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Commonwealth:  A Journal of Political Science       Volume 14, Number 1      December 2008 
Special Policy Issue on Public Health             2008 PPSA/LORL, PA House of Reps.  ISSN 0890-2410 

 

 

 
A Health Promoting Hospital: A Strategy in 

the Re-Design of the U.S. Health Care System 
 
 

Matthew G. Masiello, MD, MPH 
Office of Community Health, Memorial Medical Center 

Windber Research Institute, Windber, Pennsylvania 
 

 
Introduction 

 
      In 2006, Memorial Medical Center of the Conemaugh Health System, 
located in Southwestern Pennsylvania, became the first hospital in the 
United States to apply and be accepted as a member of the World Health 
Organization Health Promoting Hospital Network. There are over 35 
European national and regional networks and more than 700 European 
hospitals participating in this international partnership. All member 
hospitals are asked to focus on promoting the health of patients and staff, 
make a commitment to the development of a formal health promotion 
infrastructure, and to organize and coordinate community and 
environmentally based health promotion/disease prevention programs. 
The United States health care system is experiencing many challenges 
and the development of a United States Health Promoting Hospital 
initiative should be a national priority. This Pennsylvania-based, health-
promoting hospital may serve as a model program in this effort.  
 
 

Health Promotion and the World Health Organization 

The World Health Organization (WHO) Health Promoting Hospitals 
(HPH) European pilot project took place from 1993 to 1997. This initial 
effort has grown to become the International Network of Health 
Promoting Hospitals (Garcia-Barber 2002). Working within this network, 
the member hospitals have resources available to them to develop a 
corporate philosophy, which concentrates on three areas of health 
promotion (HP): changing the organization to a health promoting setting 
which will allow for a more comprehensive approach to health 



126 A HEALTH PROMOTING HOSPITAL:  A STRATEGY IN THE  
 RE-DESIGN OF THE U.S. HEALTH CARE SYSTEM 
 
 

 

promotion and disease prevention from the perspective of hospital 
patients and staff; promoting the health of the community; and promoting 
the health of the environment (Groene 2002). 

The origins of this World Health Organization Health Promoting 
Hospital (WHO-HPH) initiative were established in international 
recommendations first outlined in the 1986 Ottawa Charter for Health 
Promotion. This HPH network is now a multi-hospital organization that 
sponsors international workshops and educational forums to support the 
development of hospital based health promotion programs and initiatives 
(Pelikan 2001). As defined by the WHO, health promotion allows for the 
establishment of a process of enabling people to increase control over, 
and improve, their health. As member countries of the WHO-HPH 
Network, many European, Asian, and Australian and Canadian hospitals 
have spent the better part of the past two decades identifying and 
reorganizing themselves as health promoting hospitals. The in-country 
networking among regional and national hospitals has allowed for a 
sharing of ideas, programs, and resources.                                                                

 

Health Promotion and the United States Health Care System 

Over the past two decades, numerous references in medical and 
public health literature have commented on the need for hospitals, health 
care systems, health care professionals, and public health institutions in 
the United States to evaluate their present strategies or develop new 
strategies to address the health issues of the communities in which they 
serve (Olden and Clement 2000; Ginn and Mosley 2004; and Hancock 
1999). Hancock states that hospitals “must develop a community 
conscience rather then an institutional loyalty” (Hancock 1986). Poland 
comments on the lack of scientific rigor regarding the presence and 
degree of analysis of hospital and community based collaborative efforts 
(2005). In 2004, the Institute of Medicine reported on the need for United 
States medical and nursing schools and schools of public health to 
develop a more symbiotic relationship to better address the health issues 
of the community (Institute of Medicine 2004). Similarly, and related to 
the role of the individual health care provider, the American Academy of 
Pediatrics endorsed the need for a more defined health promotion (HP) 



Matthew G. Masiello        127 
 
 

 

 

relationship between the community pediatrician and the community 
(American Academy of Pediatrics 1999).  

Health care costs continue to rise in the United States, and the money 
spent on health care is significantly higher as compared to other 
developed countries. This expenditure has failed to demonstrate any 
significant gains in the nation’s ability to increase life expectancy, reduce 
infant mortality, or increase access to a health care system. Significant 
public health issues, such as the present obesity epidemic, the epidemic 
of gun violence, and the inability to prevent as well as treat chronic 
illnesses, lack a formal national mandate or strategy. The recent concerns 
by the U.S. Congress regarding the absence or lack of well-defined 
charitable giving policies of non-profit hospitals also comments on the 
less than optimal health promotional strategies by many of our larger 
health care systems (Pear 2006). There have been numerous reviews on 
the status of United States hospital-based HP activities and the HP 
components used by these hospitals (Olden and Clement 2000). Ginn has 
outlined the steps necessary to become a HPH (Ginn and Moleley 2004). 
However, the United States health care and public health literature fails 
to identify a United States hospital or health care system that has 
formerly adopted the comprehensive World Health Organization (WHO) 
definition of “health” as being “the state of complete physical, mental, 
and social well-being and not merely the absence of disease or 
infirmity.” Until recently, it has been difficult to identify a United States 
health care system that has embarked on a formal approach to establish a 
comprehensive health promotion/disease prevention (HP/DP) 
environment for hospital staff, patients, or community. Historically, 
disease prevention and health education have served as marketing 
strategies for health care systems in their competitive attempts to 
promote clinical programs benefiting from the growth in preventable 
chronic diseases. 

 

A Health Promoting Hospital in the United States –  
A Model Program 

The following review of the health promoting hospital activities of a 
United States-based, regional tertiary health care center is timely. In 
1997, Memorial Medical Center, of the Conemaugh Health System 



128 A HEALTH PROMOTING HOSPITAL:  A STRATEGY IN THE  
 RE-DESIGN OF THE U.S. HEALTH CARE SYSTEM 
 
 

 

(CHS), located in Southwestern Pennsylvania, embarked on a process to 
develop and propagate a more formal public health advocacy profile. The 
CHS is a multi-hospital health care system serving a predominately rural 
population. In the early years of its existence, this public health activity 
took place in the form of a Child and Adolescent Health and Wellness 
Council. In 2004, the Board of Directors expanded the role of this 
initiative and created an Office of Community Health (OCH). At that 
time the physician director of the OCH was also identified as a vice-
president in the health care system. With growing support from the 
hospital administration, a regional managed care system, and various 
other funding sources, additional staff and programmatic activities have 
been realized. Currently, the OCH has a staff of three public health 
professionals, three registered nurses, an educator, and an administrative 
assistant. Numerous other health professionals are associated with the 
OCH through contractual arrangements. Over the years, nursing, social 
service, educational, and pharmacy graduate school students have served 
as public health interns.   

 The following review comments on the adult, child, and community 
HP/DP activity of this U.S. World Health Organization Health 
Promoting Hospital.  

 

A Model U.S. World Health Promoting Hospital and Children 

 From 1999 to the present, the OCH at Memorial Medical Center, and 
the school districts of the region, have partnered in the development of 
school based health promotion/disease prevention (HP/DP) programs. 
Programmatic monitoring and evaluation are key components of these 
initiatives (Windsor 2004). Primary and secondary health data, specific 
to the schools and community of Cambria County, the largest county in 
the region, have been gathered and analyzed over this period of time. 
Based on this data and with community participation, health issues were 
discussed and prioritized. This OCH has now been able to introduce 
evidence-based health promotion/disease prevention programs to all of 
the public schools and the majority of the private schools in the county 
(CDC 2004; Pennsylvania Youth Survey 2002, 2004, 2006). 

School-based injury prevention programs allowed for the 
participation of over 10,000 children, or 90%, of the identified children 



Matthew G. Masiello        129 
 
 

 

 

based on age and program requirements. This injury prevention initiative 
now includes a teen component, scheduled child passenger safety clinics, 
and school-based bike safety clinics. An increase in knowledge and a 
decrease in risky behaviors have been documented, as well as an increase 
in the number of adolescents wearing seat belts and safety gear. In 1999, 
the OCH introduced the evidenced-based Olweus Bullying Prevention 
program to the schools of the county. Approximately 20,000 children 
have participated in this program with a documented improvement in the 
reporting of bullying and an increasing number of children coming to the 
assistance of a classmate during an observed act of bullying. We also 
documented an increase in the number of students feeling more 
comfortable and enjoying their time in school. In 2006, a regional 
managed care organization granted approximately $2 million to the 
OCH. This funding will allow for the expansion of this bullying 
prevention/cessation program throughout western and central 
Pennsylvania, potentially affecting the lives of over 200,000 children and 
the adults they encounter on a daily basis. In addition to the 
abovementioned initiatives and, again, based on local health data, 
programs addressing the elevated childhood dental cavity rate and the 
obesity epidemic have been developed and introduced into the 
community. With funding from the Pennsylvania Tobacco Fund, the 
OCH developed an innovative program that allowed for the development 
of a combined car passenger safety seat and smoking cessation program. 
In the attempt to cumulatively evaluate the various school based HP/DP 
programs of the OCH, as well as assist the schools in developing 
federally mandated school health councils, the OCH developed a 
Coordinated Regional School Health Council (WIC 2004). The school 
districts of the tri-county area actively support this effort. 

 
A Model U.S. World Health Promoting Hospital and Adults 

In 2004, when the hospital Board of Directors approved the 
development of an OCH, the scope of activity expanded beyond children. 
The mandate was to develop a more formal infrastructure to address the 
health issues of adults and community. A county-based Center for 
Disease Control Behavioral Risk Factor Survey was used as resource to 
gather primary health data. This health data allowed for the identification 
and prioritization of health needs from a larger segment of the county 



130 A HEALTH PROMOTING HOSPITAL:  A STRATEGY IN THE  
 RE-DESIGN OF THE U.S. HEALTH CARE SYSTEM 
 
 

 

population. In 2005, a formal worksite wellness program was initiated 
for the 4,000 employees of the principle system hospital. Incentivized 
employee health risk assessment (HRA) surveys were made available, 
with the data compiled and analyzed by trained public health 
professionals from this hospital based OCH. A campus-wide tobacco ban 
was a key component of this initiative. A Tobacco Ban Policy Guide was 
developed as part of this hospital-based worksite wellness effort. At the 
request of approximately 60 United States hospitals and several 
European health care professionals and hospitals, the guide has had a 
level of distribution greater then originally expected. Subsequent to these 
requests, an on-line survey was developed to monitor the use, and any 
potential impact, of this HP/DP tobacco prevention/cessation guidebook. 
The public health analyst from the OCH has developed numerous online, 
internet-driven surveys to monitor and evaluate programmatic activities. 
This service, for a nominal fee, has been made available to other hospital 
and community groups. A worksite wellness program, for local 
businesses, is now available for implementation. 

 With the oversight of this OCH, a comprehensive employee blood-
screening program has also been developed. This screening activity, 
which serves as a free benefit to the hospital employee, has been 
extensively analyzed, especially as it relates to follow up by the primary 
care physician. A cadre of monitored, nutritional, and fitness programs 
have been developed and made available to the hospital employees. 
Transfat has been eliminated from the hospital cafeteria and other dietary 
changes have been made due to the efforts of the OCH and in-hospital 
partners. Continued monitoring of the employee HRA surveys, as well as 
the hospital based worksite wellness programs, has documented costs as 
it relates to unhealthy employee practices as well as the potential for 
savings secondary to positive changes in employee behavior and health. 
Specifically, a potential savings of $300,000 to $700,000 per year may 
be realized with a decrease in the number of smoking breaks by the 
hospital staff. A formal report from the OCH has been made available to 
the hospital administration summarizing the programmatic activity of the 
worksite wellness program. This report included the results of the 
employee HRA survey, with an analysis of participating employee risk 
factors. It also comments on the potential for savings and the need for 
continued support and expansion of the program. 



Matthew G. Masiello        131 
 
 

 

 

A Model U.S. World Health Organization Health Promoting 
Hospital and the Community 

In 2004, a system-wide Acommunity benefit inventory@ was designed 
and implemented by the OCH to better identify those hospital based 
individuals and groups who were offering a varying array of formal and 
informal health and wellness programs to the community (Boscarino 
2004). As is typical in most hospitals, these hospital-based individuals or 
groups essentially function as independent entities and usually exist 
without any formal strategies to qualitatively monitor or measure for 
positive change in behavioral or health impact. Thus, a health care 
system may find it difficult to convey a clear and concise message to the 
community of exactly what the system is contributing to the community 
in the form of wellness/educational activities or as charitable giving. This 
availability of this inventory was considered timely by those in hospital 
finance who are now assigned to gather this type of activity secondary to 
congressional oversight of non-profit hospital community giving. 

As a response to the “brain drain” phenomenon experienced by many 
rural communities and the difficulty hospitals and communities have in 
attracting young physicians to a community, the Associate Director of 
the OCH, along with a community physician developed an innovative 
and popular Mentoring in Medicine (MIM) program. This summer 
“internship program” allows college and pre-medicine students to 
participate in an organized physician office and hospital-based activity 
that exposes the students to the real world of medicine. It also allows the 
hospital the opportunity to encourage these young physicians of the 
future to return to practice medicine in the community in which they 
were raised.  A stipend is provided to relieve the student of the anxiety of 
finding summer employment. If the student expresses an interest to 
return to the area, the hospital will also provide financial support for 
school loan repayments. A public health internship program is also 
available that allows nursing, pharmacy, social work, educational, and 
public health students the opportunity to have a “hands-on” experience in 
formal community based, health promotion programmatic activities. One 
former intern was recently accepted as a Center for Disease Control 
Fellow. 



132 A HEALTH PROMOTING HOSPITAL:  A STRATEGY IN THE  
 RE-DESIGN OF THE U.S. HEALTH CARE SYSTEM 
 
 

 

The OCH has produced multiple programmatic reports and an annual 
Community Health Profile and Needs Assessment, which includes 
measurable impact data, comments on the health issues of the region, and 
summaries of the hospital and community-based HP/DP programs 
developed to address these issues. The programs of this OCH have been 
presented at national and international forums. 

In recent years, a new and critical role for the health care system has 
come to fruition in the area of community (disaster) preparedness. In the 
local planning process, there is often an adequate level of emergency 
management expertise but with minimal public health input. The local 
Emergency Medical Service system has recently accepted an OCH 
prepared School and Business All Hazard Plan, which is based on current 
state and national guidelines.  

 

Discussion and Recommendations on Becoming a HPH 

The development of a United States-based Health Promoting 
Hospital infrastructure, modeled after and in partnership with the WHO-
HPH initiative, would be a viable and potentially cost effective approach 
to address the many concerning issues of a struggling United States 
health care system. A health promoting hospital could serve as both a 
community and regionally based public health program and policy 
advocate. In addition, this level of public health positioning by regional 
hospitals could dramatically enhance the efficiency and impact of local, 
state run public health offices (Weber 2007). 

Based on the history and success of this United States-based hospital, 
located in Johnstown, Pennsylvania, in advancing a health promoting 
hospital environment, the following recommendations for a hospital 
setting are offered for review and consideration: 

 Identify a public health trained individual to coordinate the overall 
HP/DP plan for the hospital/health care system. More credibility, as 
well as community and institutional support, may be recognized if 
this individual is also a physician. Preferably, this individual should 
report directly to the Chief Executive Officer of the hospital/hospital 
system. 



Matthew G. Masiello        133 
 
 

 

 

 Develop a programmatic/research partnership with a local school of 
public health. 

 Identify hospital funds or outside grant funding that will allow for 
the hiring of support staff.  

 Identify focus groups, and school and community based health 
surveys that will allow the hospital to improve its knowledge of the 
health issues of the community. 

 Support the development of institutional and community-based 
health advisory committees. The direct involvement of the hospital 
administrative leadership and Board of Directors will more likely 
allow for an enhanced propagation of a HP/DP agenda (Institute of 
Medicine 1997). 

 Incorporate public health theories and practices, as well as the WHO-
HPH Standards and Strategies, into the design and implementation of 
the HP/DP programs and work towards official membership in the 
WHO-HPH network. 

 Incorporate monitoring and evaluation tools into the program design 
process and attempt to identify a public health professional or 
institution that will assist in this effort. 

 Develop an inventory of hospital-based individuals and groups 
offering wellness and educational programs to the community as 
well as inventory any monies offered to the community as charitable 
giving.   

 Develop a chartable giving policy committee consisting of 
representatives from the hospitable administration, Board of 
Directors, and hospital-based public health representatives.  

 

Summary 

This successful hospital-based Office of Community Health should 
serve as a model program for other health care systems that wish to be 
identified as health promoting hospitals (HPH). This OCH has been 
successful in assisting in the development of positive behavioral and 
health change for large segments of the population in its service area. It 



134 A HEALTH PROMOTING HOSPITAL:  A STRATEGY IN THE  
 RE-DESIGN OF THE U.S. HEALTH CARE SYSTEM 
 
 

 

has also been successful in identifying costs associated with identified 
health risks of the hospital employee population as well as savings 
associated with well developed worksite wellness initiatives.  

The ultimate goal of a health promoting hospital would be to move 
from the historic, non-monitored, non-evaluated hospital, or community 
wellness and educational programs, to formal health promotion/disease 
prevention initiatives, which measure impact and are sustainable.  The 
practices and recommendations made available by the WHO-HPH 
network and the related goals of Healthy People 2010 should also serve 
as benchmarks and important resources to United States hospitals and 
health care systems. The success of this United States-based program 
should prompt some level of national discussion regarding a new but 
necessary approach to a struggling United States health care system. 
Having a formal health promotion oriented approach to health care in all 
of those United States hospitals receiving state or federal support should 
be the ultimate national health care goal. A United States partnership 
with the World Health Organization Health Promoting Hospital Network 
would also serve as a timely and positive international effort.  

 

References 

Academy of Pediatrics. Committee on Community Health Services, Pediatrics Vol. 103, 
No. 6, June 1999. 

Boscarino, J.A., and J. Chang. “Nontraditional Services Provided by Nonprofit and For-
Profit Hospitals: Implications for Community Health.” Journal of Healthcare 
Management, Vol. 45, No.2, March/April 2000, p. 132. 

Center for Disease Control Behavioral Risk Factor Survey. Cambria County-2004. 

Garcia-Barbero, M. “Health Promotion in Hospitals: Evidence and Quality Management. 
Country Policies, Systems and Services, Division of Country Support,” WHO 
Regional Office for Europe. May 2005, p. 1-2. 

Ginn, G.O. and C.B. Moseley. “Community Health Orientation, Community-based 
Quality Improvement, and Health Promotion Services in Hospitals.” Journal of 
Healthcare Management, Vol. 49, No. 5, Sept/Oct 2004, p. 303-306. 

Groene, Oliver. “Health Promotion in Hospitals - From Principles to Implementation.” 
“Health Promotion in Hospitals: Evidence and Quality Management.” Country 
Policies, Systems and Services, Division of Country Support, WHO Regional Office 
for Europe. May 2005, p. 2-17. 



Matthew G. Masiello        135 
 
 

 

 

Hancock, T. “Creating Health and Health Promoting Hospitals: A Worthy Challenge for 
the Twenty-First Century.” International Journal of Health Care Quality Assurance 
Incorporating Leadership in Health Services, Vol. 12, No.1, 1999, p. 14-17. 

Hancock, T. “Creating a Healthy Community: The Preferred Role for Hospitals.” 
Dimension, Sept. 1986, p. 22-23. 

Institute of Medicine. “Improving Health in the Community: A Role for Performance 
Monitoring.” National Academy Press 1997: p. 40. 

Institute of Medicine. “Who Will Keep the Public Healthy? Educating Public Health 
Professionals for the 21st Century.” The National Academy Press, 2003. 

Olden, P.C. and D.G. Clement. “The Prevalence of Hospital Health Promotion and 
Disease Prevention Services: Good News, Bad News and Policy Implications.” The 
Milbank Quarterly, Vol. 78, No. 1, 2000, p. 136-142.  

Weber, David. “American Exceptionalism.” Hospitals and Health Networks. April 24, 
2007. 

Pear, R. “Nonprofit Hospitals Face Scrutiny Over Practices.” New York Times, Sunday, 
March 19, 2006. 

Pelikan, J., K. Krajic, and C. Dietscher. “The Health Promoting Hospital (HPH): Concept 
and Development.” Patient Education and Counseling. Vol. 45 (4), 2001, p. 239-243. 

Pennsylvania Youth Survey B Cambria County. 

Poland, Blake, et al. “Working at the Margins” or “Leading from Behind?:” A Canadian 
Study of Hospital-Community Collaboration. Health and Social Care in the 
Community, Vol. 13(2), p. 125-135.   

WIC. Child Nutrition and Women Infant Child Reauthorization Act of 2004. Public Law, 
p. 108-265. 

Windsor R. Evaluation of Health Promotion, Health Education and Disease Prevention 
Programs, 2004, p.14-16. 

World Health Organization.  www.euro.who.int/AboutWHOPolicy. 


