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Putting HPH Policy into Action
Draft version, 13.05.2003
Product of the WHO Working Group „Putting HPH Policy into Action“
Commissioned by WHO-European Office for Integrated Health Care Services, Barcelona:
Mila Garcia-Barbero
Co-ordinated by the WHO Collaborating Centre for Health Promotion in Hospitals and Health
Care team:
Jürgen M. Pelikan (co-ordinator)
Working group members:
Elimar Brandt, Christina Dietscher (LBI core team), Carlo Favaretti, Pascal Garel, Bernhard J. Güntert,
Oliver Gröne (WHO Barcelona), Karl Krajic (LBI core team), Ann Kerr, Elisabeth Marty-Tschumy,
Peter Nowak (LBI core team), Raymond McCartney, Yannis Tountas
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Contents
CONTENTS ........................................................................................................................................................... 2
1
INTRODUCTION ....................................................................................................................................... 5
1.1
1.2
ON THE PAPER....................................................................................................................................... 5
THE (STRATEGIC) CONTEXT OF HPH..................................................................................................... 5
2 WHICH DISTINCTIONS ARE RELEVANT FOR PLANNING HEALTH PROMOTION
STRATEGIES IN HOSPITALS? AN INTRODUCTION TO THE CONCEPT ....................................... 7
2.1
HEALTH PROMOTION IN AND BY HOSPITALS – FOR WHOM? TARGET GROUPS........................ 7
2.2 HEALTH PROMOTION SERVICES AND HEALTH PROMOTING SETTINGS – HEALTH OUTCOMES
AND HEALTH IMPACT ............................................................................................................................ 8
2.3 HEALTH PROMOTION AS QUALITY STRATEGY VS. PROVISION OF SPECIFIC HEALTH
PROMOTION SERVICES........................................................................................................................... 8
2.4
EMPOWERMENT AS HEALTH PROMOTION CORE CONCEPT – WHAT FOR? .................................. 9
2.5
COMBINING DISTINCTIONS: SIX GENERAL HEALTH PROMOTING CORE STRATEGIES .......... 10
2.6
HEALTH PROMOTION PRINCIPLES IN THE CORE STRATEGIES ................................................... 11
2.7
18 CORE STRATEGIES – AN OVERVIEW ........................................................................................ 11
3
PATIENT ORIENTED CORE STRATEGIES ...................................................................................... 13
3.1
CORE STRATEGY PAT-1: EMPOWERMENT OF PATIENTS FOR HEALTH PROMOTING SELF CARE / SELF
MAINTENANCE / SELF-REPRODUCTION IN THE HOSPITAL .......................................................................... 13
3.1.1
Objectives of strategy PAT-1: ....................................................................................................... 13
3.1.2
Indications for strategy PAT-1 ...................................................................................................... 13
3.1.3 Implementation of strategy PAT-1 ........................................................................................... 13
3.2 CORE STRATEGY PAT-2: EMPOWERMENT OF PATIENTS FOR HEALTH PROMOTING PARTICIPATION AND COPRODUCTION IN TREATMENT AND CARE ................................................................................................... 15
3.2.1
Objectives of strategy PAT-2: ....................................................................................................... 15
3.2.2
Indications for strategy PAT-2: ..................................................................................................... 15
3.2.3
Implementation of strategy PAT-2: ............................................................................................... 15
3.3 CORE STRATEGY PAT-3: DEVELOPMENT OF HOSPITAL INTO A HEALTH PROMOTING AND EMPOWERING
SETTING FOR PATIENTS ............................................................................................................................ 16
3.3.1
Objectives of strategy PAT-3 ......................................................................................................... 16
3.3.2
Indications for strategy PAT-3: ..................................................................................................... 16
3.3.3
Implementation of strategy PAT-3: ............................................................................................... 16
3.4 CORE STRATEGY PAT-4: EMPOWERMENT OF PATIENTS FOR HEALTH PROMOTING MANAGEMENT OF
CHRONIC ILLNESS ..................................................................................................................................... 18
3.4.1
Objectives of strategy PAT-4: ....................................................................................................... 18
3.4.2
Indications of strategy PAT-4: ...................................................................................................... 18
3.4.3
Implementation of strategy PAT-4: ............................................................................................... 18
3.5 CORE STRATEGY PAT-5: EMPOWERMENT OF PATIENTS FOR HEALTH PROMOTING LIFE STYLE
DEVELOPMENT ......................................................................................................................................... 19
3.5.1
Objectives of strategy PAT-5: ....................................................................................................... 19
3.5.2
Indications for strategy PAT-5: ..................................................................................................... 19
3.5.3
Implementation of strategy PAT-5: ............................................................................................... 19
3.6 CORE STRATEGY PAT-6: PARTICIPATION IN HEALTH PROMOTING AND EMPOWERING COMMUNITY
DEVELOPMENT FOR PATIENTS .................................................................................................................. 20
3.6.1
Objectives of strategy PAT-6: ....................................................................................................... 20
3.6.2
Indication – why? .......................................................................................................................... 20
3.6.3
Implementation of strategy PAT-6: ............................................................................................... 20
4
STAFF ORIENTED CORE STRATEGIES ........................................................................................... 21
4.1
CORE STRATEGY STA-1: EMPOWERMENT OF STAFF FOR HEALTH PROMOTING SELF CARE / SELF
MAINTENANCE / SELF-REPRODUCTION IN THE HOSPITAL .......................................................................... 21
4.1.1
Objectives for strategy STA-1........................................................................................................ 21
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4.1.2
Indications for strategy STA-1 ...................................................................................................... 21
4.1.3
Implementation of strategy STA-1 ................................................................................................. 21
4.2 CORE STRATEGY STA-2: EMPOWERMENT OF STAFF FOR HEALTH PROMOTING PARTICIPATION / COPRODUCTION IN TREATMENT AND CARE ................................................................................................... 23
4.2.1
Objectives of strategy STA-2: ........................................................................................................ 23
4.2.2
Indications for strategy STA-2: ..................................................................................................... 23
4.2.3
Implementation of strategy STA-2:................................................................................................ 23
4.3 CORE STRATEGY STA-3: DEVELOPMENT OF HOSPITAL INTO A HEALTH PROMOTING AND EMPOWERING
SETTING FOR STAFF .................................................................................................................................. 25
4.3.1
Objectives of strategy STA-3: ........................................................................................................ 25
4.3.2
Indications for strategy STA-3? .................................................................................................... 25
4.3.3
Implementation of strategy STA-3:................................................................................................ 25
4.4 CORE STRATEGY STA-4: EMPOWERMENT OF STAFF FOR HEALTH PROMOTING MANAGEMENT OF
OCCUPATIONAL ILLNESS .......................................................................................................................... 27
4.4.1
Objectives of strategy STA-4: ........................................................................................................ 27
4.4.2
Indications of strategy STA-4:....................................................................................................... 27
4.4.3
Implementation of strategy STA-4:................................................................................................ 27
4.5 CORE STRATEGY STA-5: EMPOWERMENT OF STAFF FOR HEALTH PROMOTING LIFE STYLE
DEVELOPMENT .................................................................................................................................... 28
4.5.1
Objectives of strategy STA-5: ........................................................................................................ 28
4.5.2
Indication for strategy STA-5:....................................................................................................... 28
4.5.3
Implementation of strategy STA-5:................................................................................................ 28
4.5.4
Examples of (good or best) practice .............................................................................................. 29
4.6 CORE STRATEGY STA-6: PARTICIPATION IN HEALTH PROMOTING AND EMPOWERING COMMUNITY
DEVELOPMENT FOR STAFF ........................................................................................................................ 29
4.6.1
Objectives of strategy STA-6: ........................................................................................................ 29
4.6.2
Indications for strategy STA-6: ..................................................................................................... 29
4.6.3
Implementation of strategy STA-6:................................................................................................ 29
5
COMMUNITY ORIENTED CORE STRATEGIES .............................................................................. 30
5.1
CORE STRATEGY COM-1: EMPOWERMENT OF COMMUNITY FOR ADEQUATE HEALTH PROMOTING ACCESS
TO THE HOSPITAL ..................................................................................................................................... 30
5.1.1
Objectives of strategy COM-1:...................................................................................................... 30
5.1.2
Indications for strategy COM-1: ................................................................................................... 30
5.1.3
Implementation of strategy COM-1: ............................................................................................. 30
5.2 CORE STRATEGY COM-2: EMPOWERMENT OF COMMUNITY FOR HEALTH PROMOTING CO-PRODUCTION IN
TREATMENT AND CARE AFTER DISCHARGE .............................................................................................. 31
5.2.1
Objectives of strategy COM-2:...................................................................................................... 31
5.2.2
Indications for strategy COM-2: ................................................................................................... 31
5.2.3
Implementation of strategy COM-2: ............................................................................................. 31
5.3 CORE STRATEGY COM-3: DEVELOPMENT OF HOSPITAL INTO A HEALTH PROMOTING AND EMPOWERING
SETTING FOR THE COMMUNITY ................................................................................................................ 33
5.3.1
Objectives of strategy COM-3:...................................................................................................... 33
5.3.2
Indication – why? .......................................................................................................................... 33
5.3.3
Implementation of strategy COM-3: ............................................................................................. 33
5.4 CORE STRATEGY COM-4: EMPOWERMENT OF COMMUNITY FOR HEALTH PROMOTING MANAGEMENT OF
CHRONIC ILLNESS ..................................................................................................................................... 35
5.4.1
Objectives of strategy COM-4:...................................................................................................... 35
5.4.2
Indications for strategy COM-4: ................................................................................................... 35
5.4.3
Implementation of strategy COM-4: ............................................................................................. 35
5.5 CORE STRATEGY COM-5: EMPOWERMENT OF COMMUNITY FOR HEALTH PROMOTING LIFESTYLE
DEVELOPMENT ......................................................................................................................................... 36
5.5.1
Objectives of strategy COM-5:...................................................................................................... 36
5.5.2
Indications of strategy COM-5: .................................................................................................... 36
5.5.3
Implementation of strategy COM-5: ............................................................................................. 36
5.6 CORE STRATEGY COM-6: PARTICIPATION IN HEALTH PROMOTING AND EMPOWERING COMMUNITY
DEVELOPMENT FOR THE GENERAL POPULATION ....................................................................................... 37
5.6.1
Objectives of strategy COM-6:...................................................................................................... 37
5.6.2
Indications for strategy COM-6: ................................................................................................... 37
5.6.3
Implementation of strategy COM-6: ............................................................................................. 37
6
HPH THEMATIC POLICIES: ................................................................................................................ 38
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7 CHALLENGES AND BASIS FOR IMPLEMENTING HEALTH PROMOTING HOSPITAL
STRATEGIES ................................................................................................................................................ 40
7.1
7.2
7.3
7.4
7.5
7.6
7.7
7.8
7.9
CHALLENGES FOR IMPLEMENTATION OF HEALTH PROMOTION STRATEGIES IN HOSPITALS .................. 40
PRACTICAL EXPERIENCE ..................................................................................................................... 40
POLITICAL DECLARATIONS AND PROFESSIONAL RECOMMENDATIONS ................................................. 40
THE IMPLEMENTATION OF HEALTH PROMOTION INTO HOSPITALS AS A SPECIFIC QUALITY IMPROVEMENT
STRATEGY – PRINCIPAL APPROACHES ...................................................................................................... 41
SINGLE HEALTH PROMOTION PROJECT APPROACH............................................................................... 41
THE CONTINUOUS, COMPLETE, COMPREHENSIVE, HOLISTIC, OVERALL OR TOTAL HPH APPROACH ..... 42
LIST OF CRITERIA FOR A HEALTH PROMOTION MANAGEMENT SYSTEM IN A HPH – OUTCOME ............ 42
LIST OF CRITERIA FOR A HEALTH PROMOTION MANAGEMENT SYSTEM IN A HPH – STRUCTURE ......... 42
LIST OF CRITERIA FOR A HEALTH PROMOTION MANAGEMENT SYSTEM IN A HPH – PROCESSES .......... 43
8
REFERENCES .......................................................................................................................................... 44
9
GLOSSARY ............................................................................................................................................... 47
9.1
9.2
9.3
HEALTH PROMOTION RELATED ........................................................................................................... 47
HEALTH PROMOTION .......................................................................................................................... 49
HEALTH PROMOTION POLICIES OF A HOSPITAL : .................................................................................. 49
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1 Introduction
1.1 On the paper
This paper aims at informing primarily hospital managers and hospital professionals with a
strategic perspective, but also government departments and health policy actors who have
responsibility for the development of health and social policy.
It should facilitate strategic decision making for Health Promoting Hospitals (HPH) especially
for people who are already interested (it does not extensively argue why it makes sense at all
for a health care institution to think about health promotion), but on the outset of deciding
what to do on what scale.
Thus, it can be also used in training measures for health promoting hospital co-ordinators
and change mangers.
As it includes a rather comprehensive systematic theoretical formulation of the possible
content of HPH, it should be useful also for partners on that level who are working already
with HPH, wishing to evaluate and perhaps focus their strategies.
A short summary for top management will be included in the final version.
1.2 The (strategic) context of HPH
Based on the Ottawa Charter (WHO, 1986), WHO-EURO initiated 3 strands of support for
reorienting hospitals towards becoming more health promoting (hospitals):
 Conceptual development (WHO Copenhagen workshop, see Milz / Vang 1988;
Budapest Declaration 1991; Vienna Recommendations 1997);
 Implementation experiences (WHO model project “Health and Hospital” in Vienna,
1988-1996; European pilot hospital project 1993-97; hospitals in the framework of
national and regional networks since 1992 and more systematically since 1995 – see
Ludwig Boltzmann Institute 1996; Pelikan et.al. 1998, Pelikan / Wolff 1999);
 And networking media (business meetings, annual international conferences since
1993, workshops, newsletter, national and regional networks, data base, website etc.
– for further information, see web-sites of WHO-European Office for Integrated Health
Care Services: www.es.euro.who.int, and WHO Collaborating Centre for Health
Promotion in Hospitals and Health care: www.univie.ac.at/hph).
In 2001, after more than 10 years of involvement in HPH, WHO has launched 2 working
groups to develop an up-to-date strategic and quality framework for HPH. This paper
presents a shortened and focussed version of the main results of the working group “Putting
health promoting hospital policy into action”1
To understand the relationship of hospitals to health promotion and the specific potential of
hospitals for health promotion and of health promotion for hospitals, some aspects of the
situation of hospitals and the specific characteristics of health promotion need to be clarified.
The situation of hospitals is characterised by a permanent and increasing pressure of their
relevant, rather dynamic environments. Hospitals have to adapt to changing political and
economic, professional and consumer expectations concerning the content of hospital
services and the way they do their (core) business.
Two general tendencies can be distinguished within the trend of permanent hospital reform:
1
Members of the working group: Elimar BRANDT, Christina DIETSCHER (LBI core team), Carlo FAVARETTI, Pascal
GAREL, Bernhard J. GÜNTERT, Karl KRAJIC (LBI core team), Elisabeth MARTY-TSCHUMY, Peter NOWAK (LBI core team),
Raymond McCARTNEY, Jürgen PELIKAN (chair), Yannis TOUNTAS
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1) Strategic re-positioning of the hospital: This regards the need for continuously redefining the specific range and mix of services, i.e. the distinction between core
business and other services, within a given health care system (inpatient / outpatient
services; acute / chronic / rehabilitative services; inclusion of educative services;
hospital as health centre; integration with primary care, social services and other
sectors of society; specialisation of types of hospitals and departments).
2) Assuring and improving quality of services: Safety, appropriateness,
effectiveness and efficiency of services offered have to be improved for cost
containment and improved satisfaction of stakeholders. So, many hospitals are
increasingly introducing specific quality approaches like systematic process oriented
quality management (TQM, EFQM, ISO etc.), evidence based medicine / nursing,
patient’s rights etc.
To be able to delineate the specific contributions of health promotion to such strategic repositioning and quality improvement in hospitals, the concept of health promotion has to be
explained operationally.
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2 Which distinctions are relevant for planning health
promotion strategies in hospitals? An introduction to
the concept
What do we mean when talking about health promotion in and by hospitals? Over the years,
this has proven a difficult and contested issue in the development of the Health Promoting
Hospital Network, often resolved in a very pragmatic way that offers some common
orientation and sufficient leeway to adapt to national an local circumstances and also
individual preferences. But, when faced with the task of developing orientation on how to put
health promotion policy into hospital practice, the working group found a consensus that it
would be necessary to explicitly and rather comprehensively identify the content of health
promotion strategies for hospitals. We have to be explicit whether we are talking about
developing a healthy hospital setting and / or the hospital as public health agent in its local
community and / or health education services for chronically ill and / or lifestyle education for
hospital staff etc.
In the end, the working group has managed to agree in a consensus process on 18 core
strategies for Health Promoting Hospitals (Overview in Table 3 at the end of the chapter,
specification in Chapter 3), together with propositions on how central or indispensable these
strategies should be for a hospital that wants to call itself a “Health Promoting Hospital” or a
health policy that wants to systematically develop this potential.
To help the reader to understand the logical structure of these core strategies, the chapter
starts out with introducing some conceptual distinctions that are relevant to improve
orientation in the wide range of possible developments.
At least out of the perspective of health care professionals and health educators, these
distinctions will be considered rather abstract, but they try to orient themselves as what we
understand as logic of decision making on a health policy or hospital management level.
The wealth of distinctions that form the very core of providers of individual services (specific
risks, diseases, health problems, health potentials, lifestyles, social groups, personal
characteristics etc.) will come in only in the following parts. Concerning the 18 core
strategies, they will be addressed in Chapter 3-5 in an exemplary way, and they will be
explicitly named as areas for specific thematic health promotion policies in Chapter 6.
2.1
Health Promotion in and by Hospitals – for whom? Target Groups
Organising thinking around the “target groups” has a long tradition in the HPH network, and it
really makes a lot of difference for decision makers if they are to think about patients (clients
/ customers of the hospital organisation), the hospital staff and bystanders in the
community, who are not (yet) clients of the hospital.
To keep the issue of target group as simple as possible on this level, it is proposed to define
all three types of stakeholders in a broader sense:
 “Patients” include also (indirectly) the members of their social network (relatives, friends
etc.) whose health can be affected by the well-being of the patient, or by their visits to the
hospital.
 For “staff”, we propose the same strategy.
 “Community” includes not only the local bystanders (individuals, social groups,
organisations), but can include a wider horizon – as far as global ones, e.g. when Italian
hospitals form healthy alliances and work together with developing countries.
In the tradition of HPH, there still is a fourth stakeholder, the hospital as an organisation,
represented by its owners and management. Here the movement had used the term of
“health of an organisation” in a metaphorical sense, addressing issues like the hospital’s
ability to survive as an organisation in a turbulent and challenging environment. Although we
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would like to underline that the strategically well informed and professionally sound
implementation of health promotion interventions for patients, staff and community are likely
to be of benefit for the hospital organisation – and that these changes can be observed in
principle – we decide to leave out this complication. To facilitate a clearer understanding of
the very core of HPH, we have decided to discuss the implication for the organisation
primarily in chapter 7 “Implementation”.
2.2
Health Promotion Services and Health Promoting Settings – Health Outcomes
and Health Impact
A second central distinction relates between the well established dimension of health
promotion oriented at individuals / social groups vs. settings oriented health promotion. We
propose to specify this distinction for the context of health care by distinguishing between
hospital services vs. hospital settings (see Table 1 below).
In a third step, this distinction is combined with a distinction concerning the effect on health of
services and settings, the health gain (or loss).
We combine services with intended and specific health outcomes (& partly unintended,
more diffuse impacts) and settings with mostly unintended and diffuse health impacts.
The underlying assumption is that both outcomes and impacts can be observed, measured
and analysed and can also be systematically influenced by health promotion interventions.
2.3
Health Promotion as quality strategy vs. Provision of specific Health Promotion
Services
A third dimension tries to disentangle two different meanings or uses of health promotion that
are very relevant for health policy and management decisions. Health promotion can be
understood as a specific quality strategy to improve current practice of hospitals, and health
promotion can also be understood as providing “new” (at least for the hospital) specific
services.
a. Health promotion as a strategy of specific health promoting quality development can be
applied to improve the health gain of different organisational structures and processes that
determine services and thus improve the outcome of the services. This also includes
improvement of the hospital setting as material and social framework in which services are
provided – and thus improve health impact.
Like all quality development, Health Promoting Quality Development will have to define a
specific set of principles, criteria and standards, which basically will provide for making
decision making in the hospital a bit more complex and thus more powerful – extending
criteria in the way that criteria will be oriented

at disease & positive health

at somatic & psychic & social health

at protection, prevention, treatment & development of health

at expert solutions & empowerment)
This quality strategy is especially relevant for hospitals and other health care institutions,
because health outcome and impact have a direct relationship to the primary task of the
organisation, but it can be used for other organisations as well.
b. On the other hand, health promotion as the provision of specific health promotion
services or activities that are not directly part of the hospital’s core services or related to
them, has to follow not only a health promotion or professional logic (what can be done to
further improve health?), but also the logic of the specific national and local health and
welfare policy and the specific market economy. For a rational hospital organisation, it will be
possible to provide these specific services only if there is a demand and an ability and
willingness to pay for – publicly or privately, like with any other service. Of course this can be
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locally developed and where there are good professional arguments that the problem is
relevant and the hospital is in a good or best position to offer these services, there might be
good chances. In principle, many of these services might also be offered by other
organisations than hospitals.
We think this distinction is important for (Health Promoting) Hospitals. It can and should be
expected from every hospital which intends to be a Health Promoting Hospital that it uses
health promotion as a quality development strategy for everything it does and is. But it
depends on its context (national, regional and local health policy, division of labour in local
health care services, actual offers of other local providers), how far it can, should, or has to
invest in offering health promotion services itself.
Therefore health promotion as a quality development strategy could / should be mandatory
for Health Promoting Hospitals, whereas investment in health promotion services would be
very welcome, but voluntarily, depending on the specific situation of the hospital in its
context.
Table 1 below combines the last two distinctions and provides a first overview.
Table 1: Principal health promoting strategies, based on different, hospital related health
determinants, to enhance health gain attributable to hospitals (for patients, staff and
community)
Improvement of health gain
attributable to different health
determinants of hospital….
Specific HP quality
development
Provision of specific HP
services & activities
2.4
Health outcomes (& impacts) of
hospital services
Health impacts of hospital
setting & other settings
Health promoting quality
development of (core) services
(of treatment & care)
Provision of health promoting
educational, preventive and
rehabilitative services
Health promoting quality
development of hospital setting
Participation as a partner in HP
development of local community
(and other settings)
Empowerment as health promotion core concept – what for?
Combining an analysis of the empowerment concept not primarily as a community oriented
or political concept but as being related to the ability to perform specific social roles and an
analysis of the distinction between disease and positive health as resource / a potential, we
suggest to distinguish between several aspects of empowerment that can be targeted by
health promotion interventions
a. Empowerment for health promoting self-reproduction (or self-maintenance or self care)
Looking at self care / self maintenance / self reproduction in the context of the hospital might
be rather surprising for many readers, as the basic conceptualisation of the hospital patients
still seems to be the passive object of diagnostic and therapeutic interventions that is being
cared for comprehensively by the organisations.
But a closer view on patient reality in the hospital draws to our attention, that this view might
even be too simplified or even dangerous for patients (e.g. psychosocial hospitalism,
especially frequent in the groups of the elderly). Like outside the hospital, the patients are not
totally dominated by the reality of disease and illness, but also have a rather healthy part –
physically, mentally and socially, and this part can deteriorate. Health promotion as a postmodern concept draws to our attention the fact, that patients have to reproduce this part of
their health to a large extent by themselves – and can be supported or hindered by their
environment.
Self-reproduction (self-care, self-maintenance) is about taking responsibility, and to care for
one’s physical health needs (e.g. by getting enough sleep, exercising to keep up physical
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functioning level as good as possible, healthy nutrition), mental health needs (e.g. by taking
enough time for recreation, developing coping mechanisms for stress, keeping up selfrespect etc.), and social health needs (e.g. by keeping up social networks, securing support
for new needs, adapting one’s social positioning to new circumstances, etc.).
Hospital staff can enhance patient, staff and community self care by patient specific
communicative and interactive empowering support2, but also by providing supportive
conditions in the hospital setting3 (see also strategies PAT-3, STA-3, and COM-3).
b. Empowerment for health promoting co-production of diagnosis and therapy
This second specification is based on the analysis that (health) services are usually not
provided by a professional only, but need the collaboration of the customer, client, patient –
by accessing the provider (timely), by openly communicating in diagnostic procedures, by
complying to therapy, by collaborating in therapy (breathing correctly, keeping still,..), by
communicating dissent if present, by re-organising life so that it is supporting healing and recuperation, etc. There is a vast amount of literature that proves that effective co-operation
makes a difference that can be measured in outcome: hospital stay, complications, wellbeing, need for pain medication, etc.
This dimension of collaboration is utilised or hindered by hospital communication routines.
c. Empowering health promotion services for illness management
Given the fact that many patients leave the hospital not healthy, but either in different stages
of recuperation, or chronically ill, their potential contribution to the process can be either
enhanced (by empowerment) or hindered. This usually goes beyond the boundaries of the
hospital organisation and is being discussed as challenges for integrated care, interface
management etc. as one of the central quality issues for many European healthcare
systems.
d. Empowering health promotion services for lifestyle development.
Finally, we have to point out the “trivial” case of the classic health education but also
community and setting oriented strategies, aiming at empowering people to live their lives as
healthy as possible – not regarding specific diseases, but rather risk preventing or possible
health enhancing lifestyles.
2.5
Combining distinctions: Six General Health Promoting Core Strategies
Generalising all types of strategies for patients, staff and the community, we get 6 different
general health promoting core strategies for every stakeholder (i.e. patients, staff and the
community).
Table 2: Different general health promoting strategies for stakeholders of the hospital
1. HP quality development of treatment & care, by empowerment of stakeholders for health
promoting self-reproduction
2. HP quality development of treatment & care, by empowerment of stakeholders for health
promoting co-production
3. HP quality development for health promoting & empowering hospital setting for stakeholders
4. Provision of specific HP services - empowering illness management (patient education) for
stakeholders
5. Provision of specific HP services - empowering lifestyle development (health education) for
2
3
i.e. accepting, respectful, encouraging and supportive information, communication and interaction
e.g. buffets instead of food in bed, or curtains around patients beds to support privacy
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stakeholders
6. Provision of specific HP activities - participation in health promoting & empowering community
development for stakeholders
For all 6 general strategies we formulate stakeholder-specific health promotion core
strategies, which makes for the three stakeholders 18 specific strategies in total.
2.6
Health Promotion principles in the Core Strategies
In all these strategies health promotion or health promoting is understood in a broad sense,
following the definition in the Ottawa Charter: ”Health promotion is the process of enabling
people to increase control over, and to improve, their health”.
This includes maintenance and improvement of health, be it by protection or development of
positive health or – with reference to specific diseases – prevention or treatment & care, as
long as these procedures are applied in an empowering manner by the hospital. Health
promotion also means that, when adequate, that next to “empowering” 6 other guiding
principles or criteria for health promotion as defined by a WHO European Working Group on
Health Promotion Evaluation (cf. Rootman in Rootman et al., 2001, p. 4) need to be applied.
These are:
participatory,
holistic
intersectoral
equitable
sustainable
multistrategy
In all these strategies we use empowerment or “empowering for health” according to the
definition in the WHO Health Promotion Glossary (1998, Section II, p.6):“a process through
which people gain greater control over decisions and actions affecting their health.” The term
can relate to individual actors, or social groups or communities, and combines measures
aiming at strengthening actors’ life skills and capacities (e.g. “to express their needs, present
their concerns, devise strategies for involvement in decision-making”) with measures creating
supportive physical, cultural and social environmental conditions which impact upon health.
The process by which both is done, may be “social, cultural, psychological or political”.
The two terms usually are used in combination deliberately, to signal the comprehensive
health gain oriented goal and the specific empowering means by which this goal could or
should be reached effectively.
2.7
18 Core Strategies – an overview
Explicitly combining the 6 strategies with the 3 main stakeholders produces a matrix that
follows, on the one side, the traditional distinction between the HPH philosophy and the
quality philosophy (e.g. of customers, staff and society in the EFQM model of excellence),
and on the other side, of three groups of stakeholders or beneficiaries whose health is or
can be affected by hospitals: Patients, staff and community. The strategies sketched in the
cells of the matrix will be explained in more detail in the next chapter, concerning its
objectives, the scientific and political indication for it, policies how to do it and examples of
(best or good) practice.
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Table 3: Core health promotion strategies4 for HPHs
HP for/ by …
HP quality
development of
treatment & care, by
empowerment of
stakeholders for
health promoting selfreproduction
HP quality
development of
treatment & care, by
empowerment of
stakeholders for
health promoting coproduction
HP quality
development for
health promoting &
empowering hospital
setting for
stakeholders
Provision of specific
HP services empowering illness
management (patient
education) for
stakeholders
Provision of specific
HP services empowering lifestyle
development (health
education) for
stakeholders
Provision of specific
HP activities –
participation in health
promoting &
empowering
community
development for
stakeholders
4
Patients
Staff
Community
PAT-1: Empowerment
of patients for health
promoting self care /
self maintenance / self
reproduction in the
hospital
STA-1: Empowerment
of staff for health
promoting self care /
self maintenance / self
reproduction in the
hospital
COM-1: Empowerment
of community health
promoting self care /
self reproduction by
adequate access to
hospital
PAT-2: Empowerment
of patients for health
promoting participation /
co-production in
treatment and care
STA-2: Empowerment
of staff for health
promoting participation /
co-production in
treatment and care
PAT-5: Empowerment
of patients for health
promoting life style
development (after
discharge)
STA-5: Empowerment
of staff for health
promoting life style
development
COM-5: Empowerment
of community
population for health
promoting lifestyle
development
PAT-6:
Participation in health
promoting &
empowering
development of
community
infrastructures for
specific patient needs
STA-6:
Participation in health
promoting &
empowering
development of
community
infrastructures for
specific needs of staff
COM-6: Participation in
health promoting &
empowering community
development for general
population
COM-2: Empowerment
of health professionals
in the community for
health promoting coproduction in treatment
and after-care of
patients
PAT-3:
STA-3:
COM-3: Development of
Development of hospital Development of hospital hospital into a health
into a supportive, health into a supportive, health promoting &
promoting &
promoting &
empowering setting for
empowering setting for empowering setting for the community
patients
staff
PAT-4: Empowerment
STA-4: Empowerment
COM-4: Empowerment
of patients for health
of staff for health
of community
promoting management promoting management population for health
of chronic illness (after
of occupational illness
promoting management
discharge)
of chronic illness
The formulation of the titles of the 18 specific core HP strategies is intended to be as short as possible, to be
comparable with and marking of f to each other, but to signal also, if used as a single title in isolation, the
specific HP character of the strategy. More differentiated definitions and characteristics are found in the detailed
descriptions of each strategy.
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3 Patient oriented core strategies
3.1 Core strategy PAT-1: Empowerment of patients for health
promoting self care / self maintenance / self-reproduction in the
hospital
3.1.1 Objectives of strategy PAT-1:
Strategy PAT-1 aims at optimising / improving the short term impact of hospitals on patients’
positive health5, well-functioning6, well-being7 and quality of life during hospital stay (or while
being treated as outpatient), by supporting patients’ health promoting8 self care.
Self care / self maintenance / self reproduction is about taking responsibility, and to care for
one’s physical health needs (e.g. by taking enough sleep), mental health needs (e.g. by
taking enough time for recreation or developing coping mechanisms for stress), and social
health needs (e.g. by having social contacts).
Hospital staff can enhance patient self care by patient oriented / patient centred
communicative and interactive empowering support9 for patients and relatives to encourage
health promoting patient self care10 - but also by providing supportive conditions in the
hospital setting11 (see also strategy PAT-3).
3.1.2 Indications for strategy PAT-1
Health promotion concepts point out that the possibility to satisfy personal needs, to access
supportive environments and relevant information are basic preconditions for health12.
Hospitals are unfamiliar surroundings where patients usually cannot keep to their usual
habits, and where they need adequate information, orientation, communication and
interaction.
Especially for vulnerable groups of patients (like elderly), a lack of orientation may result in
symptoms of hospitalism.
Adequate information and orientation of, communication and interaction with patients are
important determinants of patients’ health and quality of life13 that can be successfully
influenced by hospitals.
3.1.3
Implementation of strategy PAT-1
The following list provides examples of possible measures for implementing strategy PAT-1:



Provide adequate information and guidance at hospital admission (example of good
practice: Griffin Hospital, USA) and discharge
Provide adequate visiting hours
Organise visiting and lay support services for unattended patients14
5
when hospitalised, patients are partly sick and partly healthy; strategy PAT-1 is about maintaining the healthy part.
keeping upright functional abilities by encouraging patient activities as far as possible in the hospital context
7
supporting specific needs (according to age, sex, cultural community, religion) – see also Budapest Declaration for Health
Promoting Hopsitals , strategy 10, and fundamental principle 1 of the Vienna Recommendations on Health Promoting
Hospitals (Health Promoting Hospitals Network 1991; WHO 1997)
8
positive health protecting and developing, disease preventing
9
i.e. accepting, respectful, encouraging and supportive information, communication and interaction
10
e.g. motivating patients to exercise , helping them to cope with anxieties, creating a welcoming atmosphere for visitors
11
e.g. buffets instead of food in bed, or curtains around patients beds to support privacy
12
(WHO 1986)
13
see e.g. (Di Blasi, Harkness et al. 2001)
6
14
as is e.g. done at Rudolfstiftung Hospital, Vienna (Nowak, Lobnig et al. 1998)
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Implement specific health promotion policies for provision of information and orientation,
health promotion communication and interaction with patients at different stages of
hospital stay
Provide offers and options to encourage patient activities (e.g. exercise, culture, patient
libraries, discussion, patient internet cafe15, ...)
Provide adequate palliative care16 and pain management
Consider the different needs of patients belonging to different age17, sex, ethnic, religious
groups (e.g. consider cultural aspects of nutrition, respect cultural taboos)
Nursing diagnoses to assess level of possible self care
Provide psychological assistance to cope with stress or anxieties related to the hospital
stay or to the patient’s disease (e.g. cancer)
Monitor patient satisfaction for continuous improvement
The effective and comprehensive implementation of strategy PAT_1 will partly rely on the
simultaneous implementation of relevant parts of strategy PAT-3 / Setting
15
EU project
see e.g. HPH-Newsletter 18, Dec. 2001
17
e.g. Baby Friendly Hospitals
16
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3.2 Core strategy PAT-2: Empowerment of patients for health
promoting participation and co-production in treatment and
care
3.2.1 Objectives of strategy PAT-2:
Strategy PAT-2 aims at optimising / improving the hospital’s short term health impact on
patients by improving their health promoting18 physical, mental and social participation and
co-production in treatment and care.
Participation and co-production in treatment and care are about optimising treatment related
information and communication for patients, about transparency of treatment processes,
about providing the possibility for patients to participate in treatment and care related
decisions, and about active performance of treatment related measures by patients where
indicated and adequate.
Hospital staff can support patient participation and co-production by empowering, enabling,
specific health literacy producing and supportive communication and interaction in the
treatment and care processes. Indications for strategy PAT-2:
Clinical and other patient outcomes of hospital services – e.g. complication rates, necessary
doses of pain medication, duration of recreation process and length of hospital stay, patient
(and relatives’) satisfaction – are partly determined by adequate and active involvement of
patients by relevant staff in treatment and care processes19.
Hospitals can successfully improve this health determinant for their patients by increasing
participation and co-production. This strategy is also in line with basic health promotion
principles20.
3.2.3 Implementation of strategy PAT-2:
The following list provides examples of possible measures for implementing strategy PAT-2:






Develop patient-oriented communication, e.g. for rounds (talk with patients, not about
patients)
Provide comprehensive patient diagnosis- and treatment related patient information and
counselling (e.g. describe alternatives; describe side effects; inform patients about how
they can contribute to the treatment)
Include patients in decisions about their treatment
Develop inter-professional teams (nursing, medical, therapeutic) in order to facilitate
comprehensive patient participation in the treatment process
Implement health promoting policies for specific health promoting diagnostic and
therapeutic, caring and nursing processes
Monitor participative, co-productive structures for continuous improvement
The effective implementation of strategy PAT-2 will rely on the implementation of strategies
PAT-1, STA-1 and STA-2.
18
positive health protecting and developing, disease preventing
(Johnston, Vögele 1992)
20
WHO-Ottawa Charter: increased control over, and thus improvement of health; (WHO 1986) see also
strategies 3 and 4 of the Budapest Declaration on HPH, implementation strategies 1.1. and 1.2 of the Vienna
Recommendations on HPH
19
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3.3 Core strategy PAT-3: Development of hospital into a health
promoting and empowering setting for patients
3.3.1 Objectives of strategy PAT-3
Strategy PAT-3 aims at optimising / improving the short term physical, mental and social
health impact of the hospital as a material and social, living (residence) and healing
environment for patients and their visitors, by developing the hospital to a more health
promoting and empowering21 supportive, environment for patients and visitors.
3.3.2 Indications for strategy PAT-3:
There is enough scientific evidence that settings have an impact on the people affected by
them22Hospital environments or contexts are important determinants of the health of their
patients, independent of the quality of services provided 23 (e.g. risk of nosocomial infections;
risk of accidents; risk of malnutrition due to inadequate provision of food or organisation of
food distribution; Therefore, in order to increase the hospital’s health impact on their patients, specific
interventions are needed to improve the quality of the hospital setting, in addition to the
quality of the services provided24.
3.3.3 Implementation of strategy PAT-3:
The implementation of strategy PAT-3 relates to the development of the material and sociocultural hospital setting (especially hotel situation, but also conditions for treatment and care
in a HP direction). It is achieve by essential policies related to the material and social context
and life-style specific aspects of the hospital setting.
The following list provides examples of possible measures for implementing strategy PAT-3:






21
Include settings development for hospital patients into the mission statement of the
hospital
Map out problematic characteristics in the material setting (e.g. areas with high risk of
accidents or nosocomial infections) and the social setting (e.g. stress on hospital
patients) and develop adequate measures for improvement (e.g. in the framework of
health circles)
Provide adequate and adequately distributed food (e.g. buffets where possible, in order
to encourage patient activity and social interaction)
Provide for the material and social needs of specific groups of patients (e.g. culturally
adequate food; baby friendly surroundings, etc.)
“Build green” (without toxic and dangerous materials) 25
Avoid material that might be dangerous for (specific groups of) patients, like latex, PVC,
mercury, etc22.
positive health protecting and developing, disease preventing
WHO Jakarta Declaration on leading Health Promotion into the 21st Century: „There is now clear evidence that particular
settings offer practical opportunities for the implementation of comprehensive strategies. These include mega-cities, islands,
cities, municipalities, local communities, markets, schools, the workplace, and health care facilities”. (WHO 1997)
23
(Di Blasi, Harkness et al. 2001; Vetter 1995)
24
see e.g. Budapest Declaration on HPH – Strategy 3: Raise awareness of the impact of the environment of the hospital on
the health of patients, staff and community. The physical environment of hospital buildings should support, maintain and
improve the healing process. (Health Promoting Hospitals Network 1991)
25
Health Care Without Harm, web-site: http://www.noharm.org/ (Health Care without Harm 2002)
22
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Provide adequate hygiene management in the hospital (as done in many Health
Promoting Hospitals all over Europe)
Provide arts in the hospital
Implement essential policies to increase the health impact of the material setting (e.g. air,
noise, light, design) and the social setting (???)
Implement policies to support safety for hospital patients (e.g. accident prevention)
Implement policies to increase the impact of the hospital setting on supporting healthy
lifestyles for patients (e.g. specific rules and regulations smoking; smoke-free areas;
exercise, ...)
Monitor measures taken for continuous improvement
Strategy PAT-3 partly overlaps with strategies PAT-1 and PAT-2 (in so far as self care / self
maintenance / self reproduction, as well as participation / co-production in treatment and care
partly depend upon settings characteristics, like e.g. privacy in patient rooms, availablity of
counselling rooms, etc.).
It is also advisable to plan and implement strategy PAT-3 in relation to strategies STA-3 and
COM-3, since they will partly overlap and as there even may be possible contradictions,
which can best be avoided by optimising settings conditions for all relevant stakeholders at
once.
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3.4 Core strategy PAT-4: Empowerment of patients for health
promoting management of chronic illness
3.4.1 Objectives of strategy PAT-4:
Strategy PAT-4 aims at investing in the improvement of the potential mid-term health
outcomes of hospitals for their patients, by offering specific empowering services, e.g. patient
education, to allow for a more health promoting26 management of physical, mental and social
consequences of disease, treatment and impairment. This will also enhance the disease
specific quality of life of patients, after discharge from the hospital.
3.4.2 Indications of strategy PAT-4:


As numerous reviews point out, knowledge and skills concerning the self-management of
specific impairments or diseases are important determinants of mid-term recuperation
and quality of life and, in the case of chronically ill patients, also of retarding the progress
of disease27.
Patient education is an adequate means to empower patients for self-management, and
is also demanded in the WHO-Ottawa Charter on Health Promotion28. The feasibility of
patient education in hospitals is demonstrated by many projects in the International
Network of HPH29.
3.4.3 Implementation of strategy PAT-4:
The implementation of strategy PAT-4 is about the provision of empowering, disease specific
counselling, education and rehabilitation services to build up particular health (& specific
disease) literacy30 to allow for recuperation and healthy living with the consequences of
(chronic) illness or the treatment of disease in everyday life. Measures and policies for
strategy PAT-4 will have to be disease and treatment specific.
The following list provides examples of possible measures for implementing strategy PAT-4:





Identify groups of patients in need of patient education and counselling services (e.g.
diabetes, COPD);
When choosing counselling methods, build upon the best available material and
methodology (check for effectiveness reviews);
Provide education and counselling services according to specific cultural (language, age,
sex, religious) needs of patients;
Provide adequate environment for education and counselling services;
Monitor services for continuous improvement.
The implementation of strategy PAT-4 will be improved if it can rely on or follow up strategies
PAT-1 and PAT-2 (and partly also PAT-3).
For some indications, counselling services can be jointly organised for patients, staff (see
also STA-4), and community (see also COM-4).
26
positive health protecting, further progress of disease preventing, and positive health developing
see e.g.(Devine, Pearcy 1996; Hirano, Laurent et al. 1994; Lacasse, et al. 1996; Mazzuca 1982; Smith, et al. 1992)
28
WHO (1986): „Enabling people to learn throughout life, to prepare themselves for all of its stages and to cope with
chronic illness and injuries is essential.”
29
see e.g. Virtual Proceedings of International HPH Conferences at www.univie.ac.at/hph
30
knowledge and motivation, skills and capacities
27
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3.5 Core strategy PAT-5: Empowerment of patients for health
promoting life style development
3.5.1 Objectives of strategy PAT-5:
Strategy PAT-5 aims at investing in the improvement of the potential long term health
outcomes of hospitals for their patients, by offering specific empowering services, e.g. health
education, for the development of health promoting31 life styles of patients. This will also
enhance the quality and longevity of patients’ life.
3.5.2 Indications for strategy PAT-5:
Lifestyles (nutrition, exercise, consumption of substances like alcohol, nicotine) have a
proven long-term effect on health32.
Research and case studies from around the world provide convincing evidence that health
promotion can develop and change lifestyles.33
Hospitals have the potential (knowledge and skills) to offer effective lifestyle education and
counselling services for their patients, as is shown in many projects of the International HPH
network34.
3.5.3 Implementation of strategy PAT-5:
Implementing strategy PAT-5 is about providing staff empowering, life-style specific health
promoting counselling, education and rehabilitation services to build up particular knowledge
and motivation, skills and capacities to facilitate healthy lifestyles and decisions of hospital
patients (after discharge).
The following list provides examples of possible measures for implementing strategy PAT-5:






If hospitals are not offering lifestyle education and counselling services themseves:
Identify lifestyle education and counselling services in the hospital community and
develop referral procedures for hospital patients when indicated;
Provide lifestyle education and counselling services based upon best available material
and methodology (check effectiveness reviews);
Offer lifestyle services at times convenient for patients;
Combine lifestyle education and counselling services with the development of supportive
conditions in the hospital setting (e.g. nutrition offers; introduction of smoke-free areas;
implementation of a gym – see also strategy PAT-3).
Implement specific lifestyle-oriented policies (e.g. smoking policy, nutrition policy – see
also PAT-3).
Monitor services for continuous improvement
Strategy PAT-5 builds on strategies PAT-1, PAT-2, and PAT-4.
It overlaps partly with strategies STA-5 and COM-5. Joint services can therefore be provided
for staff, patients and community members. When specific lifestyle problems of patients are
concerned (e.g. lifestyle problems due to work organisation), specific services will be
necessary.
31
positive health protecting and developing, disease preventing
see e.g. (World Health Organization 2002; Tubiana 2000; Willett 1995)
33
see Jakarta Declaration on Leading Health Promotion into the 21 st Century (WHO 1997)
34
see e.g. Virtual Proceedings of International HPH Conferences at www.univie.ac.at/hph
32
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3.6 Core Strategy PAT-6: Participation in health promoting and
empowering community development for patients
3.6.1 Objectives of strategy PAT-6:
Strategy PAT-6 aims at investing in the improvement of the potential long-term health impact
of the hospital for its patients by initiating of or participating in specific local health
promoting35 and empowering community development projects, oriented at health related
living conditions that are of relevance for specific needs of (former) hospitals patients.
3.6.2 Indication – why?
The impact of health promoting community development for hospital patients has not yet
been systematically researched. But there is a number of conditions that are of specific
relevance for a health promoting life after discharge from the hospital, e.g. easy access to
necessary medication and medical goods; availability of self help groups; accessibility of
public transport and public buildings for disabled; availability of community services that allow
for living at home as long as possible.
3.6.3 Implementation of strategy PAT-6:
Implementing strategy PAT-6 is about initiating or participating in health promoting
development initiatives and projects in and for local community development that focus on
the needs of specific patient groups.
The following list provides examples of possible measures for implementing strategy PAT-6:




Identify areas of community infrastructure (e.g. by questionnaire) which are of specific
concern for patients (e.g. lack of supply with specific medical goods)
Lobby for improvement of identified areas of concern (e.g. in the framework of Healthy
Cities).
Support self help groups
Support / empower community services that support patients at home (see also strategy
COM-1).
Strategy PAT-6 should be matched with strategies STA-6 and COM-6.
35
positive health protecting and developing, disease preventing
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4 Staff oriented core strategies
4.1 Core strategy STA-1: Empowerment of staff for health
promoting self care / self maintenance / self-reproduction in the
hospital
4.1.1 Objectives for strategy STA-1
Strategy STA-1 aims at optimising / improving the impact of the hospital on positive health,
well-functioning, well-being, and work-related quality of life of hospital staff, by supporting
staff’s health promoting 36 self care.
Self care / self maintenance / self reproduction is about taking responsibility, and to care for
one’s physical health needs (e.g. by taking enough breaks), mental health needs (e.g. by
developing coping mechanisms for stress), and social health needs (e.g. by having social
contacts).
Hospital management can enhance staff self care by health promoting staff-oriented37
communicative and interactive empowering support38 for staff to encourage health promoting
self care, but also by providing supportive conditions in the hospital setting39 (see also
strategy STA-3). (
4.1.2 Indications for strategy STA-1
Health promotion concepts point out that the possibility to satisfy personal needs, to access
supportive environments and relevant information are basic preconditions for health40.
Staff spend considerable time of their day at work. It is therefore important that personal
needs can be fulfilled also during work, that staff have access to relevant information about
possibilities of self care at work, and that necessary preconditions are created in the hospital
setting.
Adequate communication and interaction of management with staff can effecitvely support
staff self care and is therefore an important determinant of the quality of work life and
occupational health.
The effective implementation of strategy STA-1 will support the implementation of strategy
PAT-1 as well.
4.1.3 Implementation of strategy STA-1
The following list provides examples of possible measures / policies for implementing
strategy STA-1:


36
Include empowerment of hospital staff for self care / self maintenance / self reproduction
in the hospital into the mission statement of the hospital
Map out areas problematic for self care / self maintenance / self reproduction in the
hospital and develop adequate measures for improvement
positive health protecting and developing, disease preventing
comprehensive and continuous salutogenic, i.e. accepting, respectful, encouraging and supportive information,
communication and interaction with staff by management and all other all staff including written information,
sign-systems etc.
38
i.e. accepting, respectful, encouraging and supportive information, communication and interaction
39
e.g. adequate recreation rooms, adequate working times
40
(WHO 1986)
37
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Provide necessary information and training for new staff (e.g. University Hospital Graz,
Austria)
Provide adequate rooms for staff recreation
Provide necessary breaks for food consumption
Provide necessary time for sleep during long work shifts
Provide mentoring systems for hospital staff
Provide safe, ergonomic, and otherwise adequate working environments
Develop the communication culture in the hospital
Train management for adequate support of staff
Consider the different needs of staff belonging to different age, sex, ethnic, religious
groups (e.g. allocate work according to different expertise and conditions; have different
rest rooms for men and women; provide rooms for prayers / meditation)
Provide offers that encourage staff self care activities (e.g. exercise, discussions, ...)
Monitor staff satisfaction for continuous improvement
The effective implementation of strategy STA-1 partly depends on relevant parts of strategy
STA-3 (setting).
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4.2 Core strategy STA-2: Empowerment of staff for health
promoting participation / co-production in treatment and care
4.2.1 Objectives of strategy STA-2:
Strategy STA-2 aims at optimising / improving the hospital’s health impact on staff by
reducing avoidable work related stress through improving health promoting41 staff
participation and co-production in the work process.
Participation and co-production at work is about optimising work related information and
communication, transparency of work processes and the possibility to participate in / initiate
work-related decisions42, and improve staff commitment.
Hospital management can enhance optimal social, mental and physical participation and coproduction of staff by empowering, enabling and supporting staff to engage in participation
and co-production across hierarchical, professional and departmental boundaries. By that,
the hospital will also improve co-productive interaction with patients and thus treatment
results and health outcomes for patients.
4.2.2 Indications for strategy STA-2:
Work-related quality of life, staff well-functioning and well-being are at least partly determined
by adequate working conditions, work-related information and orientation, management
support, and visible results of work43.
In addition, clinical and other outcomes of hospital services are partly determined by
adequate and active involvement of all relevant staff in treatment and care processes.44
Hospitals can successfully improve this health determinant for their staff and patients by
increasing participation and co-production45.
4.2.3 Implementation of strategy STA-2:
The following list provides examples of possible measures / policies for implementing
strategy STA-2:










Include empowerment of hospital staff for health promoting participation / co-production
into the mission statement of the hospital
Map out areas problematic for participation / co-production in the hospital and develop
adequate measures for improvement
Management training to improve staff support
Training of hospital staff for communication with colleagues and patients
Health circles for developing specific areas of work
Change of work routines
Counselling for development of work culture
Implementation of specific health promotion policies for participative and co-productive
work organisation (protocols for decision-making, documentation, information flow, etc.)
Regular monitoring of work for continuous improvement
Outsourcing of work areas that are not part of the core competencies
41
positive health protecting and developing, disease preventing
The Luxemburg Declaration of Workplace Health Promotion calls for involvement of all affected staff
43
(Badura 2002)
44
see also Budapest Declaration on Health Promoting Hospitals, Vienna Recommendations on HPH (Health
42
Promoting Hospitals Network 1991; WHO 1997)
45
(Johnston, Vögele 1992)
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The effective implementation of strategy STA-2 will rely on implementation of strategy STA-1,
and will support the implementation of strategies PAT-1 and PAT-2.
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4.3 Core strategy STA-346: Development of hospital into a health
promoting and empowering setting for staff
4.3.1 Objectives of strategy STA-3:
Strategy STA-3 aims at optimising / improving the physical, mental and social health impact
of the hospital’s material and socio-cultural working and living conditions for its staff, by
developing the hospital setting into a more health promoting and empowering47 supportive
environment for its staff.
4.3.2 Indications for strategy STA-3?
There is enough scientific evidence that settings have an impact on the people affected by
them48. This is of course also true for work settings. Therefore, the WHO Ottawa Charter
claims that “the way society organises work should help create a healthy society”49.
Hospitals are especially risky workplaces (due to exposure to toxic agents and germs;
musculo-skeletal strains; problems caused by shift work, stress due to the contact with
severely ill and dying patients; stress through exceleration of work due to decreasing lengths
of stay and an increasing amount of patients, ...) for hospital staff who count for 3% of the
total European work force50
Research and practical experiences (e.g. in the HPH network, the European Network of
Workplace Health Promotion) demonstrate that these risky health determinants can be
influenced effectively51 by settings development. Therefore, the Budapest Declaration on
Health Promoting Hospitals and the Vienna Recommendations on Health Promoting
Hospitals contain a number of strategies oriented at developing the setting into a more health
promoting setting for hospital staff52.
4.3.3 Implementation of strategy STA-3:
The following list provides examples of possible measures / policies for implementing
strategy STA-3:



46
Include settings development for hospital staff into the mission statement of the hospital
Map out problematic characteristics in the material setting (e.g. areas with high risk of
accidents; ergonomic and hygienic conditions) and the social setting (e.g. stress) and
develop adequate measures for improvement
Provide adequate and adequately distributed food (e.g. buffets where possible, in order
to encourage patient activity and social interaction)
This description replaces slide no. 41 in Barcelona power point file
positive health protecting and developing, disease preventing
48 WHO Jakarta Declaration on leading Health Promotion into the 21st Century: „There is now clear evidence that particular
settings offer practical opportunities for the implementation of comprehensive strategies. These include mega-cities, islands,
cities, municipalities, local communities, markets, schools, the workplace, and health care facilities”.(WHO 1997)
49 (WHO 1986)
50 see Vienna Recommendations on Health Promoting Hospitals (WHO 1997)
51 see e.g. relevant chapters in Virtual Proceedings of HPH Conferences at www.univie.ac.at/hph
52 Budapest Declaration: Strategy 1: Provide opportunities throughout the hospital to develop health-orientated perspectives,
objectives and structures., Strategy 3: Raise awareness of the impact of the environment of the hospital on the health of
patients, staff and community. The physical environment of hospital buildings should support, maintain and improve the
healing process. Strategy 6: Create healthy working conditions for all hospital staff. Strategy 7: Strive to make the HPH a
model for healthy services and workplaces. Strategy 14: Improve the health promoting quality and the variety of food
services in hospitals for patients and personnel. Vienna Recommenmdations: Implementation strategy 1.3: creating
healthy working conditions for all hospital staff, including the reduction of hospital hazards, as well as psychosocial risk
factors (Health Promoting Hospitals Network 1991; WHO 1997)
47
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Provide for the material and social background that is needed for health promoting work
performance (e.g. safety, ergonomic conditions53, rules and values about work
distribution, etc.)
Implement essential policies to increase the health impact of the material setting (e.g. air,
noise, light, design)and the social setting (e.g. rules about decision-making)
“Build green” (without toxic and dangerous materials) 54
Avoid material that might be dangerous for (specific groups of) staff, like latex, PVC,
mercury, etc55.
Provide arts in the hospital
Implement policies to increase the impact of the setting on supporting healthy lifestyles
(e.g. specific rules and regulations smoking; smoke-free areas; exercise / provision of
gym)
Monitor measures taken for continuous improvement
Strategy STA-3 partly overlaps with strategies STA-1 and STA-2 (in so far as self care / self
maintenance / self reproduction, as well as participation / co-production partly depend upon
settings characteristics, like e.g. recreation rooms, staff meeting rooms, EDP infrastructure,
etc.).
It is also advisable to plan and implement strategy STA-3 in relation to strategies PAT-3 and
COM-3, since they will partly overlap and as there even may be possible contradictions,
which can best be avoided by optimising settings conditions for all relevant stakeholders at
once.
53
e.g. lifting aids
Reference: Health Care Without Harm, web-site: http://www.noharm.org/
55
Reference: Health Care Without Harm web-site: http://www.noharm.org/
54
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4.4 Core strategy STA-4: Empowerment of staff for health
promoting management of occupational illness
4.4.1 Objectives of strategy STA-4:
Strategy STA-4 is about investing in the improvement of potential mid-term health outcomes
of hospitals for staff affected by occupational diseases, by offering specific empowering
services, e.g. education and counselling, to allow for a more health promoting56management
of physical, mental and social consequences of relevant occupational diseases and
impairments. This will also enhance the disease specific quality of life of staff.
4.4.2 Indications of strategy STA-4:
Hospital staff are affected by a number of occupational illnesses, the most discussed being
infections, musculo-skeletal impairments, and different stress symptoms57.
As numerous reviews point out, knowledge and skills concerning the self-management of
specific impairments or diseases are important determinants of mid-term recuperation and
quality of life and also of retarding the progress of disease58.
Education and counselling are adequate means to empower staff for health promoting selfmanagement. The feasibility of patient education in hospitals is demonstrated by many
projects in the International Network of HPH59.
4.4.3 Implementation of strategy STA-4:
The implementation of strategy STA-4 is about the provision of empowering, disease specific
counselling, education and rehabilitation services to build up particular health (& specific
disease) literacy60 to allow for recuperation and healthy living with the consequences of
(chronic) illness at work and in everyday life. Measures and policies for strategy STA-4 will
have to be disease and treatment specific.
The following list provides examples of possible measures for implementing strategy STA-4:

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
Identify groups of staff in need of education and counselling services (e.g. low back pain
disorders, stressed staff);
When choosing counselling methods, build upon the best available material and
methodology (check for effectiveness reviews);
Provide education and counselling services according to specific cultural (language, age,
sex, religious) needs of staff;
Combine disease-specific education and counselling with the development of supportive
environments (e.g. lifting aids – see also strategy STA-3)
Provide adequate environment for education and counselling services;
Monitor services for continuous improvement.
Strategy STA-4 builds upon strategies STA-1 and STA-2 and complements strategy STA-3.
It overlaps partly with strategies PAT-4 and COM-4, therefore joint services can be provided
for staff, patients and community members.
But for specific indications (like back ache, etc.) specific services need to be offered for staff.
56
57
positive health protecting, further progress of disease preventing, and positive health developing
see e.g. Canada’s National Occupational Health and Safety Resource
(http://www.ccohs.ca/oshanswers/occup_workplace/nurse.html); McAbee, R.R. (1988).
58
see e.g.(Devine, Pearcy 1996; Hirano, Laurent et al. 1994; Lacasse, et al. 1996; Mazzuca 1982; Smith, et al. 1992)
59
see e.g. Virtual Proceedings of International HPH Conferences at www.univie.ac.at/hph
knowledge and motivation, skills and capacities
60
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4.5 Core strategy STA-5: Empowerment of staff for health
promoting life style development
4.5.1 Objectives of strategy STA-5:
Strategy STA-5 aims at investing in the improvement of the potential long-term health
outcomes of hospitals on their staff, by offering specific empowering services, e.g. health
education, to allow for the development of more health promoting61 lifestyles of staff: This will
also enhance the quality and longevity of staff’s life.
4.5.2 Indication for strategy STA-5:
Lifestyles (nutrition, exercise, consumption of substances like alcohol, nicotine) have a
proven long-term effect on health62.
Research and case studies from around the world provide convincing evidence that health
promotion can develop and change lifestyles.63
Hospital staff exhibit a relevant amount of lifestyle risks and problems (e.g. smoking,
overweight due to nutrition problems and lack of exercise). Hospitals have the potential
(knowledge and skills) to offer lifestyle education and counselling services for their staff, as is
shown in many projects of the International HPH network64.
4.5.3 Implementation of strategy STA-5:
Implementing strategy STA-5 is about providing staff empowering, life-style specific health
promoting counselling, education and rehabilitation services to build up particular knowledge
and motivation, skills and capacities for healthy lifestyles and decisions of hospital staff.
The following list provides examples of possible measures for implementing strategy STA-5:

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
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
Identify major lifestyle problems of staff (e.g. nutrition, smoking);
Identify and use expertise in the hospital;
Provide services based upon best available material and methodology (check
effectiveness reviews);
Offer lifestyle services at times convenient for staff;
Combine lifestyle education and counselling services with the development of supportive
conditions in the hospital setting (e.g. nutrition offers; introduction of smoke-free areas;
implementation of a gym – see also strategy STA-3).
Implement specific lifestyle-oriented policies (e.g. smoking policy, nutrition policy).
Monitor services for continuous improvement
Strategy STA-5 builds on strategies STA-1, STA-2, and STA-4.
It overlaps partly with strategy PAT-5 and COM-5. Joint services can therefore be provided
for staff, patients and community members. When specific lifestyle problems of staff are
concerned (e.g. lifestyle problems due to work organisation), specific services will be
necessary.
61
positive health protecting and developing, disease preventing
see e.g. see e.g. (World Health Organization 2002; Tubiana 2000; Willett 1995)
63
see Jakarta Declaration on Leading Health Promotion into the 21st Century (WHO 1997)
64
see e.g. Virtual Proceedings of International HPH Conferences at www.univie.ac.at/hph
62
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4.5.4 Examples of (good or best) practice
Core strategy STA-665: Participation in health promoting and
empowering community development for staff
4.6.1 Objectives of strategy STA-6:
Strategy STA-6 aims at investing in the improvement of the potential long-term health impact
of hospitals for their staff, by initiating or participating in specific local health promoting66
community development projects which aim at improving health related living conditions /
infrastructures in the local community for specific needs of their staff.
4.6.2 Indications for strategy STA-6:
The impact of health promoting community development for staff has not yet been
systematically researched. But there is a number of conditions that are of specific relevance
for healthy and safe work performance (especially when shift work is involved), e.g.
availability and opening times of kindergartens, opening times of shops, availability of public
transport around the clock, street lights (for walking home at night), availability of health
promoting leisure time activities.
The feasibility of hospital involvement in community development for their staff is shown by
many projects of the International Network of HPH67.
4.6.3 Implementation of strategy STA-6:
The implementation of strategy STA-6 is about participating in / initiating of health promoting
initiatives and projects in the local community, which (also) benefit the health of staff.
Strategy STA-6 builds upon strategy STA-3. It should be matched with strategies PAT-6 and
COM-6.
The following list provides examples of possible measures for implementing strategy STA-6:


65
Identify areas of community infrastructure (e.g. by questionnaire) which are of specific
concern for hospital staff – e.(e.g. lack of kindergarten places, insufficient public
transport)
Lobby for improvement of identified areas of concern (e.g. in the framework of Health
Cities).
This description partly, together with PAT-6 and COM-6, replaces slide no. 45 in Barcelona power point file
positive health protecting and developing, disease preventing
67
See e.g. Virtual Proceedings of International HPH Conferences at www.univie.ac.at/hph
66
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Community oriented core strategies
5.1 Core strategy COM-1: Empowerment of community for
adequate health promoting access to the hospital
5.1.1 Objectives of strategy COM-1:
Strategy COM-1 aims at optimising / improving the health outcome of the hospital for
members of the community, by improving adequate health promoting68 access (avoid both
over- and under-use) to hospital services for all (ill or diseased) members of the local
community who are in need of these specific services. The goal is to improve the
effectiveness of hospital services by improving both timeliness and the scope of access of
patients, as well as the quality of admission. This can only partially be achieved within the
hospital, but has to include also the improvement of partnerships of the hospital with all
relevant health care institutions who are responsible for initiating admission or assigning
patients to the hospital.
5.1.2 Indications for strategy COM-1:
The quality of admission policies of hospitals and of co-operation between the intra- and
extra-mural sector of the health care system affect possibilities for effective treatment and
care, and by that the health of the population69. (references?)
Hospitals therefore need – and can –successfully improve these conditions. 70
5.1.3 Implementation of strategy COM-1:
Strategy COM-1 refers to developing the admission processes of the hospital to make them
more accessible for all in need of the specific services, especially by lowering specific
cultural barriers and better information policies to empower patients for timely access, and to
developing good partnerships with and empowering institutions in the extra-mural sector of
health care and in the community for better co-operation and co-production in the
assignment and admission of patients.
The following list provides examples of possible measures for implementing strategy COM-1:
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Include community empowerment for adequate access to the hospital into the hospital’s
goals.
Map out status quo of community empowerment for access to the hospital and develop
adequate measures
Provide adequate information about hospital admission for general practitioners and
other health service providers in the hospital community (e.g. develop admission
protocols for specific diagnoses);
Provide adequate information about hospital admission for the general public, e.g. via
internet or via local mass media (e.g. when and how to contact the hospital).
Provide adequate information about hospital admission for specific population groups via
adequate channels (e.g. elderly; cultural communities)
positive health protecting and developing and – progress of – disease preventing
(WHO - Europe 1999)
70
as is also demanded by the Ljubljana Charter on Health Care Reforms (WHO - Europe 1996)
68
69
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Provide alternatives for hospital stay by offering day care hospitals, short stay hospitals,
hospitals without beds71
Empower health care providers in the community to avoid unnecessary hospital stays by
providing hospital at home services72
Monitor community empowerment for admission for regular improvement.
Strategy COM-1 should be developed in accordance with strategy COM-2, since they partly
involve the same partners.
Core strategy COM-2: Empowerment of community for health
promoting co-production in treatment and care after discharge
5.2.1 Objectives of strategy COM-2:
Strategy COM-2 aims at optimising / improving mid-term health outcomes of hospital
treatment and care for patients by securing optimal health promoting73 () continuity of care
after discharge, through empowering, enabling and supporting carers next in the chain (or
network) of care, for those patients whose condition demands it.
5.2.2 Indications for strategy COM-2:
Continuity of care is a determinant of the effectiveness of health care and therefore of health
gain74. Hospitals therefore need – and can successfully – contribute to improving the
continuity of care75.
Those next in the chain / network are willing and able to cooperate, if approached
adequately, as demonstrated by numerous projects in HPHs all over Europe. Therefore,
central strategies of the Budapest Declaration and the Vienna Recommendations on Health
Promoting Hospitals call for an improvement in intersectoral co-operation in health care76.
5.2.3 Implementation of strategy COM-2:
COM-2 is about developing the discharge processes of the hospital to make these more
compatible with the needs and possibilities of carers next in line, by developing good
partnerships with and empowering institutions in the extra-mural sector of health care and in
community for better co-operation and co-production in discharge and take-over of patients.
The following list provides examples of possible measures for implementing strategy COM-2:

Include community empowerment for health promoting co-production in treatment after
discharge into the hospital’s goals.
71
(WHO - Europe 1999)
(WHO - Europe 1999)
73
positive health protecting and developing, disease preventing
74
(WHO - Europe 1999)
75
see e.g. New South Wales Better Pratice Guidelines for Admission and Discharge (NSW Health Department
1998)
76
Budapest Declaration: Strategy 9: Improve communication and collaboration with existing social and health
services in the community. Strategy 17: Develop an epidemiological data base in the hospital specially related
to the prevention of illness and injury and communicate this information to public policy makers and to other
institutions in the community. Vienna Recommendations: Implementation strategy 2.4: improving the
hospital’s communication and cooperation with social and health services in the community, communitybased health promotion initiatives and volunteer groups and organisations, and thus helping to optimise the
links between different providers and actors in the health care sector (Health Promoting Hospitals Network 1991;
72
WHO 1997)
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Map out status quo of community empowerment for health promoting co-production in
treatment after discharge and develop adequate measures
Developing discharge protocols
Improve information flow between hospital and those next in the chain / network of care,
including patient relatives
Empower carers in the community for hospital at home services
Monitor re- admissions to the hospital for regular improvement.
Strategy COM-2 should be developed in accordance with strategy COM-1, since both involve
partly the same partners.
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5.3 Core strategy COM-3: Development of hospital into a health
promoting and empowering setting for the community
5.3.1 Objectives of strategy COM-3:
Strategy COM-3 aims at optimising / improving the long term health impact of the hospital as
a material and social environment for the (neighbouring) population in the community and in
the wider society, whose health is affected by hospital decisions and actions. The aim is to
developing the hospital into a more health promoting and empowering77 () supportive setting
for these stakeholders.
5.3.2 Indication – why?
There is enough scientific evidence that settings have an impact on the people affected by
them78. For the surrounding population, hospitals produce specific risks (e.g. waste,
transport), but also specific resources (e.g. hospitals are important regional purchasers).
Trough adequate measures, hospitals can successfully reduce the risks for the community
and increase their respective resources79, as is also demanded in the Budapest Declaration
and the Vienna Recommendations on Health Promoting Hospitals80.
5.3.3 Implementation of strategy COM-3:
The implementation of strategy COM-3 relates to the development of the material and sociocultural inputs and output processes in a more health promoting direction.
The following list provides examples of possible measures for implementing strategy COM-3:
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77
Include settings development for the community into the mission statement of the hospital
Map out problematic characteristics in the setting (e.g. areas with huge amounts of
waste) and develop adequate measures for improvement
Reduce energy consumption of the hospital (implement an energy commission)
Implement adequate waste and emission management
Implement a traffic policy (e.g. lobby for adequate public transport to the hospital in order
to reduce visitor and staff commuting in the neighbourhood)
Implement a purchasing policy (e.g. purchase only in the near environment to avoid long
transport; purchase biological products where available)
Open the hospital as a meeting place for the community (as is done in combination with
arts in many projects in HPHs all over Europe)
Monitor measures for regular improvements
positive health protecting and developing, disease preventing
WHO Jakarta Declaration on leading Health Promotion into the 21st Century: „There is now clear evidence
that particular settings offer practical opportunities for the implementation of comprehensive strategies. These
include mega-cities, islands, cities, municipalities, local communities, markets, schools, the workplace, and
health care facilities”.(WHO 1997)
79
E.g. the Vienna Hospital Association has launched a policy that hospitals should purchase goods in the near
community if possible, and that biological food products are to be preferred.
80
Budapest Declaration: Strategy 3: Raise awareness of the impact of the environment of the hospital on the
health of patients, staff and community. The physical environment of hospital buildings should support, maintain
and improve the healing process. Vienna Recommendations: Hospitals are producers of large amount of waste.
They can contribute to the reduction of environmental pollution and, as consumers of large amounts of products,
they can favour healthy products and environmental safety. (Health Promoting Hospitals Network 1991)
78
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It is advisable to plan and implement strategy COM-3 related to strategies STAFF-3 and
PAT-3, since there will be overlap and may be partly even possible contradictions, which can
best be solved by optimising settings conditions for all relevant stakeholders at once.
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5.4 Core strategy COM-4: Empowerment of community for health
promoting management of chronic illness
5.4.1 Objectives of strategy COM-4:
Strategy COM-4 is about investing in the improvement of potential mid-term health outcomes
of hospital for the general population in the local community by offering specific empowering
services, e.g. patient education, to allow for a more health promoting81 management of
physical, mental and social consequences of chronic disease. This will also enhance the
disease specific quality of life for patients from the local community.
5.4.2 Indications for strategy COM-4:
As numerous reviews point out, knowledge and skills concerning the self-management of
specific impairments or diseases are important determinants of mid-term recuperation and
quality of life and, in the case of chronically ill patients, also of retarding the progress of
disease82.
Patient education is an adequate means to empower patients for disease-specific selfmanagement, and is also in line with the Ottawa-Charter on Health Promotion83.
The feasibility of patient education in hospitals is demonstrated by many projects in the
International Network of HPH84.
5.4.3 Implementation of strategy COM-4:
The implementation of strategy COM-4 is about the provision of empowering, disease
specific counselling, education and rehabilitation services to build up particular health (&
specific disease) literacy85 to allow for recuperation and healthy living with the consequences
of (chronic) illness in everyday life. Measures and policies for strategy COM-4 will have to be
disease and treatment specific.
The following list provides examples of possible measures for implementing strategy COM-4:

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


Identify diagnosis groups in need of education and counselling services (e.g. diabets,
COPD);
When choosing counselling methods, build upon the best available material and
methodology (check for effectiveness reviews);
Provide education and counselling services according to specific cultural (language, age,
sex, religious) needs of population groups;
Provide adequate environment for education and counselling services;
Monitor services for continuous improvement.
Strategy COM-4 overlaps partly with strategies PAT-4 and STA-4. Therefore joint services
can be provided for staff, patients and community members.
81
positive health protecting, further progress of disease preventing, and positive health developing
see e.g. (Devine, Pearcy 1996; Hirano, Laurent et al. 1994; Lacasse, et al. 1996; Mazzuca 1982; Smith, et al. 1992)
83
WHO: „Enabling people to learn throughout life, to prepare themselves for all of its stages and to cope with
chronic illness and injuries is essential.” (WHO 1986)
84
see e.g. Virtual Proceedings of International HPH Conferences at www.univie.ac.at/hph
85
knowledge and motivation, skills and capacities
82
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5.5 Core strategy COM-5: Empowerment of community for health
promoting lifestyle development
5.5.1 Objectives of strategy COM-5:
Strategy COM-5 aims at investing in the improvement of the potential long term health
outcomes of hospitals for the general population in the local community, by offering specific
empowering services, e.g. health education, for more health promoting86 lifestyles of the
general population the in community. This will also enhance the quality and longevity of their
life.
5.5.2 Indications of strategy COM-5:
Lifestyles (nutrition, exercise, consumption of substances like alcohol, nicotine) have a
proven long-term effect on health87.
Research and case studies from around the world provide convincing evidence that health
promotion can develop and change lifestyles.88
Hospitals have the potential (knowledge and skills) to offer effective lifestyle education and
counselling services, as is shown in many projects of the International HPH network89.
5.5.3 Implementation of strategy COM-5:
Implementing strategy COM-5 is about providing staff empowering, life-style specific health
promoting counselling, education and rehabilitation services to build up particular knowledge
and motivation, skills and capacities to facilitate healthy lifestyles and decisions of the
general population in the hospital community.
The following list provides examples of possible measures for implementing strategy COM-5:





Open hospital lifestyle education and counselling services for community members and
provide adequate information about accessibility of services (e.g. information sheets for
GPs and community pharmacies, information via internet – see also strategy COM-1);
Provide lifestyle education and counselling services based upon best available material
and methodology (check effectiveness reviews);
Offer lifestyle services at convenient times;
Combine lifestyle education and counselling services with general community
development (see also strategy COM-6).
Monitor services for continuous improvement
Strategy COM-5 builds on strategies COM-1, COM-2, and COM-4.
It overlaps partly with strategies STA-5 and COM-5. Joint services can therefore be provided
for staff, patients and community members. When specific lifestyle problems of patients are
concerned (e.g. lifestyle problems due to work organisation), specific services will be
necessary.
86
positive health protecting and developing, disease preventing
see e.g. (World Health Organization 2002; Tubiana 2000; Willett 1995)
88
see Jakarta Declaration on Leading Health Promotion into the 21st Century (WHO 1997)
89
see e.g. Virtual Proceedings of International HPH Conferences at www.univie.ac.at/hph
87
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Core strategy COM-6: Participation in health promoting and
empowering community development for the general
population
5.6.1 Objectives of strategy COM-6:
Strategy COM-6 aims at investing in the improvement of the potential health impact of
hospitals on the populations of their local communities, by initiating or participating in specific
health promoting90 community development projects, which aim at improving health related
living and working conditions (housing, traffic, nutrition etc.) in the local community.
5.6.2 Indications for strategy COM-6:
Living and working conditions have a proven impact on health (e.g. quality of drinking water,
exposure to noise and pollution, hazardous traffic situations, availability of healthy nutrition).
Community development is therefore an important goal of health promotion strategies91.
From the diagnoses that are the reasons for hospital admissions, hospitals usually have a
good overview about health hazards in their local communities (e.g. specific risky
workplaces, traffic situations, exposure to specific toxic agents, ...) and about specifically
affected population groups. They also have a lot of knowledge and expertise to guide /
support relevant interventions.
The feasibility of hospital involvement in community development is shown by many projects
of the International Network of HPH92.
5.6.3 Implementation of strategy COM-6:
Implementing strategy COM-6 is about initiating and participating in health promoting
development initiatives and projects in and for the local community.
The following list provides examples of possible measures for implementing strategy COM-6:





90
Analyse hospital data to identify major health problems in the community
Use hospital data for health reporting to the community
Initiate action on major local health problems93
Join / support local health promotion initiatives
Initiate / participate in healthy alliances (e.g. in the framework of Healthy Cities, Healthy
Enterprises, Healthy Schools initiatives)
positive health protecting and developing, disease preventing
e.g. Ottawa Charter (WHO 1986). Jakarta Declaration (WHO 1997).
92
See e.g. Virtual Proceedings of International HPH Conferences at www.univie.ac.at/hph
93
Examples: Graz University Hospital (Austria) initiated a traffic safety campaign after having identified some
„hotspots“ for traffic accidents with children in the city of Graz. Linköping University Hospital (Sweden) cooperated with supermarkets in order to increase provision of healthy goods)
91
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6 HPH thematic policies:
Within and across to the core strategies, we propose to follow specifically focused, but for
that specific focus comprehensive, single thematic health promoting policies to be planned
and implemented in Health Promoting Hospitals.
Specific thematically focused health promoting policies deal with particular health factors or
determinants of health within and of a hospital in a comprehensive way.
These thematic health promoting policies partly do overlap, so there is need for matching
them with each other and for tuning these policies as instruments of HPH action.
So as the strategies, thematic policies too have to follow health promotion criteria:
1.
Be oriented at a comprehensive multi-dimensional understanding of health
2.
Be oriented at all stakeholders involved and at health of all categories of people
possibly affected by the policy
3.
But accept differences in specific needs and cultural diversity of people involved or
affected
4.
Take into account the different ways health is re-produced by individual selfreproduction, and individual and collective action
5.
Be oriented at all relevant determinants of health, personal as well as situational,
material as well as socio-structural and cultural
6.
Follow the HP principles of being empowering, participatory, holistic, equitable
sustainable, intersectoral and multistrategy in the content of as well as in the planning
and implementation of the policy.
Exemplary list of thematic HPH policies related to self care and lifestyles:
Accidents & Safety policy
Alcohol policy
Communication policy
Drugs policy
Exercise poliy
Nutrition policy
Physical activity
Privacy policy
Smoking policy
Exemplary list of thematic HPH policies for creating supportive hospital settings for
patients and staff:
Air
Architecture, design and landscaping policy
Cleaning management
Ergonomics
Heating management
Hygiene policy
Light
Materials, used
Noise
Pollution management
Safety
Transportation management
Waste management
Structuring of hospital day (e.g. times of wake up, rounds, meals, sleeping)
Visitors ( times, facilities)
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The hospital as a health protecting and disease preventing setting for the health of
people in its environment
Comprehensive eco-management system
Emission and sewage management policy (to reduce and ecological dispose of chemical
and biological pollutants in used air and water, e.g. antibiotic relay, CO2, Cytostatica,
dioxin, mercury and fluorocarbon from cooling systems)
Energy and resources reduction policy
Purchasing management (preference for biological, ecologically produced and
ecologically packaged products; cf. guidelines for food by Viennese Hospital Trust)
Traffic management policy (connecting the hospital with public transport system; offering
staff tickets to use public transport)
Waste management policy (to reduce, separate, and ecological dispose solid material,
especially nuclear, biological and chemical contaminated materials)
Specific thematic policies for the hospital as a staff oriented healthy workplace
Health circles for staff
Safety at work
Support for managing private life (Hospital Kindergarten etc. )
Working load
Working time
The hospital as a strong partner in local health promoting community development
Community health documentation, monitoring and reporting (e.g. analysis of hospital
patient data, participation in population screening projects or population health surveys)
HP information and education for local community (for specific HP community
development projects;
within curriculum of schools or adult education programs; by organising specific events or
by establishing health information centres or health information terminals in public places,
health platforms on the web; or by cooperation in initiatives and projects with other
partners (health care providers like general practioners and pharmacies, specific
treatment agencies)
HP counselling for local enterprises, schools and other organisations
Engagement in specific HP developments projects
(e.g. Healthy housing for the underprivileged, Healthy traffic and playgrounds for children)
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7 Challenges and basis for implementing Health
Promoting Hospital strategies
7.1 Challenges for implementation of health promotion strategies
in hospitals
The introduction of a holistic and more complex understanding of health (expected health
outcomes) and the production of health in the hospital, as explained in the 18 HPH core
strategies, has to be followed by more comprehensive and complex processes and
structures in the hospital organisation.
These processes and structures have to be integrated into all existing procedures and be
accepted and followed by everybody working in the hospital. This cannot be implemented by
just making some structural changes in hospitals, but the introduction of these paradigm
extensions requires basic changes in the culture of the hospital and the culture of the
professionals working there.
These changes best have to start in the basic professional education and be supported by
specific further education and training for health promotion in hospitals.
Without initiative and strong leadership support, this kind of culture change will not happen,
and not develop in a sustainable way in hospitals.
The three health promotion potentials (of achieving improved short-term, mid-term and longterm health outcomes) provide quite different challenges for implementation in hospitals.
Some specialised health promotion strategies need to be implemented by adding on new –
or by differentiating already existing – departments or positions / roles in hospitals. This could
be either
 units for rehabilitation, prevention, health education / promotion, safety & occupational
health or even community development,
 or new types of professionals like rehabilitation specialists, psychologists, education
specialists, social workers, specialists for hygiene, occupational health, health promotion,
or even sociologists etc.
7.2 Practical experience
Since the existence of the international HPH network, and of course also before and outside
of it, hospitals all over the world have developed and implemented health promotion
solutions, although these have been rarely properly documented and evaluated. But there
are examples of good and best practice, which demonstrate that effective solutions can be
successfully implemented by hospitals.
Descriptions of these solutions have been presented at HPH and other conferences, have
been published in the HPH newsletter, in conference proceedings and other journals, and
they can be found in the HPH project data base and at other websites.
7.3 Political declarations and professional recommendations
Based on research experience, evidence, and consensus processes, many agencies
investing in health policy, lead by WHO, the World Bank, EU have laid down principles and
declarations supporting the implementation of health promotion principles and practices (in
hospitals).
The same holds true for professional bodies and NGOs like IUHPE, European Network of
Workplace Health Promotion, and others who have developed health promotion relevant
materials, guidelines and recommendations.
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7.4 The implementation of health promotion into hospitals as a
specific quality improvement strategy – principal approaches
The introduction of health promotion strategies does not just happen or cannot just be left to
chance in hospitals. Health promotion strategies have to become an integral part of the
official hospital (quality) policy, and be institutionalised and supported in a systematic
fashion, analogous to quality management.
We propose therefore to understand HPH as a specific strategy to improve hospital quality
by developing
 health promotion processes,
 health promotion structures and
 a specific health promotion quality system
As we can see from quality management, there are two principal approaches to implement
good quality (in hospitals):
1. Single quality development projects
2. Comprehensive “total” quality management
7.5 Single health promotion project approach
Health promotion can be implemented into hospitals by selected health promotion projects,
to realise specific health related aims or solve specifically assessed health problems of a
hospital, a strategy which has been followed by many hospitals within the last decennium.
Health promotion implementation projects have to follow the usual project implementation
cycle: setting goals  assessing problems (and causes)  planning and implementing
measures (using best available evidence for section of measures)  evaluation  and so
on.
Evaluation should follow 7 principal criteria in 3 phases:
1. comprising a feasibility study (criteria 1-3)
 Plausibility of intervention
 Acceptability for stakeholders
 Socio-technical feasibility of measure in a specific context
2. quality monitoring or process evaluation (criteria 4)
 Quality of implementation of measure
3. outcome evaluation (criteria 5-7).
 Effectiveness (outcome & impact)
 Sustainability
 Cost-effectiveness/ efficiency
But in order to follow health promotion principles not only in content, but also in process, the
development of a health promotion project (planning, implementation and evaluation) has to
be done in a participatory manner including all relevant stakeholders involved in and affected
by the issue in question. So, following health promotion principles, standards have to be
formulated concerning the adequate health promoting development of projects.
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7.6 The continuous, complete, comprehensive, holistic, overall or
total HPH approach
But to become a Health Promoting Hospitals is more than the occasional tackling of health
promotion projects in a hospital. There is a (more or less) total approach of HPH evolving,
which could be understood as a systematic, comprehensive and continuous organisational
development strategy or process, comparable to other comprehensive strategies which are
already (partly) followed or could be used by hospitals, like (total) quality management (e.g.
EFQM or CQI, Kaizen), learning or intelligent organisation.
To be effectively implemented and realised, such comprehensive developmental approaches
have to rely on a specific organisational subsystem institutionalised within the hospital,
specialised for and focused on initiating and supporting the development process throughout
all the sub-units of the hospital.
Therefore, what a “quality management system” (e.g. SO 9000 certification) is for hospital
total quality policy, a “health promotion management system” will be for total HPH policy.
A number of necessary or favourable characteristics of a health promotion management
system, in the sense of a specific supporting system for continuous and comprehensive
implementation of health promotion, can be identified. For these characteristics criteria can
be formulated, which have to be developed into health promotion standards and integrated
into protocols and guidelines:
7.7 List of criteria for a health promotion management system in a
HPH – Outcome
There have to be explicit
 goals,
 criteria,
 standards and
 indicators for health promotion outcomes,
 (as well as for health promotion processes, for health promotion structures and for health
promotion quality monitoring)
 so that fulfilment of being a HPH can be regularly observed, monitored, documented,
evaluated, reported and improved.
7.8 List of criteria for a health promotion management system in a
HPH – Structure





Health promotion as explicit aim and value in mission statement of hospital (should
include reference to patients rights, health of patients, staff and community etc.)
Formulated health promotion strategic policy document, specifying aims, goals, targets
and health promotion principal and core strategies and policies to reach them
Specific annual health promotion action plan
Specific budget ear-marked for health promotion
Specific health promotion management structure
 health promotion steering committee (including a member of the directorate of
the hospital),
 health promotion manager / team (reporting directly to directorate of hospital),
 network of health promotion focal points in all sub-units of hospital
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Specific health promotion organisational manual
7.9 List of criteria for a health promotion management system in a
HPH – Processes





Regularly monitoring, evaluation, reporting and improvement initiatives of health
promotion outcomes and impact (by surveys, balanced score card, reporting)
Regularly health promotion information and health promotion involvement of staff and
leadership
health circles,
employee suggestion system
implementation projects
news-letters,
annual presentations,
forum on website
Health promotion education and training for staff and leadership
Regularly conducting health promotion projects for planning and implementation of
specific health promotion policies
Regular involvement of hospital in healthy alliances and partnerships with other
partners in local community
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9 Glossary
The intention of this glossary is to propose the usage of specific terms of relevance for health
promation in an interrelated and connected way.
9.1 Health promotion related
Disease (vs. positive health): an impairment of the normal state of an organism that
interrupts or modifies its vital functions.” (Encyclopädia Britannica;
http://www.britannica.com/), but we propose to use the term disease for mental and
social impairments as well
Disease, absence of: absence of physical, mental, social disease / impairments of a person
Disease, treatment of: clinical and nursing, caring and curing/ therapeutic interventions to
stabilize or improve the health (>)of an individual, by eliminating, reducing or
mitigating causes and effects of specific diseases (>)
Disease prevention: interventions to maintain the health (>) of individual(>) or of
populations (>), by measures directed at eliminating or controlling the
pathogenic (>) effects of particular risk factors (>), known to be causal for the
genesis and development of specific diseases (>)
Empowerment: improving/ improvement of control of an individual or a population
over its health determinants (>)/ factors (>)
Fitness (vs. wellness):
Health: a quality of human beings (living systems) related to their capacity of selfreproduction / self-maintenance in time, which can be observed in a multi-dimensional
(>) way
Health determinants: pathogenic (>) and/ or salotogenic (>) qualities of a human being
(living system) and its relevant environments which (causally) determine the selfreproduction of the human being (living system), and, by that, its health (>)
Health, development of: improvement/ increasing the level of individual (>) or population
(>) health (>), by interventions like rehabilitation, exercise, training etc. enhancing
positive (>) health
Health, dimensions of: health is a multi-dimensional quality, i.e. it can be observed
concerning at least 4 different dimensions: ill/ well-functioning/ feeling, absence of
disease (>)/ presence of positive health (>), somatic/ mental/ social, individual/
population
Health factor: qualities of a human being (living system) and its relevant environments,
which affect the self-reproduction of the human being (living system) - and by that its
health (>) - in a complex way
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Health, individual (vs. population): individual level of physical, psychological and
social health
Health, population (vs. individual): statistical aggregation (sum, average, variation)
of indicators for individual health of the members of a defined collective
Health, positive: physical/somatic, mental and social health resources - well functioning
(fitness) (with vital functions at its core) and well being (wellness)- of individual human
beings or populations
Health, protection of (vs. disease, prevention of): interventions to maintain individual or
population health (>), by measures protecting loss of positive health
Health, re-production of: the way a human being (living system) reproduces his / her / its
physical, psychological and social status by adequate behaviour and action
Health care context: the situational circumstances under which health services are provided
Health care service: specific professionally organized interventions to improve individual,
primarily somatic health
Health care setting: health care services and the context in which services are provided
Health counselling: professional interventions to influence health related decision
making by communicative means
Health education: professional interventions to influence specific individual determinants of
health, like health literacy (>), by communicative means
Health gain (vs. loss): the sum of health outcomes and health impacts, attributable to a
specific intervention, action, behaviour or to an actor, an object or a situation.
Health impact (vs. outcome): rather diffuse and unintended health related consequences of
an object, a situation, or an action
Health improving (vs. healthy): health gain attributable to qualities of …..
Health literacy: positive health /disease related knowledge, skills and attitudes of an
individual or population
Health loss (vs. gain): the sum of adverse effects on health, attributable to a specific
intervention, action, behaviour or to an actor, an object or a situation.
Health maintaining (vs. improving):
Health outcome (vs. impact): rather specific and intended health related effects, attributable
to an health promoting intervention
Health promoting (vs. healthy): health improving, i.e. disease reducing or positive health
developing, qualities or healthoutcomes, attributable to an object (e.g. medication), a
situation or an action (e.g.treatment, rehabilitation, training)
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Health promoting hospital: a hospital that is engaged to improve its health gain by
systematically, continually and comprehensively applying HP principal strategies (>),
HP core strategies (>) and HP policies (>)
9.2 Health promotion
Health promotion management system in a HPH: organisational structures and processes
institutionalised in a HPH to initiate and support a total HPH approach to optimise the health
gain of the hospital (see chapter 7 of the paper)
9.3 Health promotion policies of a hospital :
Health promotion, principles of: principals concerning aims and strategies of health
promotion
Health resource factor (vs. risk): determinant/ factor known/ proven to be salutogenic (>)
Health risk factor (vs. resource): determinant/ factor known/ proven to be pathogenic (>)
Healthy (vs. health promoting): health maintaining, i.e. positive health protecting and
disease preventing, qualities or positive health impact, attributable to an object, situation
or action
Lifestyle (vs. setting) approach in HP: a strategy of health education (>) / health promotion
(>)to improve the health (>) of a human individual or population by trying to change
health related behaviour/ action by improving personal health literacy (>)
Pathogenic (vs. salutogenic): negative, i.e. disease (>) producing health impact (>) on the
self-reproduction of a living system, attributable to an object, a situation or an action
Salutogenic( vs. pathogenic): positive, i.e. positive health (>) producing, health impact (>)
on the self-reproduction of a human being (living system), attributable to an object, a
situation or an action
Setting (vs. lifestyle) approach in HP: a comprehensive strategy to improve the health (>)of
a human population, by improving the health gain attributable to an organisation
(business enterprise, hospital, prison, school, university) or community (city, island,
village) by health related organisational or community development
Wellness(vs. fitness): subjective judgement of personal physical, psychological and social
status