Prof. Dr. Hanne Tønnesen CEO, International HPH Secretariat History, Philosophy, Standards and Implementation of HPH Tokyo, Japan, 15th September 2012

Prof. Dr. Hanne Tønnesen

CEO, International HPH Secretariat

History, Philosophy, Standards

and Implementation of HPH

Tokyo, Japan, 15th September 2012

HPH

Slide-01

Run the Intl HPH Secretariat

Support countries to:• Implement WHO principles for HP and use HP strategies and standards• Create further evidence• Teach and train staff in EB HP• Implement best EB practice for HP

WHO Terms of reference

Slide-02

Slide-03

• Philosophy: Evidence-based HP, CHP and HPH

• History and organization of HPH

• Standards, models and tools of HPH

• Implementation of HPH: A National HPH Network of Japan

This presentation will cover…

Slide-04

What is CHP?

• Health Promotion = “enabling people to increase control over, and to improve their health”*

• Clinical = involving patients (klinikos)

• EB: Evidence at highest level (RCT)

HPH

*Ottawa Charter, Budapest Declaration, Vienna Recommendations, Bangkok Charter and WHO Standards for Health Promotion in Hospitals

Slide-05

What is CHP?HPH

HPH bridges clinical treatment and public health together

Hence, CHP helps patients, families, community and society

Slide-06

Why hospitals?

• High prevalence of patients with unhealthy lifestyle and NCDs

• Adding HP to treatment improves the outcome on short and long term

• Hazardous working conditions in hospitals– Reduce risks & improve working conditions

• Hospitals as knowledge-organizations– Intersectoral development of HP activities for

community orientation

• Production of waste & hazardous substances– Ecological approach towards waste, energy

management

HPH

Slide-07

Best HP PracticeIncludes three parts

Patient preference

Staff expertise

BestEvidence

(Sackett, DL, Strauss SE, Richardson WS et al. Evidence-based medicine. Churcill Livingstone 2000)

HPH

Slide-08

• Philosophy: HP, CHP and HPH





Slide-09

What is HPH?

• The International Network of Health Promoting Hospitals & Health Services

• WHO initiated, strong global network

• Global strategy

• Organization & History

• What members commit to

• Projects and activities

HPH

Slide-10

1988 WHO Project

1997 European Network2004 Int. HPH Network and Secretariat2005 Gen Assembly & Governance Board2008 HPH Constitution2009 HPH Strategy2010 MoU w. WHO2011 Sc J Clin HP2012 First Intl Conference in Asia (Taipei)

HPH History HPH

Slide-11

HPH World Map

N/R Network Individual Member – No network yet

897 members by August, 2012. Slide-12

Mission• HPH shall work towards incorporating the WHO

concepts, values, strategies and standards or indicators of HP into the organizational structure of the H/HS

• Exchange knowledge & experiences

Vision• Better health gain through HP

for patients, staff and community

HPH Constitution

Slide-13

Global strategy

Priorities 2011 – 2013

Growth & Member Care

Visibility & Publication

Partnerships & Aff. Members

Qualitative Growth

Action Plan

HPH

Slide-14

HPH Structure

General Assembly

Governance Board

HPH Secretariat

WHO CC Vienna

WHO CC Copenhagen

National/Regional Networks

Individual hospitals/health services

Task Forces

Working Groups

HPH

Slide-15

Organizational bodies• General Assembly• National / Regional HPH Coordinators• WHO CC representatives• WHO representative (observer)• Task Force Leaders• Observers from upcoming networks

• Governance Board• 7 elected members (HPH Coordinators)• 2 WHO CC representatives (Vienna, Copenhagen)

• 1 WHO representative

Slide-16

New GB elected by GA (April 2012)

1. Shu-Ti Chiou (Taiwan) (Chair)

2. Raffaele Zoratti (Italy) (Vice Chair)

3. Sally Fawkes (Australia)

4. Tiiu Härm (Estonia)

5. Manel Santina (Spain)

6. Somsak Pattarakulwanich (Thailand)

7. Heli Hatonen (Finland)

Slide-17

N/R Networks

Minimum 3 hospitals / health services N/R Coordinator and coordinating

institution HPH Network Agreement with the HPH

Secretariat

Individual Member Hospital / HS

Signing the HPH Letter of Intent

HPH MembershipHPH

Slide-18

Member commitments

Follow the HPH Constitution:• Endorse principles of WHO on HPH • Intend to implement principles, strategies and

policies of HPHImplement HP activitiesDevelop a policy for HP Become smoke-free H/HSDevelop and evaluate an HPH action plan Pay annual feeIdentify H/HS CoordinatorShare information and experiences (nat / intl)

HPH

Slide-19

HPH Member Fee/Year

0 to 1000 Employees

= 250 Eur

1000 to 2000 = 500 Eur 2000 to 3000 = 750 Eur3000 to 4000 = 1000 Eur(and so forth)

250 € per H/HS ( 300 € from 2015)

Bigger organizations:

Slide-20






Slide-21

Invisible HP becomes visible by using HPH tools/models

• WHO Standards for HP• Organisational level• Centre, department or ward level

• HPH Data Model (identification)• Patient level

• Documentation Model for HP Activities• Patient level

Slide-22

Standards + DATA + Doc-Act

Slide-23

Hospitals needed a set of HP standards to:

• Provide a framework• Help with planning, documentation and evaluation• Be systematic • Help quality management • Support learning processes• Provide a platform for comparisons and exchange of

experience• Uncover new needs for HP• Support cooperation between primary and secondary

care• Support the need for training

Slide-24

Shu-Ti

• 5 standards• 13 substandards• 40 measurable

elements• 18 indicators

Slide-25

Development of the standardsStandards developed according to the ALPHA programme

Fulfill the ISBRA ChriteriaSlide-26

Pilot evaluation of WHO-HPH Standards (in %)

36 hospitals in 9 countries replied:

• Participation in self-assessment was useful

• Identified new potentials for quality improvement activities

• Data collection could be incorporate into normal practice

• Recommend other hospitals interested in carrying out self-assessment

• All HPH members should carry out self-assessment

Slide-27

Standards + DATA + Doc-Act

Slide-28

HPH

2.2.1. Documentation in MR HPH DATA Model

Standard 2: Patient Assessment

The organisation ensures that health professionals, in partnership with patients, systematically assess needs for HP activities

2.2.1. Guidelines on ID of smoking status, alcohol consumption, nutritional status etc

HPH DATA Model

Slide-29

Background(Patient level)

• A critical step in improving health is implementing HP

• This requires systematical and easy documentation of the patients with health risks at first visit

• In this process there is also the benefit of reducing inequity in health

• Identify 5 health determinants– Physical inactivity, Malnutrition, Overweight,

Smoking & Harmful drinking

HPH

Slide-30

BackgroundImportant Factors for Clinical Pathway

• Disease / Diagnosis

• Treatment

• Organisation

• Patient-related health & co-morbidity– Health status: physical inactivity,

malnutrition, overweight, harmful drinking and smoking

Slide-31

Participants

• Clinical specialists

• 63 hospitals from 11 countries from 3 continents

• WHO-CC Copenhagen

HPH

Slide-32

AIM

• To evaluate a simple 9 Q HPH DATA Model for patients need of HP intervention

– To determine if this model is understandable, applicable and sufficient in a clinical work day

– To evaluate the variation among Networks and hospitals of the model in a standardized setting

Slide-33

The HPH DATA Model

• 9 Q with documentation codes based on the 5 most frequent risk factors for outcome

• Categorisation of the 5 risk factors, – Yes – No – Unable to categorize

HPH

Slide-34

9 Q for documentation of 5 HD

Risk of malnutrition1. Does the patient have a BMI < 20.52. Has the patient suffered from weight-loss in the past month3. Has the patient suffered from decreased food intake in the

last week 4. Is the patient severely ill (sepsis, burns, etc)?

Overweight1. Does the patient have BMI > 252. Waist-measurement > 80 cm (W) or 94cm (M)

Is the patient physically active < 1/2 hr / day

Does the patient smoke daily

Does the patient drink > 14 drinks/wk (W) or 21 (M)

Slide-35

Definitions

• Usefulness– Was the Documentation Model useful to the

clinical specialists?

• Applicability – Was the Documentation Model applicable to the

patients? • Sufficiency

– Was the Documention Model sufficient for these patients and the activity it covered?

HPH

Slide-36

Data collection flow: Part A

MR10

10 x10 x

A

WHO-CC

Pilot Centres

Form10+1

CSCSA

N/R Coord

Slide-37

Data collection flow: Part B

10 x10 x

B

WHO-CC

Pilot Centres

Form20+1

CSCSB

N/R Coord

Lo-cal MR

+

Slide-38

Analysis

• The results were reported anonymously

• Comparison of the evaluation results in part A and B, respectively.

• The results were given in absolute numbers, frequencies, median (range)

• Kappa statistics for agreement of registration among the specialists in material part A (inter-observer variation)

HPH

Slide-39

Participants

Part A Part B

Total 71 59

Returned

without info - 8 - 6

For analyses 63 53

Slide-401

Agreement Part A

0

20

40

60

80

100

MR 1 MR 2 MR 3 MR 4 MR 5 MR 6 MR 7 MR 8 MR 9 MR 10

%

Slide-41

Agreement Part A

• Kappa Statistics for calculation of agreement among the specialists– 0.85 (ranging from 0.65 to 0.99)

• Interpretation– 0.41 to 0.60 Moderate agreement– 0.61 to 0.80 Substantial agreement– 0.81 to 1.00 Near a perfect agreement

Slide-42

B) Documentation in local MR

The clinical specialists categorised

66% (29 - 94%)

of their patients re need for HP

Slide-43

0

20

40

60

80

100

Understandable Useful Sufficient

Clin specialists HPH DATA Model ( 12 nations)

Clin HP 2012

HPH

Slide-44

Conclusion

• HPH Networks developed and successfully evaluated a simple model for the systematic MR documentation of 5 significant HD

• Recent implementation of HPH DATA in – Denmark (national)– Norway (regional)– Canada (local)– Sweden (national level)– And others

Slide-45

Workshop

• Please discuss with your neighbour how this could be carried out at your hospital/ health service

Slide-46

The HPH Doc-Act Model

Slide-47

Invisible HP becomes visible by using HPH tools/models

• Documentation Model for HP Activities at patient level

Slide-48

3.1. Information and Plan for HP Activities

HPH

3.1.1. Patient info recorded

3.1.2. HP activities & results documented

3.1.3. Patient satisfaction

MR Audits

MR AuditsDocumentation Model for HP Activities

Surveys interviews

Slide-49

Participants

• 6 countries from the HPH-Network

Ireland 5Italy 3 Estonia 3England 2

Canada 4Sweden 3 Participants 20

Clin

ical U

nit

of

Healt

h P

rom

oti

on

HPH

Slide-50

Two Steps

• First support of motivation (I)

• Then intervention programs (II)

Slide-51

Rehabilitation program: COPD

ElementsTobacco cessation Alcohol interventionNutrition Physical activity Psycho-social supportMedicine after-treatment

Patient education

Svend Juul Jørgensen & Carsten Hendriksen: Ugeskr Laeger 2005;166:263-266Slide-52

Ann-Dorthe Zwissler, PhD: http://www.cardiacrehabilitation.dk

Rehabilitation program: Cardiac Patients


Patient educationSlide-53

Gæde P, Vedel P, Larsen N et al. N Engl J Med 2003;348:383-93.

Rehabilitation program: Diabetes


Patient educationSlide-54

Program for surgical patients


Patient education

Tønnesen H, Nielsen PR, Lauritsen RB, Moeller AM. Br J Anaesth 2009 Slide-55

7 codes for motivational counselling

Smoking XX01 Alcohol

XX02 Nutrition XX03 Physical activity XX04 Psycho-social relation XX05 Other risk factors XX06

Integrated counselling

(consisting of several factors) XX07

HPH

Slide-56

8 codes for intervention, rehabilitation, after-treatment

Tobacco cessation YY01 Alcohol intervention

YY02 Nutrition YY03 Physical activity YY04 Psycho-social support YY05 Medicine after-treatment YY06 Patient education YY07

Integrated rehabilitation (consisting of several elements) YY08

HPH

Slide-57

0

20

40

60

80

100

Tob Alc Nutr Phys Psych-soc

Others Integr

%

I) Local Med Records Mot Counselling: response rate 97-100%

Slide-58

0

20

40

60

80

100


Others Integr

%

I) Local Med Records Mot Counselling: response rate 97-100%

Slide-59

0

20

40

60

80

100


Medopt

Patientedu

Integr

%

II) Local MR Intervention etc: response rate 97-100%

Slide-60

0

20

40

60

80

100


Medopt

Patientedu

Integr

%

II) Local MR Intervention etc: response rate 97-100%

Slide-61

Clin specialists Doc Model: HP Activities ( 6 nations)

0

20

40

60

80

100

Useful Applicable Sufficient

Tønnesen H, et al. BMC Health Services research 2007, 7:14

HPH

Slide-62

Ex: Re-imbursement

• Sweden – Lift out part of DRG-budget for identification

and referral of patients with diagnosed Health Risk Factors to existing HP clinics in- or outside H/HS (6 € extra /patient)

• The U.S.– All trauma patients are offered alcohol and

smoking intervention (separate bill number)

• Denmark– Lift out part of DRG-budget for physiotherapy in

hospitals (separate documentation)Slide-63






Slide-64

Visioner & Values of Health Promotion Ottawa Charter, Budapest Declaration, Vienna Recom

Intervention programmes for individualsCore strategies to put HPH into action

Evidence-based Clin guidelines

Standards&

Indicators

Reimburse-ment through

DRG

Edu-cation

Implementation of HPH

Slide-65

Best Evidence-Based HP Includes three parts

Patient preference

Staff expertise

Best Evidence

(Sackett, DL, Strauss SE, Richardson WS et al. Evidence-based medicine. Churcill Livingstone 2000)

Slide-66

Highest level of Evidence

In Vitro studies

Animal Studies

Editorial papers and Consensus (’GOBSAT’)

Cases (Obs)

Cohorts, Case-Control studies (Obs)

CCT (intervention)

RCT (intervention)

Meta-analysesSyst reviews

(Eccles M BMJ 1998)Slide-67

BackgroundImportant Factors for Clinical Pathway

• Disease / Diagnosis

• Treatment

• Organisation

• Patient-related health & co-morbidity– Health status: physical inactivity,

malnutrition, overweight, harmful drinking and smoking

Slide-68

Description

Unhealthy lifestyle

Lifestyle-related physical and psychosocial damage

Aggravation of other diseases & conditions, outcome & prognoses

Intervention

Better lifestyle

Reduced lifestyle-related damages

Improved outcome & prognoses of others

Slide-69

Adding HP to surgery

0

20

40

60

80

100 WithoutIntervention

Intervention

*

%

Postop complications(BMJ 1999)

Alcohol cessation int.Colorectal Resection

0

2

4

6

8


Intervention

*

days

Postop recovery(BMC Health Serv Res 2008)

Physical exercise int.Major spine Surgery

0

20

40

60

80


Intervention

*

%

Postop complications(Lancet 2002)

Smoking cessation int.Hip/Knee Replacement

Slide-70

Teaching & Training

• WHO HPH Schools• PhD Courses• Physicians• Diploma Nurses• Pre-graduate Courses• Text book (Engage in the Process of Change)

• Master of Clin HP (2013)

• Evaluation Project

Slide-71

Clinical expertise The influence of specially trained nurses

• 100 + 100 Emergency patients (smokers and alcohol abusers)

• 47 of 100 accepted when offered brief intervention by the staff nurses

• 97 of 100 accepted when offered BI by an experienced/trained nurse from another department

Nelbom et al 2004, Backer et al 2007Slide-72

WHO-HPH Schools

WHO-HPH Summer School in Taiwan April 2012

WHO-HPH Autumn School in Indonesia October 2012

WHO-HPH Winter School in Singapore January 2013

WHO-HPH Summer School in Sweden May 2013

Slide-73

• International HPH Conference• National and regional conferences • GA Meetings• Staff exchange program • WHO-HPH Schools (2 – 4 annually)• HPH Newsletter• Teaching & training• Sc J: Clin HP – Research & Best Practices• Web-site: web-forums, e-learning etc.

Exchange of knowledge & experience

Slide-74

Slide-75

Slide-76

• HPH Library• E-learning • Toolboxes • Reporting on progress of Networks & TF• Best practice database • Discussion Forum • Project Zones • N/R and TF sub-sites • News

www.hphnet.org Exchange of knowledge & experience

Slide-77

• Signing of Network Agreement• Approval by the GB (which is very positive and looking forward to it!)

A new National HPH Network of Japan

Slide-78

HPH Network

Obligations and tasks include:• putting mission, purpose and objectives of HP into

practise • developing a strategy and action plan• designating a Coordinating Institution and

Coordinator• recruiting new H/HS• collecting membership fee • delivering progress report (bi-annual)• having rules / functioning approved by members• Participating in annual GA

Slide-79

Intl. Obligations for H/HS Members

Support the WHO HPH principles of HP (the Ottawa charter, Vienna Recommendations etc.)

Management support of membership Pay membership fee Smoke-free policy Indentify a local coordinator – local steering

group

Slide-80

• What is in it for us?• A well-established Network of highly professional

HPH colleagues all over the world• Easy and effective identification of partners for

collaboration • Inspiration on what and how• Staff exchange program• Invitation to participate in international research,

task forces and working groups• Build on other’s knowledge and experience• Education, teaching and training• Access to technical support, tools (Act. DB, SAT,

Doc Model, DATA etc.)• ….. Synergy (when 2 + 2 > 4)

FAQ (Intl Benefits)

Slide-81

Ex. Norway (Nat. benefits)

The national coordinator works full time A professor is employed 20% on a research project The secretariat is placed at the only Centre for

Health Promotion in a Norwegian hospital The network is lead by a steering committee, with

highly knowledgeable and enthusiastic people National working groups on specific topics for

exchange of knowledge and who work on projects A national strategy with a detailed work plan Newsletter – for spreading news from the members

to the rest of the network and also other partners

Slide-82

Bridging public health and health care through

• a strong Intl Network with effective ID of collaborators

• building on existing knowledge and experience

• go from good practice to best practice based on EVIDENCE

• education, teaching, staff exchange and training

• international invitations (research, TFs, WGs, GA)

• a broad HP framework, technical support, tools etc.

…and get better health in H&HS through the new National HPH Network of Japan!

Please use HPH for…

Slide-83

N/R Network Individual Member – No network yet

National Japanese HPH Network

Slide-84

Documents

Prof. Dr. Hanne Tønnesen CEO, International HPH Secretariat History, Philosophy, Standards and Implementation of HPH Tokyo, Japan, 15th September 2012