This website is intended for healthcare professionals only.

Newsletter      
Hospital Healthcare Europe
HOPE LOGO
Hospital Healthcare Europe

Health promotion in hospital quality and governance systems: addressing the missing link

Oliver Groene
1 January, 2008  

Many hospitals all over Europe struggle to comply with standards and ­regulations, and health promotion is often seen as a luxury. A strategy that can benefit patients, staff, the hospital as an ­organisation and the community is outlined in this article.

Oliver Groene
Programme
Manager, Quality of Health Systems & Services
World Health
Organization
Regional Office for Europe

Oana Groene
Trainer, Intercultural communication and mediation QUORUM

Our experience is that the concept of health promotion in healthcare is often misunderstood. Health professionals are convinced that most of their activities (except paperwork) fall into this category. But health promotion literature aims at a broader understanding. It focuses on both individuals and contextual factors that shape individuals’ actions with the aim to prevent and reduce ill-health and improve wellbeing. In the following paragraphs we will draw a distinction between different approaches which are often mistakenly used concurrently (see Table 1).
Typical medical activities or interventions such as immunisations or beta-blocker prescriptions after acute myocardial infarction are disease prevention processes. Smoking cessation clinics reflect ­behavioural measures aimed at health education. Health promotion, however, goes beyond medical ­approaches directed at curing individuals. An example would be a comprehensive programme for immigrants ­requiring hospital admission for conditions that could have been prevented had they been able to understand the written instructions provided at a previous visit. Health promotion aims at understanding the contextual factors which shape an individual’s behaviour and hopes to design interventions that fit an individual’s environment Health promotion in perspective
One of the most frequent objections we hear is: “Yes, that might all be important, but is it really the role of the hospital to engage in health promotion?” However, many people argue that health promotion can benefit patients, staff, the community and also the organisation itself.
From the perspective of clinical effectiveness, safety and patient-centred care, it should be ­emphasised that nowadays chronic diseases account for most hospitalisations, which often require lifestyle changes or adherence to complicated drug and nutrition regimens. There is evidence that patients are more receptive to advice and counselling in situations of experienced ill-health.2 Therefore, there is an opportunity to make patients understand the need for behavioural change while in hospital – an opportunity that does not exist during the next consultation with the general practitioner, when the patient has stabilised and returned to work and/or their usual routine. However, research shows that most patients in Europe are only moderately satisfied with their doctor’s communication and listening skills. Apparently doctors do not explain situations in a way patients can understand, nor do they listen or give adequate time for questions (see Table 2).3
The lack of satisfaction among patients regarding the communication skills of their doctors is a ­concern, considering that good communication with the patient is a key prerequisite to achieving high- quality, safe and patient-centred care (see Box 1).
Health promotion also yields benefits from a human resource perspective. With the increasing ­migration of health professionals, hospitals have to compete for the best staff. Hospitals that offer a safe and health-promoting working environment and involve staff in creating such an environment will be more successful in attracting and maintaining staff. Hospital finances will benefit directly from such effects by reducing expenditure on recruitment and induction trainings. There is also evidence that workplace health promotion reduces costly short-term absenteeism.7 A major field of research has developed around so-called “magnet” hospitals (ie, hospitals that attract better staff for their reputation as being a good workplace and achieve better care and patient satisfaction because of their staff). Investment in staff thus leads to a virtuous cycle of recruiting better staff, producing better care, improving work routines and again ­recruiting better staff.8,9 The nature of the patient’s condition and the way most hospital services are reimbursed means that health promotion pays off for the hospital. Many health promotion interventions are ­inexpensive and can reduce length of stay and complications while increasing patient ­satisfaction. Researchers from Denmark showed in various randomised controlled trials that complication rates and length of stay after surgery were shortened when smokers or heavy drinkers underwent ­cessation ­programmes before surgery.10,11 Furthermore, patients who feel that they experienced good communication or that they were involved in the care process have a higher satisfaction level and are more likely to recommend the hospital to their friends and families.

Advances in linking health promotion and quality management
There are many quality issues in healthcare that go beyond the traditional clinical way of thinking about disease, and hospitals appear to perform worse on these issues as compared with clinical issues.12 Keeping in mind the potential benefits of health promotion, the question can be asked as to whether quality management systems address health promotion issues sufficiently. We carried out a review of the standards used by major accreditation bodies in 2003 and found that the issue of health promotion is only addressed marginally, if at all. Nevertheless, there are many issues addressed in accreditation systems that are linked to enabling the organisation to engage in health promotion, such as standards regarding patients and family rights, continuity in the provision and transfer of information, or family and patient education. 
To fill the gap in existing accreditation systems we developed a practical tool to assess to what extent health promotion is currently institutionalised in hospitals and to help management to plan ­evidence-based health promotion interventions. It is based on a set of standards and indicators that were extensively piloted in hospitals participating in the World Health Organization Health Promoting Hospitals
Network.13 Going a step further, we started a pilot project at the Immanuel Diakonie Group in Berlin, Germany, to integrate the standards for health promotion into the holdings’ organisational policy. Using a combined approach of the European Foundation for Quality Management Model together with the balanced scorecard, we integrated the health promotion perspective into all 20 strategic objectives of the organisation.14 All decision-making in the organisation is now linked to the organisation’s objectives and summarised in a strategy map that illustrates for every staff member the relationship between objectives and key organisation processes.
Since organisations are not only driven by internal objectives but also by external pressures, we ­carried out an international pilot test for a coding system for health promotion activities. Our study showed that the codes were considered to be applicable and useful in different contexts and consultation with experts showed that there are no technical reasons not to include such codes in revisions of existing coding or reimbursement systems.15 Based on the health promotion codes, indicators could be computed (such as the proportion of stroke patients with assessment of smoking status documented or the proportion of stroke patients being smokers that were referred to a cessation clinic) based on which incentives could be given for achieving certain quality targets.

Conclusion
We wanted to show in this brief paper that quality and health promotion cannot be separated. The health promotion literature contains many studies illustrating how health promotion can improve quality of care. In order to systematically implement the results of such studies, health promotion needs to be embraced by hospital quality management systems.
Since our first review of quality standards, many changes have occurred in quality systems and a stronger focus is being placed worldwide on involving the patient in supporting self-management. Among the most interesting innovations in this field are the use of tracer methodologies to assess whether care is provided according to the comprehensive needs of chronic patients or the focus on communication skills of doctors and health literacy of patients. According to leading authority Professor Michael E Porter (Harvard Business School), institutions that not only measure their success in terms of survival and recovery rates of patients but also aim at ­reducing the long-term consequences of therapy will survive in the competitive hospital environment.16 Health ­promotion in this context is not a luxury, as it provides a toolbox for hospitals to ensure good quality of care and competitiveness in the future.

References
1. Groene O. Health promotion in hospitals – from principles to ­implementation. In:  Groene O, Garcia-
Barbero M, editors. Health promotion in hospitals: evidence and quality management. ­Copenhagen: World Health Organization; 2005. p. 3-21.
2. Downie RS, et al. Health promotion: ­models and values. Oxford: Oxford University Press; 1996.
3. Coulter A, et al. Euro J Public Health
2005;15(4):355-60.
4. Coulter A. Health Expect 2006;9(3):205-6.
5. Entwistle VA. Differing perspectives on patient involvement in patient safety. Qual Saf Health Care 2007;16(2)82-3.
6. “What did the doctor say?” Improving health literacy to protect patient safety. The Joint
Commission; 2007. Available at:
www.jointcommission.org/PublicPolicy/health_literacy.htm
7. Sounan C, et al. ­Relationships among work climate, ­absenteeism, and salary insurance in teaching hospitals. Healthc Manage Forum 2005;18(3):35-8.
8. Scott JG, et al. J Nurs Adm 1999;29(1):9-19.
9. Havens DS, Aiken L. J Nurs Adm 1999;29(2):14-20. Erratum in: J Nurs Adm 1999;29(4):5.
10. Moller AM, et al. Lancet 2002;359:114-7.
11. Tonnesen H, et al. BMJ 1999;318:1311-6.
12. McGlynn EA, et al. N Engl J Med 2003;348(26):2635-45.
13. Groene O, editor. Implementing health promotion in hospitals: manual and self-
assessment forms.
Copenhagen: WHO; 2006. Available at:
www.euro.who.int/
document/E88584.pdf
14. Brandt E, et al. Implementing the health promoting hospitals strategy through a combined application of the EFQM excellence model and the balanced scorecard. In: Groene O, Garcia-Barbero M, editors. Health promotion in hospitals: evidence and quality management.  Copenhagen: WHO; 2005: p. 84-102.
15. Tønnesen H, et al.
Evaluating a model for the systematic ­documentation of hospital-based health promotion activities: results from a multi-centre study. In press 2007.
16. Porter ME. On competition. Presented at the WHO Congress, Washington, 2007. Available at: www.world congress.com/events/nw700/highlights