Health Promoting Hospitals

"A health promoting hospital does not only provide high quality comprehensive medical and nursing services, but also develops a corporate identity that embraces the aims of health promotion, develops a health promoting organisational structure and culture, including active, participatory roles for patients and all members of staff, develops itself into a health promoting physical environment and actively cooperates with its community." This definition can be found in WHO´s Health Promotion Glossary, which is based on WHO´s Budapest Declaration on Health Promoting Hospitals. Thus, health promoting hospitals are actively attempting to become healthy organisations.

Background and Development of the International HPH Network

Health promoting Hospitals (HPH) is a child of WHO´s Ottawa Charter for Health Promotion (OC). One of the OC´s principles is to reorient health services, a principle which is also followed by the HPH network. To implement health promotion in hospitals the comprehensive settings approach is applied, which also was introduced by the OC. For instance hospitals are a setting and are defined as "place or social context in which people engage in daily activities in which environmental, organisational and personal factors interact to affect health and wellbeing."(WHO, 1998). Therefore settings offer convenient opportunities to implement comprehensive health promotion strategies by reducing risk factors as well as by promoting resources and capacities for health.

The OC's principle of reorienting health services postulates that "the role of the health sector, must move increasingly in a health promoting direction, beyond its responsibility for providing clinical and curative services". Furthermore, health services "should support the needs of individuals and communities for a healthier life", which must then "[...] lead to a change of attitude and organisation of health services, which refocuses on total needs of the individual as a whole person." (WHO, 1986). These principles have been reinforced by subsequent WHO conferences and declarations, especially by The Ljubljana Charter on Reforming Health Care, the conference in Mexico City and the Nairobi Call for action, which has a specific chapter on "Strengthening Health Systems".

Based on the OC, a first concept for HPH was developed by a WHO consultation, which then was tested in a feasibility study and a model project at the Rudolfstiftung hospital in Vienna. In the context of this project the WHO-Euro initiated in 1990 the international HPH network that endorsed the Budapest Declaration on Health Promoting Hospitals as the foundation for a European-wide Pilot Hospital Project (1993-1997) consisting of 20 hospitals in 11 countries. Based on the experiences gained from this project, the Vienna Recommendations on Health Promoting Hospitals were formulated defining concrete action areas and implementation strategies for HPH.

Parallel to the European pilot hospital project, international network structures and media have been established: Annual conferences (19 to date), a newsletter and regular business meetings, summer schools and workshops. Since 1995 national or regional networks have been founded, offering similar structures and media on national or regional basis. From then on the international HPH network has been continuously expanding, especially since 2005 when HPH opened for non-European networks. Moreover, task forces for specific vulnerable groups – migrants, arising from an EU project "Migrant friendly Hospitals" (www.mfh-eu.net), children and adolescents and psychiatric patients - or specific issues of Health Promotion (HP) – tobacco, alcohol, nutrition and environment - have been initiated and offer quality criteria, instruments and model of good practice. An overview and further information of all task forces and also working groups of the HPH are available online (www.hphnet.org).

In 2008, the international network became an international association under Swiss law, opened up to other health services than hospitals and broadened its name to "International Network of Health Promoting Hospital and Health Services" (HPH). The HPH constitution defines national/regional networks as core members of the international network, which recruit healthcare organisations as members. (For countries without a network yet, also single healthcare organisations can become individual members in the international network.) HPH has a governance board elected by the general assembly, an international secretariat at the WHO-CC for Evidence-Based Health Promotion in Copenhagen (www.hphnet.org) and a secretariat for international conferences at the WHO-CC for Health Promotion in Hospitals and Health Care in Vienna (www.hphhc. cc). Since 2010 the network is related to the WHO-Euro by a Memorandum of Understanding comprising annual action plans (WHO-Euro, 2009). Currently, HPH consists of 39 networks in 26 countries in five continents plus 93 individual members. In total, HPH has 841 members, mainly hospitals, worldwide (see Box 1, page 20).

Mission, Vision, Concepts, Tools and Measures of HPH

According to the constitution, HPH's mission is to "work towards incorporating the concepts, values, strategies and standards or indicators of health promotion into the organisational structure and culture of the hospital or health service. The overall goal is better health gain by improving the quality of healthcare, the relationship between hospitals/health services, the community and the environment, and the conditions for and satisfaction of patients, relatives and staff." (WHO, 2009).

Two sets of general tools link HPH to quality philosophy and management:

• 18 HPH core strategies – a strategic and quality framework for health promoting interventions; 
• Five standards on health promotion - a self-assessment tool with measurable elements for health promotion in hospitals (see Box 2).

There also are more specific tools, e.g. for workplace HP (Guide to Promoting Healthy Workplaces in Healthcare Institutions), migrants (Standards for Equity in Health Care for Migrants and other Vulnerable Groups) or children (self-evaluation model and tool on the respect of children's rights in hospital).

Patient Involvement 

There is also a wide range of measures to successfully promote the health of different hospital stakeholders. Patient-orientated measures focus on empowering people throughout the treatment process in order to gain better health literacy, for adherence with therapy and for self-management of diseases and health. Therefore, health professionals need specific knowledge and communication skills. Also, systematic patient involvement, health education or lifestyle development must be part of treatment routines (e.g. in form of guidelines, programmes, trainings, documentation). Specific examples for evidencebased health promotion in clinical practice are patient education for patients suffering from chronic diseases such as COPD, early rehabilitation after stroke, preoperative smoking cessation and alcohol intervention for patients undergoing elective surgery and integrated rehabilitation program for diabetic patients.

Healthy Staff 

Many jobs in hospitals are characterised by high physical and mental strain; therefore worksite health promotion is an important field of action for HPH. Proven measures for a healthy staff go beyond basic occupational health and safety programmes and combine structural prevention (e.g. working conditions, environment and culture) with behaviour oriented prevention. As knowledge centres for health, hospitals can also have an impact on their communities by public campaigns on risk factors and lifestyles and by providing health education services to specific vulnerable groups in the population, e.g. ethnic minorities and migrants. In an era of climate change, the hospital sector has an important role to play by setting norms and standards for environmentally friendly hospitals and applying evidence-based sustainable healthcare intervention programmes.

The Benefits of Investing in HPH Development

Different stakeholders of a hospital; patients, staff, community, management, owners, financing agencies and society as a whole - can expect somewhat different benefits through integrating health promotion into the daily routines of a hospital.
The benefits for patients resulting from health promotion programmes and strategies are improving health gains, higher quality of life and more satisfaction with the treatment and care. Subsequently this will enhance the effectiveness, efficiency and reputation of hospital services as well. 

The staff benefit from workplaces with reduced stresses and strains and an increased effort-reward balance is created. This is all the more important, since the major challenge of an ageing hospital workforce requires timely measures to maintain the work ability of employees. Studies report that the return of investment for work health promotion ranges between 1:2.5 and 1:10.1 simply for absenteeism.

For communities, population health needs will be better fulfilled by an HPH that sees this as part of its mandate and invests in community action as well. For hospital management, therefore, HPH is a possible answer to the rising and changing expectations of patients and their relatives, of employees, of communities, of health policy or administration and the public in healthcare market that is becoming a more and more competitive.

But before benefits can be expected from HPH, all these stakeholders will first have to make some specific investments in order to get their particular ROI. All stakeholders will have to take on greater responsibility and a more complex perspective, but in the end this will be worthwhile as relevant outcomes improve. But to invest in HP, hospitals need adequate regulations and financing schemes given by health policy as a precondition and an incentive to make their specific contributions.

Role of Hospital Managers

Deciding to become a HPH is a strategic decision comprising reform or reorientation, a step owners and top management of a hospital have to take together. This should be based on a health promotion strategic policy document, specifying aims, goals and targets as well as structures and processes for HP. To implement such a decision sustainably, nearly all staff members have to comply and therefore have to be motivated for this task. To support staffs' everyday experience of health promotion orientation and principles, a hospital has to build specific capacities for health promotion, as part of its quality management or as an own HP support system. Data from our current evaluation study of the HPH networks show that already 29 percent of the member hospitals choose the strategy of integrating health promotion into quality management. In order to influence everyday clinical practice, health promotion must be included into clinical guidelines and pathways.
All of these actions are definitely the task of hospital management and need leadership and continuous support by hospital managers. Research shows that one of the main barriers of successful implementation of HPH is a deficit of engaged leadership by top management and a lack of infrastructures and resources.

A literature review found that for good functioning of hospital health promotion services in their communities in the USA: "Managers used leadership and strategic planning to create mission, vision, goals and culture for HP. They allocated resources, delegated authority, assigned responsibility, motivated staff, measured results, made decisions, coordinated within the hospital, and collaborated outside the hospital. Skills and methods for marketing, finance, organisation design, human resources, operations management, performance evaluation, and inter-organisational relationships are needed to manage HP services." (Olden and Hoffman, 2011) Thus, hospital managers have quite a demanding, but also rewarding role to play supporting their hospitals on the way towards a HPH and a more healthy organisation.