Health Promotion International, Vol. 16, No. 3, 281-287,
September 2001
© Oxford University Press 2001
Health promoting hospitals: a typology of different organizational approaches to health promotion
Department of Public Health, Flinders University, Adelaide, Australia
Address for correspondence: Address for Anne Johnson Department of Public Health Flinders University Flinders Medical Centre Bedford Park South Australia 5042
SUMMARY
This paper draws on a review of the literature about the types of health promotion activities conducted by health promoting hospitals and an observation of how some Australian hospitals have structured the organizational arrangements to be more health promoting. This paper also draws on the experiences of one of the authors (A.J.) in managing and evaluating an organizational change process at a major specialist hospital in Adelaide, South Australia, that sought to re-orientate the hospital towards placing more emphasis on health promotion. From these three sources, a typology of four approaches of organizational arrangement to health promotion is presented. These approaches are: ‘doing a health promotion project’; ‘delegating it to the role of a specific division, department or staff’; ‘being a health promotion setting’; and ‘being a health promotion setting and improving the health of the community’. For the re-orientation of the specialist hospital to occur and be sustainable, the research indicated that over the case study period of 1994–1998 there had to be strong organizational commitment to change, supported at multiple levels of the organization, and reflected in policy and practice change. The paper concludes that more evaluative research of this type will be important if the rhetoric of healthy settings is to become a reality.
Key words: health promotion; health promoting hospitals; organizational arrangements; organizational change; re-orientation of health services
INTRODUCTION
The Ottawa Charter for Health Promotion (WHO, 1986) has led to the development of a series of health promotion initiatives based on settings. These settings have included cities, villages, schools, workplaces and hospitals. The focus of this paper is on hospitals as a setting for health promotion. In the paper we argue that the settings approach to health promotion is about much more than introducing a variety of opportunities for individuals using the hospital to change their behaviour. The case study of the process of sustainable re-orientation at a major specialist hospital in Adelaide, South Australia, suggests that to be health promoting in any meaningful sense a hospital has to be committed to instituting a process of organization development and change. The pressures for hospitals to broaden their role from the focus on treating diseases towards health promotion has been felt for more than a decade. Hancock argued that hospitals should not continue to function in isolation from the community around them and that they ‘must develop a community conscience rather than an institutional loyalty’ [(Hancock, 1986
), p. 23]. Despite such calls, Lalonde noted that hospitals were ignoring the pressure to embrace a more health promoting role and summed up their attitude as ‘let somebody else do it; we already have too much to do’ [(Lalonde, 1989), p. 40].
A settings approach endorses Hancock and Lalonde's perspectives and stresses the need for a significant re-orientation of the way in which hospitals operate. Given the strong institutional focus of modern hospitals with their very heavy reliance on high technology medicine, such a re-orientation would not be possible without significant and organization-wide commitment to the re-assessment of the hospital's role and function.
Why promote health through hospitals?
Hospitals are in a strong position within the health care system to be advocates for health promotion. They represent the main concentration of health service resources, professional skills and medical technology. Communities readily identify with hospitals. They generally have substantial prestige and their staff are well respected. They are seen as credible sources of advice and expertise on health issues beyond their responsibilities for sick care services (Aiello et al. ,1990). So although hospitals are the high temples of sick care, the extensive resources they command mean that even a small shift of focus has the potential to bring about an increase in resources dedicated to health promotion and, in time, health benefits to a community.
Health promoting hospitals
The basic premise of the notion of a health promoting hospital is to put into practice the fifth strategy of the Ottawa Charter for Health Promotion, that is the re-orientation of health services. Using the hospital as a setting also means implementing the Ottawa Charter's other strategies of devising healthy public policy, creating environments that are supportive of health, involving community people, and developing personal skills for promoting the health of staff and community members.
In practice, since the emergence of the health promoting hospital concept in the late 1980s, there have been many different interpretations of the concept and many of these have not incorporated the range of strategies suggested by the Ottawa Charter. Some examples of health promoting hospital practice have simply relied on behaviour change strategies and little else. The varying methods of implementation and differential interpretation of the concept of a health promoting hospital have led a number of commentators to call for a more consistent approach to the concept (Taillon and LeTouze, 1989; Health Education Authority, 1993; Pelikan and Krajic, 1996). The research reported here has resulted in the production of a typology of health promoting hospitals that should assist discussion by enabling clarity about the particular type of organizational approach being undertaken and the impact this will have on the way staff view their role in health promotion.
METHODS
The typology, which resulted from this research, is based on three sources of data. The initial source was derived from international literature that described the types of health promotion activities conducted by hospitals claiming to be health promoting. The activities were categorized into the five major themes identified during this analysis of the literature.
The second source of data was obtained through an observation of the most common organizational arrangements that several Australian hospitals adopted in their approach to be more health promoting. These were reviewed and analysed in relation to the themes emerging from the literature.
The third source of data was from the experiences gained by one of the authors (A.J.) in managing and conducting a case study of an organizational change process at a major specialist hospital in Adelaide, South Australia, which sought to re-orientate the hospital towards placing more emphasis on health promotion. The case study was conducted between 1994 and 1998 at the Adelaide hospital and was based on an action research approach (Johnson, 1998) This involved extensive participant observation by one of the authors (A.J.), and a variety of other data collection methods including surveys, interviews and focus groups. The case study provided the opportunity to explore in detail the concept of health promotion and how it applied to that particular hospital. In addition, the case study data in conjunction with the literature review and assessment of organizational arrangements for health promotion in other Australian hospitals permitted a synthesis of the organizational arrangement that indicated the best chance of sustainability of the health promotion approach in large specialist hospitals in Australia. The following sections use case study data to provide concrete examples of health promotion action within an acute care hospital and combines perspectives from the three data sources to develop a typology of health promotion in hospitals.
RESULTS
Health promotion at the case study hospital
The findings of the case study of the Adelaide hospital will be used to provide concrete examples of the different categories of health promotion activities.
The staff of the Adelaide hospital engaged in a range of health promotion activities that impacted not only on the health of patients and their families, but on staff, the organization, the physical environment and the broader community. These five categories of hospital health promotion activity were also consistent with the range of activities being undertaken by other health promoting hospitals, as reported in the WHO Health Promoting Hospitals Newsletters. Pelikan, based on his observations of WHO Health Promoting Hospitals Network, identified four categories of activities: patient, staff, organizational and community (Pelikan, 1996). The range of health promotion projects given awards through the New South Wales Health Promoting Hospitals Project (NSWHPH Project, 1996) were also consistent with these four types of categories identified by Pelikan and at the Adelaide hospital. It also supported the additional category of ‘physical environment’ that had been identified in the case study at the Adelaide hospital.
The main focus of health promotion activity during the period of the case study at the Adelaide hospital was on disease management and prevention, activities oriented towards ‘patients and their families’. This was through using the strategies of health education and health counselling, and developing partnership-in-care relationships between staff and patients and their families. The coordination of care and linking of patients and their families to community supports were also emphasized.
There were several ‘community’-oriented health promotion activities implemented by staff at the Adelaide hospital. The staff developed working relationships with consumers and a range of community groups and organizations, both within the health sector and other sectors. These relationships had the purposes of improving hospital to community support; collaborating to develop health education resources; collaborating to undertake health promotion projects to impact on the health of targeted groups of the community, e.g. ‘Never Shake a Baby’, ‘Folate before Pregnancy’, ‘Partnerships with Youth’, ‘State Food and Nutrition Health Promotion Program’, ‘State Asthma Program’, ‘Stop the Rot’ (prevention of dental caries in toddlers), ‘Safe Eating for the Under 4s’, ‘Safe Sleeping in the Under 2s’, and ‘Lock Up and Away! Poison Prevention Project’. Community education activities such as monthly health seminars, a hospital awareness programme for children <7 years of age, the infant cardio pulmonary resuscitation programme; and health information available through the Internet and health information centre were also introduced. An emphasis was also placed by the hospital on increasing the amount of information about health and illness provided to the community through the mass media.
Health promotion activities directed at staff and developed during the case study period were as follows: staff immunization; women's health clinic; nutritious hospital food for staff; lunchtime walking groups; and staff aerobics classes. However, staff health promotion was not seen as a priority by clinical staff. Their main focus was on patients and their families and the broader community. The staff that organized staff health promotion activities tended to come from the corporate services division of the hospital.
Activities that were categorized as ‘organization’ health promotion were: organization-wide programmes that primarily related to the occupational health and safety programme; an infection control programme; and the implementation and maintenance of the no-smoking policy. These programmes also meet legislative requirements. Activities in this area tended to come under the banner of continuous improvement projects as part of the quality management programme, rather than being described as health promotion activities.
‘Physical environment’ activities related to the waste management programme to reduce the amount of medical and general waste and improve recycling, and the different strategies used within the hospital to reduce energy consumption and green house gas emissions. As with the ‘organization’ activities, the ‘physical environment’ activities were generally described as quality management programmes that had an impact on the health of the organization (setting), and, in the instance of ‘physical environment’ activities, also on the broader physical environment of the community. Both of these areas involved a significant number of staff at all levels of the organization and resulted in significant cost savings to the organization.
The development of a hospital health promotion programme emerged as central to supporting these different types of health promotion activities. The key elements of a hospital health promotion programme identified were:
- strong leadership at different levels of the organization (especially from the Board of Management, Chief Executive Officer, Assistant Chief Executive Officer, Health Promotion Consultant and several champions from corporate and clinical areas);
- incorporation of health promotion into the hospital's vision and strategic role statements, policies, service agreements with divisions, and job descriptions for staff, as well as a specific health promotion policy;
- strategic, operational and evaluation plans for health promotion;
- staff development and education; and
- resources allocated (human, physical facilities and financial).
The case study of the Adelaide hospital suggests that unless each of these key elements is present and supportive of health promotion within a hospital, then a significant organizational re-orientation to health promotion is unlikely.
Organizational approaches to health promoting hospitals
The insights from the case study, an analysis of the various types of organizational arrangements for health promotion observed in different Australian hospitals and the categories of health promotion activities described in the literature led to the identification of two factors that enabled subsequent classification of types of organizational arrangements for health promoting hospital initiatives. These two factors are: (i) the degree of organizational commitment made by hospitals; and (ii) the types of health promotion activities undertaken.
As previously identified, the types of health promotion activities undertaken by hospitals could be grouped into five categories. These five categories are:
- patients and their families;
- staff;
- the organization as a whole;
- the physical environment; and
- the community that is served by the hospital.
When the various types of health promotion activities were combined with the level of organizational commitment to health promotion observed in various hospitals, four distinct approaches to health promotion emerged. These were:
- ‘doing a health promotion project’;
- ‘delegating it to the role of a specific division, department or staff’;
- ‘being a health promotion setting’; and
- ‘being a health promotion setting and improving the health of the community’.
It was evident that the first two of these approaches did not necessarily require an organizational commitment towards health promotion. Health promotion was often marginalized to the role of specific staff, departments or divisions, and was not integrated into the practice of staff throughout the organization.
The last two approaches, ‘being a health promotion setting’ and ‘being a health promotion setting and improving the health of the community’, require an organizational commitment to extend its role to be more health promoting. The case study at the Adelaide hospital suggests that to create a supportive hospital environ-ment for staff, and for a hospital to succeed in developing a more sustainable approach to becoming more health promoting, a hospital health promotion programme needs to be in place and health promotion needs to be integrated into the practice of staff throughout the organization. The components of a hospital health promotion programme have been discussed previously.
The following section describes each of the four types of health promoting hospitals suggested by the authors as being of relevance to understanding how different hospitals approach implementing the concept of health promoting hospitals.
Doing a project
The ‘doing a health promotion project’ approach does not generally challenge hospitals to re-orient the whole organization and the roles of staff to health promotion. In this approach, health promotion projects are usually ad hoc isolated events. The projects are not part of a strategic approach to re-orient the hospitals’ role in the community towards improving the health of the population, or develop the ‘setting’ to improve the health and well-being of patients and their families and staff. In this approach, the projects can be oriented towards any of the five categories (patients and families, staff, organization, physical environment, or community).
This approach has been criticized by Rushmere, who states ‘a health promoting hospital has health promotion as a core value within the organization. It is not simply a hospital with a few health promotion projects’ [(Rushmere, 1996), p. 11]. However, despite this criticism of the ‘doing a health promotion project’ approach, it may have an important place in the evolution, rather than transformation, of a hospital to become more health promoting. For example, it may be an appropriate starting point for staff who are interested in their hospital becoming involved in health promotion, but do not have the support of senior management for an organizational commitment at that stage. Implementing and evaluating an individual health promotion project may serve as a catalyst for gaining an organizational commitment. However, sustainability becomes a key issue if an organization continues to undertake ad hoc health promotion programmes without developing an organizational infrastructure to support the health promotion efforts of staff.
Delegating health promotion to the role of a specific division, department or staff
This approach has been observed in hospitals that have a health promotion unit, have designated health promotion workers, or have established community-oriented divisions or departments who ‘do health promotion’ or ‘have a community orientation’ for the hospital. If health promotion is restricted to particular divisions, departments or staff it remains a marginalized activity and does not necessarily challenge the whole organization to re-orient its role in the community, or for health promotion to be integrated into the roles of staff throughout the organization. A common phenomenon observed in organizations with this orientation is that staff working in these roles, departments or divisions often became limited in the impact they can have on re-orientation of the broader hospital, as health promotion was often seen as ‘their job’.
Being a health promotion ‘setting’
This approach tends to be the most prominent approach identified in the examples published by the WHO Health Promoting Hospital Network. This approach is predominantly focused on the hospital becoming a health promotion ‘setting’. In these cases the organization is committed to health promotion in the form of a hospital health promotion programme and health promotion activities directed at the health of patients and their families, staff, organization, and the physical environment of the hospital. However, there is no broader commitment to improve the health of the community served by the hospital. This approach is also consistent with the ‘get our own house in order’ philosophy expressed in some hospitals. This philosophy is based on the premise that until such time as the hospital is a healthy environment and has addressed the health needs of patients, their families and staff, the hospital cannot broaden their approach to improve the health of the community.
Being a health promotion setting and improving the health of the community
This approach signifies an organizational commitment to re-orient the hospital to be a health promotion ‘setting’, as well as improving the health of the community. Within this approach there is a hospital health promotion programme and there can be health promotion activities in all five categories. Vang supports this approach and states that it is important for hospitals to improve the balance between projects that are oriented towards the ‘setting’, and projects that are aimed at improving the health of the community (Vang, 1995). What is significant about this approach is that the hospital has to systematically develop effective and collaborative working relationships with patients and their families, other service providers and the broader community to achieve the best outcomes.
Table 1 represents a typology of the four types of hospital organizational arrangements for health promotion identified through this study. The four orientations towards being a health promoting hospital provide a framework to analyse how a hospital and its staff may perceive their health promotion role and responsibilities. For example, if a hospital approaches the concept of health promoting hospitals as type one or two, staff would view health promotion very differently to staff in a hospital that chooses to integrate health promotion into practice to ‘be a health promotion setting’ (type three) or to ‘be a health promotion setting and improve the health of the community’ (type four). With the first two types, staff would view health promotion as a marginal role for the hospital and externalize it as ‘someone else's role’ or the role of specific staff. The staff working in a hospital that adopts either type three or four would see health promotion as integrated into their own role as being part of the core business of staff throughout the hospital.
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CONCLUSION
This study has demonstrated that there can be a variety of interpretations of the meaning of a health promoting hospital initiative. Some hospitals do little more than move beyond providing health information and education to patients, while other initiatives achieve a significant re-orientation of their activities and institute significant organizational reform supported by strong policy and leadership. The typology offered in this paper provides a benchmark against which health promoting hospital developments can be evaluated. As sustainability is a key issue in any type of organizational change process, it is suggested that hospitals that develop approaches to health promotion in line with either types three and four of the typology would be more sustainable. This is because health promotion becomes integrated into the roles of staff throughout the organization and because of the development of crucial supportive organizational infrastructure, such as that described as being part of an organizational health promotion programme.
This paper also highlights the importance of being clear about the nature of any healthy settings initiative. There is a danger that the rhetoric of reform can be used (in this case labelling an initiative as a healthy setting project whether it be a healthy city, school, workplace or hospital), while in practice the initiative is doing little that is new and certainly not achieving the structural and organizational changes that are foreshadowed by the Ottawa Charter. We believe a more critical assessment of hospital health promotion initiatives is essential if the concept is to achieve its promise.
REFERENCES
Aiello, J., Barry, L., Lienert, L. and Byrnes, T. (1990) Health promotion—a focus for hospitals. Australian Health Review, 13, 90–94.
Hancock, T. (1986) Creating a healthy community: the preferred role for hospitals. Dimension, September, 22–23.
Health Education Authority (1993) Barriers and solutions to the progress of a health promoting hospital. Summary of feedback from groupwork. In Health Promoting Hospitals: Principles and Practice, Chapter 8, pp. 24–25. Health Education Authority, London.
Johnson, A. (1988) Reorienting a hospital to be more health promoting. A case study of the Women's and Children's Hospital Adelaide. Unpublished thesis, Flinders University, Adelaide.
Lalonde, M. (1989) Hospitals must become true health centres. Dimensions, November, 39–41.
New South Wales Health Promoting Hospitals Project (1996) Report on the 1996 Health Hospitals Awards. Wentworth Centre for Health Promotion, Blaxland East, New South Wales.
Pelikan, J. (1996) What is a ‘Health Promoting Hospital’? Presentation at Health Promoting Hospital Seminar, Rural Health Training Unit, Adelaide, 29 July 1996.
Pelikan, J. and Krajic, K. (1996) Editorial. In WHO Health Promoting Hospitals Newsletter, No. 8, October, p. 1.
Rushmere, A. (1996) Health promoting hospitals in the South and West Region of England. In WHO Health Promoting Hospitals Newsletter, No. 8, October, pp. 11–12.
Taillon, S. and LeTouze, D. (1989) A local survey of hospital health promotion programs. Dimensions, March, 27–29.
Vang, J. (1995) What does health gain orientation mean for hospital management. Health Promoting Hospitals Newsletter, No. 6, December, pp. 1–3.
Women's and Children's Hospital (1997) Vision, Role and Values Statement.
World Health Organization (1986) Ottawa Charter for Health Promotion, An International Conference on Health Promotion, Ottawa, Canada, 17–21 November.
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