Health promotion in hospitals—a strategy to improve quality in health care

The International Network of Health Promoting Hospitals (HPH) was initiated more than 10 years ago with the aim to reorient health care institutions to integrate health promotion and education, disease prevention and rehabilitation services in the curative care.1 An increasing number of chronic patients, requiring continuous support, and hospital staff frequently being exposed to physical and emotional strains pushed in this direction. Health promotion is defined in the Ottawa Charter as “the process of enabling people to increase control over, and improve, their health”.2 Health in this context not only refers to the objective view of the absence of disease but also to implying a subjective and holistic view, adding mental resources and social well-being to physical health. Health promotion is understood to embrace health education, disease prevention and rehabilitation services, but stresses that information, education and advice only lead to sustained behavioural change if supported by prevailing norms, rules and cultures. Health promotion interventions in organizations therefore have to address these underlying causes. There is large scope and public health motivation for offering health promotion strategies in health care settings. Hospitals consume between 40% and 70% of the national health care expenditure and typically employ about 1% to 3% of the working population.3 These working places are characterized by certain physical, chemical, biological and psychosocial risk factors. Paradoxically, in hospitals—organizations that aim to restore health—the acknowledgement of factors that endanger the health of their staff is poorly developed. Hospitals can also have a lasting impact on influencing the behaviour of patients and relatives, who are more responsive to health advice in situations of experienced ill-health.4,5 Given the increasing prevalence of chronic disease in Europe and throughout the world and low compliance with treatment, therapeutic education is becoming a major issue.6 Most hospital treatments do not cure but rather aim at improving the quality of life of patients. To maintain this quality, patients and relatives have to be prepared and educated more intensively for discharge. Hospitals produce high amounts of waste and hazardous substances. Introducing health promotion strategies to hospitals can help to reduce the pollution of the environment and cooperation with other institutions and professionals can help to achieve the highest possible coordination of care. Furthermore, as research and teaching institutions, hospitals produce, accumulate and disseminate a lot of knowledge and can have an impact on the local health structures and influence professional practice elsewhere. In order to draw attention to the issue of health promotion, hospitals in the International Network commit themselves to becoming a smoke-free hospital and to run three specific projects/activities addressing health issues of staff, patients, the community, or improving organizational routines with a possible impact on health. A database was established to register projects and activities, providing information on key indicators of the hospital and the health promotion activities (table 1): Table 1: Five most frequent activities related to patients, staff, organizational and community issues. The projects have a strong patient and staff orientation but mostly do not address the underlying structural or cultural problems. A further review indicated that most health promoting activities are still limited to a specific project or within the responsibility of a single staff member, rather than being implemented organization-wide.7 While initially many health promotion activities were driven by the conviction of individuals that hospitals could do more for the health of the people, evidence now supports the effectiveness of health promotion activities in hospitals. In addition, greater impact on the health of individuals and groups will be accomplished by health promotion activities being integrated in quality improvement programmes. The evidence base for health promotion is a main factor for HPH, since the lack of evidence, coupled with prevailing cost pressures in almost any health care system, tends to make health promotion programmes an easy choice for budget cuts.8 Evidence for health promotion was the focus of the International Conference on Health Promoting Hospitals in 2001 and the identification of present evidence and the creation of evidence where it is absent is now one of the main targets for the international network. Health promotion in hospitals includes interventions directed at structures and processes, as well as interventions directed at individuals (patients and staff). The quantitative approach is relevant in the evaluation of many interventions. The value of specific interventions such as induced tobacco cessation or alcohol abstinence prior to planned surgery is unquestionably documented in randomized controlled trials.9,10 Also more complex interventions as rehabilitation programmes are documented by the quantitative approach.11,12 A prospective controlled trial proving the effects of an overall hospital programme for health promotion, a quality management plan or an accreditation program, however, is not feasible. Processes and structures in a programme must be assessed by a qualitative approach and this leaves room for interpretation of the results and a subjective or political judgment.13 A further development of assessment tools is important for HPH in the enforcement of the evidence base. The dominant approach to quality assessment of health care organizations is based on the definition of standards for the activities. Several organizations have developed standards mainly directed at hospitals but also some for the primary health care sector. Analysis of the standards reveals that they are relevant in focus and cover hospital services sufficiently except the issue of health promotion and patient education.14,15 This problem was taken up in the European HPH Network and a working group was established in May 2001 to develop a set of standards for health promotion in hospitals. The International Society for Quality in Health Care has developed guidelines for quality standards described in the ALPHA programme.16 The working group decided to follow these guidelines in order to develop a set of standards to fill out the gap in the existing standards. However no decision was made about the assessment of the compliance to the standards by the hospitals in the International Network of Health Promoting Hospitals. The five core standards describe the responsibility of the management to set a framework for health promotion and the demands on the organization and the staff in order to meet the patients' needs for health promotion.17 This implies the identification of patients' needs, patient education and advice (in order to empower the patient to correct risk factors), programmes for interventions and rehabilitation, cooperation with other sectors in health care to ensure continuity of care, and a special focus on facilitating a healthy workplace. The standards were pilot-tested in 36 hospitals in nine countries and in their revised form presented at the 11th International Conference on Health Promoting Hospitals in May 2003.18 The pilot test demonstrated that the standards were assessed by health professionals to be applicable and relevant, but compliance with standards was very low. Future work has been carried out in developing indicators, and a self-assessment tool for standards in health promotion in order the strengthen the systematic planning, implementation of evaluation of health promotion in hospitals.19 Despite little legislative support in many member countries the number of hospitals and countries joining the International Network of Health Promoting Hospitals has increased steadily over time (table 2). The network was build on philosophical principles and values without guidelines or concrete programmes for the implementation of activities in member hospitals and there is still a lack of information on the scope and quality of health promotion activities being carried out in these hospitals. Also there is no information available on the motivation for hospitals joining the network. Health promotion has to prove that it is worth the investment and so far we have little knowledge that a HPH is better than a non-HPH. However, only limited resources have been used to strengthen health promotion, so there is no reason to believe that it had a detrimental effect on hospital activities by reallocating resources from the core functions of the hospital. To obtain more information on the content and quality of health promotion activities in member hospitals, and to further anchor health promotion in hospital services and health care reform there is strong need for standards and the development of assessment tools for health promotion. Projects related to patients, staff, organization and community (HPH database) Development of International Network of Health Promoting Hospitals

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