data gathering about community needs based on public health and other publicly available information. Data was gathered and summarized in the CHNA Ozaukee Secondary Data Report.

The third level of data was gathered through a key stakeholder interview process. CSM and Aurora leaders had agreed upon key stakeholders in the community. A survey tool that had been developed by the MHCP members was used for Ozaukee interviews. Five interviews were conducted of public health, academic and community leaders. CUPH was contracted to gather and summarize the key stakeholder interviews. CUPH produced the CHNA Ozaukee Key Informant Summary Report.

The CHNA process was designed to gather data and input from all available resources in an organized and collaborative manner. The participating health system staff do not believe that any data gaps exist.

Each of the CHNA reports was developed in a.pdf format able to be posted on the Ascension Columbia St. Mary’s website as well as other MHCP health system and public health websites.

Ascension Columbia St. Mary’s Review and Approval Process

The Ascension Columbia St. Mary’s Policy #305208 Community Health Improvement Process describes the infrastructure for the Community Health Improvement Process. An Ozaukee Community Benefit Committee is primarily responsible for developing and approving the CHNA and developing, approving and monitoring the Community Health Improvement Plan. The committee is led by the CSM Director of Community Services and reports to the Vice President of Mission and Advocacy. The CHNA and CHIP are reviewed by the CSM Board of Directors and included in the health system’s Integrated and Strategic Operational and Financial Plan (ISOFP). The ISOFP includes approval of the health system budget, including the expenses for CHIP programs and services. The ISOFP is also communicated to and approved by the health system’s national sponsor, Ascension Health.

The Community Health Improvement Committee reviewed the CHNA to determine those needs most appropriate to be addressed by CSM Ozaukee by considering attributes of the Community Service Philosophy and history of programs serving the community. Community Services Department staff prepared a set of plans and metrics to assist in tracking progress of community health improvement work. The Community Health Improvement Committee made edits to the draft and approved a Community Health Improvement Plan (CHIP) for submission to the CSM Board. A combined report was developed to show the connection between the community needs and community health improvement plan and metrics. The Community Health Improvement Strategy, containing the CHNA and CHIP, was approved by the CSM Board on April 16, 2016.

The CHNA and CHIP will be posted on the CSM website on June 3rd in a format suitable for downloading by an interested party. Additionally, the CSM Community Services Committee will provide written copy of the reports for those without access to printed copy via the internet. The website will contain the annual reports for each current year and will be updated appropriately.

Monitoring and Reporting

The CSM Ozaukee Community Health Improvement Committee develops a Measures and Timeline document for its use in monitoring the progress of Plan elements. The Committee meets every other month to review progress. Additionally, the Committee provides input on measures of progress and strategies for improvement.

The Committee provides input to the development of the Ozaukee Community Health Improvement Report which produces specific information about costs and outcomes of CSM’s contribution to community health across categories as described by the Catholic Health Association and the IRS 990 Report in Section H.


  • Ozaukee CHIP