Hospitals as Health Promoting?

The idea of a hospital as a health-promoting institution strikes us in the U.S. as strange. But it doesn’t need to be that way, according to a terrific editorial published in Health and Hospitals Network OnLine.


Many of us on the Integrative Pediatrics Council are working with children’s hospitals around the world to be more “health promoting” than purely “disease-treating.” On a personal note, I am fortunate to consult at the completely green Joseph M. Sanzari Children’s Hospital at HUMC in NJ. I am working with the Deirdre Imus Environmental Center to develop a healing environment in the hospital, including nutritional programs, integrating CAM therapies for children and families, and educating families about how to live a healthier life. This should be the norm, but as David Ollier Weber notes, at least in our country, we’re not there yet.

American Exceptionalism

By David Ollier Weber

Health-promoting hospitals are proliferating globally … except here in the United States, where one is a lonely number.

Twenty years ago, in November 1986, delegates from around the world met under the auspices of the World Health Organization in Ottawa, Canada, and drafted a charter for health promotion that embraced revolutionary definitions and goals.

Health, they affirmed, means much more than simply the absence of disease or injury. It is, indeed, “a state of complete physical, mental and social well-being.” Fundamental to that ideal of fully realized human potential, they declared, are “peace, shelter, education, food, income, a stable ecosystem, sustainable resources and social justice and equity.”

That being agreed upon, they challenged themselves, their communities, their professions, their institutions and their governments to work together to create a new kind of health care system. Its mandate would extend far beyond the mere provision of curative and clinical services. Health care would encompass traditional education, disease prevention and rehabilitation services, of course, but also “health enhancement by empowering patients, relatives and employees … enabling people to increase control over, and to improve, their health” in all its dimensions.

This sweeping reorientation would involve “open[ing] channels between the health sector and broader social, political, economic and physical environmental components,” the Ottawa charter made clear. It would demand a “change of attitude and organization of health services which refocuses on the total needs of the individual as a whole person.”

Europeans, in particular, took these noble intentions as a call to action.

Health-Promoting Hospitals

Hospitals are a natural focus for health promotion. In many countries, as much as 20 percent of the population will visit a local hospital as a patient within a single year. They bring with them myriad family and friends. The hospitals, even the small ones, are quite often the biggest employer in their community. In Europe, at least 3 percent of the entire workforce earns a paycheck from some 30,000 hospitals.

As collection points for the sick, hospitals are fraught with peril–for patients, visitors, caregivers and even their own neighbors. They teem with germs, toxins, dangerous substances, sharp points and deadly machines. The work is inherently stressful. Their output, along with happy cures and bodies to be buried, are tons of wastes–both infectious and routinely polluting. A health-promoting hospital (HPH) is almost, on balance, an oxymoron.

And yet, look at the opportunities for improvement. That was the upbeat attitude of the WHO Regional Office in Europe. After a round of cross-border consultations, a pilot HPH program to further the Ottawa principles was launched at the Rudolfstiftung Hospital in Vienna in 1989. Four years later, the promising Austrian model was expanded and tested at 20 cooperating hospitals in 11 European countries. By 1997, regional and national networks of HPHs were taking shape across the globe. Today they include 669 institutions in 34 countries. And yes, the United States is among them.

More about that later.

What’s a Health-Promoting Hospital?

HPH principles were fleshed out at subsequent WHO international conferences in Ljubljana, Budapest and Vienna. A hospital’s duty, it was concluded, should be to:

– Promote human dignity, equity, solidarity and professional ethics, acknowledging differences in the needs, values and cultures of different population groups.

– Be oriented toward quality improvement, the well-being of patients, relatives and staff, protection of the environment and realization of the potential to become learning organizations.

– Focus on health with a holistic approach, not only on curative services.

– Be centered on people providing health services in the best way possible to patients and their relatives, facilitating the healing process and contributing to the empowerment of patients.

– Use resources efficiently and cost-effectively, and allocate resources on the basis of contribution to health improvement.

– Form as close links as possible with other levels of the health care system and the community.

One of the key goals of the HPH program was to develop standards and substantiating indicators of hospital progress in health promotion. Many countries have hospital accrediting bodies that gauge institutional quality and monitor performance by various measurements. But according to Hanne Tønnesen, M.D., Ph.D., director of the WHO Collaborating Centre for Evidence-Based Health Promotion and head of the International HPH Secretariat, based at Bispebjerg Hospital in Copenhagen, a systematic review of existing standards found few if any that were “relevant to health promotion.” And of 300 quality indicators in use internationally, all but a handful were targeted at “the clinical effectiveness domain,” he reports.

So the next step was to develop and pilot a core of standards that would characterize a hospital as committed to health promotion. They began with five:

1. The hospital has a written policy for health promotion.

2. The hospital is obligated to assess the patient’s needs for health promotion, disease prevention and rehabilitation.

3. The hospital provides the patient with information about his or her health condition and health promotion interventions.

4. Managers at the hospital establish conditions for ensuring that the hospital is a healthy workplace.

5. The hospital takes a planned approach to collaborating with other health service sectors and institutions.

Talking the Talk vs. Walking the Walk

At the Joint Commission–this country’s major hospital credentialing body–spokesperson Charlene Hill takes issue with the notion that its standards fail to address health promotion. (She had not, however, previously heard of the HPH program.) Patient empowerment and community involvement are implicit throughout the Joint Commission’s quality measures, she maintains.

To be sure, “empowerment,” “self-management” and “collaborative” care now receive enthusiastic lip service within the American hospital establishment. University of Michigan Medical School educational psychologist Robert Anderson grants that much–especially when it comes to chronic life-style conditions such as diabetes, his area of expertise. But so deeply ingrained is the paternalistic “acute-care paradigm” among physicians, nurses and other health care professionals, he says, that all too many still view their role as “getting people to do what’s good for them” and resenting or internalizing “noncompliance” as their personal failure.

On the contrary, “the essence of the collaborative, patient-centered approach,” he argues, “is to view the patient as the expert in his or her own condition. We offer our professional knowledge to help them manage their disease. Most of us would resist someone trying to take over and control our lives.” (Anderson will present a session on this topic at the 2007 International HPH Conference in Vienna in April. He, too, had never heard of the HPH program until he received the invitation.)

Certainly, many American hospitals have trained an Ottawa charter-compatible wide-angle lens on the health needs of their communities.

In Boston, pediatrician Barry Zuckerman, M.D., grew frustrated at his inability to treat the underlying causes of many of the diseases he saw in his young patients at Boston Medical Center (BMC). The substandard housing and inadequate nutrition that weakened their immune systems and exacerbated their asthma and diabetes could often be traced to landlord violations of building and housing codes or improper denials of aid by social service agencies–problems for lawyers, not doctors. And so he spearheaded the Medical Legal Partnership for Children, a program funded by and based at BMC. It now includes six lawyers and four paralegals who counsel and assist more than 1,000 pediatric patient families a year, train health care providers in effective advocacy for children, and lobby government agencies and legislators for systemic reforms. With expanded funding from the Robert Wood Johnson and Kellogg foundations, the BMC model is now being emulated at more than 50 hospitals and clinics around the country.

In Siler City, N.C., tiny Chatham Hospital–an 18-bed critical access facility in a rural area of 12,000 people–reaches out to its changing community with a variety of Spanish-language health promotion roundtables, screenings, dental clinics and even a communal vegetable garden to feed homebound and needy diabetic patients. The primary target is the booming Hispanic population, drawn by the local poultry processing industry. (In Guadalajara last summer, Chatham’s Immigrant Initiative director Pamela Frasier was startled to see Siler City listed as a destination on a bus terminal bulletin board.)


But for all the potential affinities and shared goals, only one American hospital has chosen to ally itself with progressive counterparts from Canada to Taiwan. (Australia, South Africa and Israel are also countries with only one HPH Network member; in many areas–Northern Ireland and Denmark are just two examples–nearly every hospital has joined.)

That atypical U.S. institution is 400-bed Memorial Medical Center of the Conemaugh Health System in Johnstown, Pa. For more than a decade, Conemaugh has been integrating public health initiatives deep into its mission. Under pediatrics chief Matthew Masiello, M.D., an office of community health was established in 1996 and programs were developed that ranged from school-based injury prevention, bullying prevention, and nutrition and dental health programs (some 30,000 children have participated, with documented positive results) to community worksite wellness and screening programs for Memorial’s 4,000 employees.

A tobacco ban on the Memorial campus has saved as much as $700,000 a year in lost smoking-break time by nurses, says Masiello. Transfats have been eliminated from the hospital cafeteria menu. And more than $3.5 million in grant funds for local agencies have been secured by office of community health proposal writers.

“If you plant just one public health person in a hospital,” says Masiello, “that will turn the hospital around in how it organizes its services. My budget is less than 1 percent of the entire hospital budget, and we bring in three times that amount in grant monies. You can save amazing amounts in one fell swoop just by following up on employee health risk assessments.”

Masiello himself earned a master’s degree in public health with Conemaugh support, and in 2004 was named a system vice president. He learned about the HPH initiative in 2005 when he contacted the WHO in a routine search for health promotion information.

“It flabbergasted me!” he exclaims, to be told not a single U.S. hospital was participating. “It was mind-boggling!”

Enrollment in the HPH program requires only the recommendation of another member hospital, which in most countries means a member of a regional or national network made up of at least three institutions and a coordinating center. But, like Memorial, applicants can seek sponsorship directly from the International HPH Secretariat in Copenhagen. There is a nominal annual fee of €250, which is about $300 at the current exchange rate. Memorial will be happy to act as advisor and coordinating center for other U.S. organizations, notes Masiello.

What’s the Benefit?

“Hospitals are constantly looking for benchmarks,” says Masiello, “places that have gotten their act together to do something really well. This program is a gathering of experts from across the world to talk about what hospitals can be.”

E-mailing from Copenhagen, Tønnesen says he’s eager to hear from more American cousins. Adding that they can visit the home page at for more information.

“The HPH network warmly welcomes all interested hospitals,” he declares. “The inclusion of American hospitals in the network would be fruitful and beneficial to us all.”

For that matter, a visit to Vienna in the spring might be nice.


David Ollier Weber is principal of The Kila Springs Group in Placerville, Calif. He is also a regular contributor to H&HN OnLine.

This article 1st appeared on March 20, 2007 in HHN Magazine online site.

Copyright ©2007 Health Forum. All rights reserved.

H&HN is published by Health Forum, Inc.

an American Hospital Association information company.

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