Microsoft Word - Volume 14.doc 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.