1. Prof. Dr. Hanne Tønnesen CEO, International HPH Secretariat History, Philosophy, Standards and Implementation of HPH Tokyo, Japan, 15th September 2012 HPH Slide-01

2. 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

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4. 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

5. 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

6. What is CHP? HPH HPH bridges clinical treatment and public health together Hence, CHP helps patients, families, community and society Slide-06

7. 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

8. Best HP Practice Includes three parts Patient preference Staff expertise Best Evidence (Sackett, DL, Strauss SE, Richardson WS et al. Evidence-based medicine. Churcill Livingstone 2000) HPH Slide-08

9. Philosophy: 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-09

10. 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

11. 1988 WHO Project 1997 European Network 2004 Int. HPH Network and Secretariat 2005 Gen Assembly & Governance Board 2008HPH Constitution 2009 HPH Strategy 2010MoU w. WHO 2011 Sc J Clin HP 2012 First Intl Conference in Asia (Taipei) HPH History HPH Slide-11

12. HPH World Map N/R Network Individual Member – No network yet 897 members by August, 2012. Slide-12

13. 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

14. Global strategy Priorities 2011 – 2013 Growth & Member Care Visibility & Publication Partnerships & Aff. Members Qualitative Growth Action Plan HPH Slide-14

15. 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

16. 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

17. 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

18. 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 Membership HPH Slide-18

19. Member commitments Follow the HPH Constitution: Endorse principles of WHO on HPH Intend to implement principles, strategies and policies of HPH Implement HP activities Develop a policy for HP Become smoke-free H/HS Develop and evaluate an HPH action plan Pay annual fee Identify H/HS Coordinator Share information and experiences (nat / intl) HPH Slide-19

20. HPH Member Fee/Year 0 to 1000 Employees=250 Eur 1000 to 2000=500 Eur 2000 to 3000=750 Eur 3000 to 4000=1000 Eur (and so forth) 250 € per H/HS ( 300 € from 2015) Bigger organizations: Slide-20

21. Philosophy: 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-21

22. 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

23. Standards + DATA + Doc-Act Slide-23

24. 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

25. Shu-Ti 5 standards 13 substandards 40 measurable elements 18 indicators Slide-25

26. Development of the standards Standards developed according to the ALPHA programme Fulfill the ISBRA Chriteria Slide-26

27. 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

28. Standards + DATA + Doc-Act Slide-28

29. 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

30. B ackground (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

31. Background Important 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

32. Participants Clinical specialists 63 hospitals from 11 countries from 3 continents WHO-CC Copenhagen HPH Slide-32

33. 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

34. 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

35. 9 Q for documentation of 5 HD Risk of malnutrition 1.Does the patient have a BMI < 20.5 2.Has the patient suffered from weight-loss in the past month 3.Has the patient suffered from decreased food intake in the last week 4.Is the patient severely ill (sepsis, burns, etc)? Overweight 1.Does the patient have BMI > 25 2.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

36. 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

37. Data collection flow: Part A MR 10 10 x A WHO- CC Pilot Centres Form 10+1 CS A N/R Coord Slide-37

38. Data collection flow: Part B 10 x B WHO- CC Pilot Centres Form 20+1 CS B N/R Coord Lo- cal MR + Slide-38

39. 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

40. Participants Part APart B Total71 59 Returned without info - 8 - 6 For analyses63 53 Slide-401

41. Agreement Part A % Slide-41

42. 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

43. B) Documentation in local MR The clinical specialists categorised 66% (29 - 94%) of their patients re need for HP Slide-43

44. Understandable Useful Sufficient Clin specialists HPH DATA Model ( 12 nations) Clin HP 2012 HPH Slide-44

45. 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

46. Workshop Please discuss with your neighbour how this could be carried out at your hospital/ health service Slide-46

47. The HPH Doc-Act Model Slide-47

48. Invisible HP becomes visible by using HPH tools/models Documentation Model for HP Activities at patient level Slide-48

49. 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 Documentation Model for HP Activities Surveys interviews Slide-49

50. Participants 6 countries from the HPH- Network Ireland5 Italy3 Estonia3 England2 Canada4 Sweden3 Participants 20 Clinical Unit of Health Promotion HPH Slide-50

51. Two Steps First support of motivation (I) Then intervention programs (II) Slide-51

52. Rehabilitation program: COPD Elements  Tobacco cessation  Alcoholintervention  Nutrition  Physical activity  Psycho-social support  Medicine after-treatment  Patient education Svend Juul Jørgensen & Carsten Hendriksen: Ugeskr Laeger 2005;166:263-266 Slide-52

53. Ann-Dorthe Zwissler, PhD: http://www.cardiacrehabilitation.dk Rehabilitation program: Cardiac Patients Elements  Tobacco cessation  Alcoholintervention  Nutrition  Physical activity  Psycho-social support  Medicine after-treatment  Patient education Slide-53

54. Gæde P, Vedel P, Larsen N et al. N Engl J Med 2003;348:383-93. Rehabilitation program: Diabetes Elements  Tobacco cessation  Alcoholintervention  Nutrition  Physical activity  Psycho-social support  Medicine after-treatment  Patient education Slide-54

55. Program for surgical patients Elements  Tobacco cessation  Alcoholintervention  Nutrition  Physical activity  Psycho-social support  Medicine after-treatment  Patient education Tønnesen H, Nielsen PR, Lauritsen RB, Moeller AM. Br J Anaesth 2009 Slide-55

56. 7 codes for motivational counselling  SmokingXX01  AlcoholXX02  NutritionXX03  Physical activityXX04  Psycho-social relation XX05  Other risk factorsXX06  Integrated counselling (consisting of several factors)XX07 HPH Slide-56

57. 8 codes for intervention, rehabilitation, after-treatment  Tobacco cessation YY01  AlcoholinterventionYY02  Nutrition YY03  Physical activity YY04  Psycho-social supportYY05  Medicine after-treatmentYY06  Patient education YY07  Integrated rehabilitation (consisting of several elements)YY08 HPH Slide-57

58. % I) Local Med Records Mot Counselling: response rate 97-100% Slide-58

59. % I) Local Med Records Mot Counselling: response rate 97-100% Slide-59

60. % II) Local MR Intervention etc: response rate 97-100% Slide-60

61. % II) Local MR Intervention etc: response rate 97-100% Slide-61

62. Clin specialists Doc Model: HP Activities ( 6 nations) Tønnesen H, et al. BMC Health Services research 2007, 7:14 HPH Slide-62

63. 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

64. Philosophy: 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-64

65. Visioner & Values of Health Promotion Ottawa Charter, Budapest Declaration, Vienna Recom Intervention programmes for individuals Core strategies to put HPH into action Evidence-based Clin guidelines Standards & Indicators Reimburse- ment through DRG Edu- cation Implementation of HPH Slide-65

66. 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

67. 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-analyses Syst reviews (Eccles M BMJ 1998) Slide-67

68. Background Important 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

69. 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

70. Adding HP to surgery Postop complications (BMJ 1999) Alcohol cessation int. Colorectal Resection Postop recovery (BMC Health Serv Res 2008) Physical exercise int. Major spine Surgery Postop complications (Lancet 2002) Smoking cessation int. Hip/Knee Replacement Slide-70

71. 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

72. 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 2007 Slide-72

73. 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

74. 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

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77. 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

78. 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

79. 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

80. 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

81. 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

82. 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

83. 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

84. N/R Network Individual Member – No network yet National Japanese HPH Network Slide-84