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1 出版機關 衛生福利部國民健康署 出版年月 103 年 12 月

2 / 87 / / 115 / / 142 / / 170 / 176 / / 203 /

3 / 238 / / 266 / / 298 / / 321 / / 357 / 362 I LOVE / 367

4 WHO WHO )

5 Primary Health Care 103 8

6

7

8 1948 World Health Organization, WHO WHO, Health Field Concept Laframboise, 1973 Lalonde Report Lalonde, Lalonde Report Surgeon General's Report % 20% 20% 10% U.S. Department of Health, Education and Welfare, WHO "Health promotion is the process of enabling people to increase control over, and to improve, their health." 2

9 Anonymous, 1986 know-how know-what Health Promoting Hospitals Initiative 1988 Rudolfstiftung Health and Hospital Pelikan et al., The HPH Network, 2014 WHO Ludwig Boltzmann Institute WHO Collaborating Center for Health Promotion in Hospitals and Health Care Bispebjerg University Hospital WHO Collaborating Centre for Evidence-Based Health Promotion in Hospitals & Health Services HPH ( ) HPH Groene, HPH ( HPH "A Health Promoting Hospital and Health ServiceHPH is an organization that aims to improve health gain for its stakeholders by developing structures, cultures, decisions and processes."who, 2007 HPH stakeholders 3

10 HPH Garcia- Barbero, ( ) Ottawa Charter HPH stakeholders ( ) co-producer ( ) well-being health-related quality of life WHO, Anonymous,

11 Pelikan Pelikan et al., 2001 Johnsen et al., 2001 HPH Oliver Groene Groene, 2005 HPH WHO, HPH Groene, 2006 HPH 2007 HPH HPH 1. HPH 2. HPH 5

12 HPH 3. health circles HPH ( ) Continuous Quality Improvement 6. HPH 7. HPH HPH HPH WHO, 2007 HPH HPH 1. HPH HPH HPH 2. HPH HPH 6

13 HPH 3. HPH HPH HPH HPH 4. HPH 5. HPH

14 12 SOP HPH Standards & Self-assessment Tools 2005 WHO HPH HPH HPH 2006 WHO HPH Hanne Tønnesen Tønnesen HPH " " 2012 " " " " HPH HPH (

15 ) HPH HPH HPH HPH HPH 9

16 HPH HPH HPH HPH HPH ( ) ( ) HPH (%) * 0.3 * HPH HPH ( ) ( ) % 24,000 32, ,869 50, ,999 31, , , HPH ( ) 10

17 Anonymous. (1986). Ottawa Charter for Health Promotion. Canadian Journal of Public Health, 77, Garcio-Barbero, M. (2005). Introduction. In Groene, O., & Garcio-Barbero, M. (Eds.), Health promotion in hospitals: evidence and quality management. Copenhagen: World Health Organization Regional Office for Europe. Groene, O. (2006). Implementing health promotion in hospitals: manual and self-assessment forms (ed.). Copenhagen: WHO. Groene, O. (2005) Health promotion in hospitals - from principles to implementation. In Groene, O., & Garcio- Barbero, M. (Eds.). Health promotion in hospitals: evidence and quality management. Copenhagen: World Health Organization Regional Office for Europe. Johnson, A., & Baum, F. (2001). Health promoting hospitals: a typology of different organizational approaches to health promotion. Health Promotion International, 16, Laframboise, H. L. (1973). Health policy: breaking the problem down into more manageable segments. Canadian Medical Association Journal, 108, Lalonde, M. (1974). A new perspective on the health of Canadians: a working document. Ottawa: National Health and Welfare. U.S. Department of Health, Education and Welfare. (1979). Healthy people: The Surgeon General's Report on Health Promotion and Disease Prevention. Washington, D.C.: U.S. Department of Health, Education and Welfare. World Health Organization. (1948). About WHO. Retrieved Febuary 21, 2007, from html. World Health Organization, the 3rd Workshop of National/ Regional Health Promoting Hospitals Network Coordinators, Vienna. (1997). The Vienna Recommendations on Health Promoting Hospitals. Retrieved Febuary 22, 2007, from pdf World Health Organization, Collaborating Centre for Health Promotion in Hospitals and Health Care, Vienna: WHO Working Group. (2006). Putting HPH policy into action: working paper of the WHO collaborating centre on health promotion in hospitals and health care. Retrieved Febuary 22, 2007, from Publications/wp-strategies-final.pdf. World Health Organization. (2007). The International Network of Health Promoting Hospitals and Health Services: integrating health promotion into hospitals and health services; concept, framework and organization. Copenhagen: World Health Organization. Pelikan, J., Lobnig, H., & Krajic, K. (1997). Health-promoting hospitals. World Health, 50(3), Pelikan, J. M., Krajic, K., & Dietscher, C. (2001). The health promoting hospital (HPH): Concept and development. Patient Education and Counseling, 45, The HPH Network. (2014). About HPH. Retrieved October 17, 2014, from 11

18 1a. 1b. 2a. 2b Hanne Tønnesen ( ) HPH HPH 12

19 (1) (2) (3) (4) ( ) (1) (2) (3) (4) ( ) (1) (2) (3) ( ) (1) (2) (3) (4) (5) (6) 13

20 (7) 67% 25 50% 40%

21 52% 18% 1/3 31% vs. 5% 10% vs. 0%15% vs. 4% 4 74% 31% 10% Tønnesen, H., Fugleholm, A. M., & Jørgensen, S. V. (2005). Evidence for health promotion in hospitals. In Groene, O., & Garcio-Barbero, M. (Eds.). Health promotion in hospitals: evidence and quality management. Copenhagen: World Health Organization Regional Office for Europe. Moller, A. M., Villebro, N., Pedersen, T., & Tønnesen, H. (2002). Effect of preoperative smoking intervention on postoperative complications: a randomised clinical trial. Lancet, 359, Tønnesen, H., Rosenberg, J., Nielsen, H. J., Rasmussen, V., Hauge, C., et al. (1999). Effect of preoperative abstinence on poor postoperative outcome in alcohol misusers: randomised controlled trial. BMJ, 318,

22 Groene, 2006 WHO, 2003b ISQUA, The International Society for Quality in Healthcare International Accreditation Program ALPHA 20 16

23 Groene, 2006 WHO, 2004; Groene, WHO, 2003b Groene, 2006 Groene,

24 HPH

25 Groene, O. (Ed.). (2006). Implementing health promotion in hospitals: Manual and self-assessment forms. Retrieved from Groene, O., & Garcia-Barbero, M. (2005). Health promotion in hospitals: Evidence and quality management. Retrieved from Groene, O., & Jorgensen, S. J. (2005). Health promotion in hospitals--a strategy to improve quality in health care. European Journal of Public Health, 15 (1), 6-8. Mainz, J. (2003). Defining and classifying clinical indicators for quality improvement. International Journal for Quality in Health Care, 15 (6), Speller, V., Evans, D., & Head, M. J. (1997). Developing quality assurance standards for health promotion practice in the UK. Health Promotion International, 12 (3), WHO. (2003a). Developing standards for health promotion in hospital results of a pilot test in nine European countries. Retrieved from hphstandardsfinrpt.pdf. WHO. (2003b). Standards for health promotion in hospitals: development of indicators for a self-assessment tool. Retrieved from WHO. (2004). Standards for health promotion in hospitals. Retrieved from 19

26 1 Self-assessment Forms for Implementing Health Promotion in Hospitals 1 2 3, : 20

27 1. Groene O. ed. Implementing Health Promotion in Hospitals: Manual and Self-assessment Forms. Copenhagen: WHO Regional Office for Europe;

28 Introduction: The role of health promotion in hospitals is changing. It is no longer restricted to providing additional lifestyle-related information to the patient after the clinical procedures have been completed. Health promotion is becoming an integral part of the health care process and is related to clinical, educational, behavioural, and organizational issues 1. In order to improve the quality of care for patients with chronic diseases and long-term conditions, health promotion activities in hospitals need to become better embedded in the larger health systems framework. With the expanded scope of health promotion activities, questions are raised regarding the quality assessment and improvement of these activities. Among the prominent tools to improve quality in health care, such as professionally c o n s e n t e d g u i d e l i n e s, s t a n d a r d s a n d performance indicators, there is little focus on health promotion issues. We therefore developed a self-assessment tool for health promotion in hospitals that addresses the following issues: the hospitals' management policy; the patients' assessment with regard to risk factors and health needs, patients' health promotion information and intervention; promoting a healthy workplace and continuity and cooperation of the hospital with other health, social and informal care providers 2. This document provides a self-standing tool to assess, monitor and improve health promotion activities in hospitals. In detail, this document should facilitate: assessing health promotion activities in hospitals; developing the capacity of health care organizations in improving health promotion activities; formulating recommendations for the improvement of health promotion activities in hospitals; involving all professionals and the patient in improving health promotion activities; improving the coordination of care with other providers of care; improving the health and safety of staff and patients; assisting with modernizing and changing healthcare practice and service delivery to make it more efficient and effective. Health promotion covers conceptually a broad range of activities, interventions, methods and approaches, some of which were too broad for the scope of this document. A decision was taken to address in this self-assessment tool only those issues that are most easily recognized by professionals working with patients, and for which the strongest evidence base is available. Consequently some health promotion activities that were included in previous guiding d o c u m e n t s o f t h e H e a l t h P r o m o t i n g Hospitals' Network are not fully reflected 3,4. A comprehensive framework to guide strategic 22

29 implementation of health promotion in hospitals and to guide the further development of health promotion standards is summarized in the Eighteen Core Strategies for Health Promotion in Hospitals 5. Some of the standards (like patient assessment or information and intervention) are directly linked to patient safety issues 6 ; however, this document provides additional tools for a wider approach to empower patients and staff and to complement existing quality and safety activities. This document was developed for all hospitals and quality agencies interested in improving health promotion. Organizations working in the field of quality improvement are encouraged to review and incorporate the standards and indicators for health promotion in hospitals into their existing systems. References 1. Groene O, Garcia-Barbero M. eds. Health promotion in hospitals. Evidence and quality management. Copenhagen, WHO Regional Office for Europe, accessed 08 May Standards for Health Promotion in Hospitals. Copenhagen, WHO Regional Office for Europe, accessed 08 may Ottawa Charter for Health Promotion. Geneva, World Health Organization, NPH/docs/ottawa_charter_hp.pdf, accessed 08 May The Vienna Recommendations on Health Promoting Hospitals. Copenhagen, WHO Regional Office f o r E u ro p e, h t t p : / / w w w. e u ro. w h o. i n t / healthpromohosp/publications/ _1, accessed 08 May Pelikan J, Dietscher C, Krajic K, Nowak P. Eighteen core strategies for Health Promoting Hospitals. In: Groene O, Garcia-Barbero M, eds: Health promotion in hospitals. Evidence and quality management. Copenhagen, WHO Regional Office for Europe, 2005: euro.who.int/document/e86220.pdf, accessed 08 May Forward Programme World Alliance for Patient Safety. Geneva, World Health Organization, pdf, accessed 08 May

30 Standard 1. Management Policy. The organization has a written policy for health promotion. The policy is implemented as part of the overall organization quality improvement system, aiming at improving health outcomes. This policy is aimed at patients, relatives and staff. Objective To describe the framework for the organization's activities concerning health promotion as an integral part of the organization's quality management system. Substandards 1.1 The organization identifies responsibilities for health promotion The hospital's stated aims and mission include health promotion [ Evidence: e.g. time- table for the action ] Minutes of the governing body reaffirm agreement within the past year to participate in the WHO HPH project [ Evidence: e.g. date for the decision or for payment of the annual fee ]. WHO The hospital's current quality and business plans include health promotionhp for patients, staff and the community [ Evidence: e.g. health promotion is explicit in the plan of action ] The hospital identifies personnel and functions for the coordination of HP [ Evidence: e.g. staff member nominated for the coordination of HP ]. 24

31 1.2 The organization allocates resources for the implementation of health promotion There is an identifiable budget for HP services and materials [ Evidence: e.g. budget or staff resources ] Operational procedures such as clinical practice guidelines or pathways incorporating HP actions are available in clinical departments [ Evidence: e.g. check guidelines ] Specific structures and facilities required for health promotionincluding resources, space, equipmentcan be identified [ Evidence: e.g. facilities to lift patients available ]. 1.3 The organization ensures the availability of procedures for collection and evaluation of data in order to monitor the quality of health promotion activities Data are routinely captured on HP interventions and available to staff for evaluation [ Evidence: e.g. availability assessed in staff survey ] A programme for quality assessment of the health promoting activities is established [ Evidence: e.g. time schedule for surveys is available ]. 25

32 Standard 2. Patient Assessment. The organization ensures that health professionals, in partnership with patients, systematically assess needs for health promotion activities. Objective To support patient treatment, improve prognosis and to promote the health and well-being of patients. Substandards 2.1 The organization ensures the availability of procedures for all patients to assess their need for health promotion Guidelines on how to identify smoking status, alcohol consumption, nutritional status, psycho-socialeconomic status are present [ Evidence: check availability ] Guidelines/procedures have been revised within the last year [ Evidence: check date, person responsible for revising guidelines ] Guidelines are present on how to identify needs for HP for groups of patientse.g. asthma patients, diabetes patients, chronic obstructive pulmonary disease, surgery, rehabilitation[ Evidence: e.g. for groups of patients specifically treated in the clinical department ]. ( COPD 26

33 2.2 The assessment of a patient's need for health promotion is done at first contact with the hospital. This is kept under review and adjusted as necessary according to changes in the patient's clinical condition or on request The assessment is documented in the patients' record at admission [ Evidence: for all patients. Identified by patient records audit ] There are guidelines / procedures for reassessing needs at discharge or end of a given intervention [ Evidence: guidelines present ]. 2.3 The patient's needs-assessment reflects information provided by others and ensures sensitivity to social and cultural background Information from referring physician or other relevant sources is available in the patient's record [ Evidence: for all patients referred from physician ] The patient's record documents social and cultural background as appropriate [ Evidence: religion that requires special diet or other specific attention. Social conditions indicating that the patient is at risk ]. 27

34 Standard 3. Patient Information and Intervention. The organization provides patients with information on significant factors concerning their disease or health condition and health promotion interventions are established in all patient pathways. Objective To ensure that the patient is informed about planned activities, to empower the patient in an active partnership in planned activities and to facilitate integration of health promotion activities in all patient pathways. Substandards 3.1 Based on the health promotion needs assessment, the patient is informed of factors impacting on their health and, in partnership with the patient, a plan for relevant activities for health promotion is agreed Information given to the patient is recorded in the patients record. [ Evidence: random review of patient records for all patients ] Health promotion activities and expected results are documented and evaluated in the records [ Evidence: e.g. patient records' audit ]

35 3.1.3 Patient satisfaction assessment of the information given is performed and the results are integrated into the quality management system [ Evidence: e.g. various assessment methods: survey, focused group interview, questionnaire. Time schedule ] The organization ensures that all patients, staff and visitors have access to general information on factors influencing health General health information is available [ Evidence: e.g. availability of printed or online information, or special information desk ] Detailed information about high/risk diseases is available [ Evidence: e.g. availability of printed or online information, or special information desk ] Information is available on patient organizations [ Evidence: e.g. contact-address is provided ]

36 Standard 4. Promoting a Healthy Workplace. The management establishes conditions for the development of the hospital as a healthy workplace. Objective To support the development of a healthy and safe workplace, and to support health promotion activities of staff. Substandards 4.1 The organization ensures the development and implementation of a healthy and safe workplace Working conditions comply with national/regional directives and indicators [ Evidence: e.g. national and internationaleuregulations are recognized ] Staff comply with health and safety requirements and all workplace risks are identified [ Evidence: e.g. check data on occupational injuries ]. 4.2 The organization ensures the development and implementation of a comprehensive Human Resources Strategy that includes training and development of health promotion skills of staff New staff receive an induction training that addresses the hospital's health promotion policy [ Evidence: e.g. interviews with new staff ]. 30

37 4.2.2 Staff in all departments are aware of the content of the organization's health promotion policy [ Evidence: e.g. annual performance evaluation or staff participation in the HP programme ] A performance appraisal system and continuing professional development including health promotion exists [ Evidence: e.g. documented by review of staff files or interview ] Working practicesprocedures and guidelinesare developed by multidisciplinary teams [ Evidence: e.g. check procedures, check with staff ] Staff are involved in hospital policy-making, audit and review [ Evidence: check with staff; check minutes of working groups for participation of staff representatives ]. 4.3 The organization ensures availability of procedures to develop and maintain staff awareness on health issues Policies for awareness on health issues are available for staff [ Evidence: e.g. check for policies on smoking, alcohol, substance misuse and physical activity ] Smoking cessation programmes are offered [ e.g. Evidence on availability of programmes ] Annual staff surveys are carried out including an assessment of individual behaviour, knowledge on supportive services/policies, and use of supportive seminars [ Evidence: check questionnaire used for and results of staff survey ]. 31

38 Standard 5. Continuity and Cooperation. The organization has a planned approach to collaboration with other health service levels and other institutions and sectors on an ongoing basis. Objective To ensure collaboration with relevant providers and to initiate partnerships to optimize the integration of health promotion activities in patient pathways. Substandards 5.1 The organization ensures that health promotion services are coherent with current provisions and regional health policy plans The management board is taking into account the regional health policy plan [ Evidence: e.g. regulations and provisions identified and commented in minutes of the meeting of management board ] The management board can provide a list of health and social care providers working in partnership with the hospital [ Evidence: e.g. check update of list ] The intra- and intersectoral collaboration with others is based on execution of the regional health policy plan [ Evidence: e.g. check congruency ] There is a written plan for collaboration with partners to improve the patients' continuity of care [ Evidence: e.g. criteria for admittance, plan for discharge ]. 32

39 5.2 The organization ensures the availability and implementation of health promotion activities and procedures during out-patient visits and after patient discharge Patientsand their families as appropriateare given understandable follow-up instructions at outpatient consultation, referral or discharge [ Evidence: e.g. patients' evaluation assessed in patient surveys ] There is an agreed upon procedure for information exchange practices between organizations for all relevant patient information [ Evidence: e.g. check availability of procedure ] The receiving organization is given in timely manner a written summary of the patient's condition and health needs, and interventions provided by the referring organization [ Evidence: e.g. availability of copy ] If appropriate, a plan for rehabilitation describing the role of the organization and the cooperating partners is documented in the patient's record [ Evidence: e.g. review of records ]. 33

40 / Overview on health promotion indicators 34

41 2 Self-assessment Forms for Implementing Health Promotion in Hospitals (Modified by Taiwan HPH Network) 1 2 : 3,

42 1. Groene O ed. Implementing Health Promotion in Hospitals: Manual and Self-assessment Forms. Copenhagen: WHO Regional Office for Europe;

43 Introduction: The role of health promotion in hospitals is changing. It is no longer restricted to providing additional lifestyle-related information to the patient after the clinical procedures have been completed. Health promotion is becoming an integral part of the health care process and is related to clinical, educational, behavioural, and organizational issues 1. In order to improve the quality of care for patients with chronic diseases and long-term conditions, health promotion activities in hospitals need to become better embedded in the larger health systems framework. With the expanded scope of health promotion activities, questions are raised re g a rd i n g t h e q u a l i t y a s s e s s m e n t a n d improvement of these activities. Among the prominent tools to improve quality in health care, such as professionally c o n s e n t e d g u i d e l i n e s, s t a n d a r d s a n d performance indicators, there is little focus on health promotion issues. We therefore developed a self-assessment tool for health promotion in hospitals that addresses the following issues: the hospitals' management policy; the patients' assessment with regard to risk factors and health needs, patients' health promotion information and -intervention; promoting a healthy workplace and continuity and cooperation of the hospital with other health, social and informal care providers 2. This document provides a self-standing tool to assess, monitor and improve health promotion activities in hospitals. In detail, this document should facilitate: assessing health promotion activities in hospitals; developing the capacity of health care organizations in improving health promotion activities; formulating recommendations for the improvement of health promotion activities in hospitals; involving all professionals and the patient in improving health promotion activities; improving the coordination of care with other providers of care; improving the health and safety of staff and patients; assisting with modernizing and changing healthcare practice and service delivery to make it more efficient and effective. Health promotion covers conceptually a broad range of activities, interventions, methods and approaches, some of which were too broad for the scope of this document. A decision was taken to address in this self-assessment tool only those issues that are most easily recognized by professionals working with patients, and for which the strongest evidence base is available. Consequently some health promotion activities that were included in previous guiding documents of the Health Promoting Hospitals' N e t w o r k a r e n o t f u l l y r e f l e c t e d 3,4. A comprehensive framework to guide strategic 37

44 implementation of health promotion in hospitals and to guide the further development of health promotion standards is summarized in the Eighteen Core Strategies for Health Promotion in Hospitals 5. Some of the standards (like patient assessment or information and intervention) are directly linked to patient safety issues 6 ; however, this document provides additional tools for a wider approach to empower patients and staff and to complement existing quality and safety activities. This document was developed for all hospitals and quality agencies interested in improving health promotion. Organizations working in the field of quality improvement are encouraged to review and incorporate the standards and indicators for health promotion in hospitals into their existing systems. References 1. Groene O, Garcia-Barbero M. eds. Health promotion in hospitals. Evidence and quality management. Copenhagen, WHO Regional Office for Europe, accessed 08 May Standards for Health Promotion in Hospitals. Copenhagen, WHO Regional Office for Europe, accessed 08 may Ottawa Charter for Health Promotion. Geneva, World Health Organization, hp.pdf, accessed 08 May The Vienna Recommendations on Health Promoting Hospitals. Copenhagen, WHO Regional Office for Europe, publications/ _1, accessed 08 May Pelikan J, Dietscher C, Krajic K, Nowak P. Eighteen core strategies for Health Promoting Hospitals. In: Groene O, Garcia-Barbero M, eds: Health promotion in hospitals. Evidence and quality management. Copenhagen, WHO Regional Office for Europe, 2005: accessed 08 May Forward Programme World Alliance for Patient Safety. Geneva, World Health Organization, pdf, accessed 08 May

45 Standard 1. Management Policy. The organization has a written policy for health promotion. The policy is implemented as part of the overall organization quality improvement system, aiming at improving health outcomes. This policy is aimed at patients, relatives and staff. Objective To describe the framework for the organization's activities concerning health promotion as an integral part of the organization's quality management system. Substandards 1.1 The organization identifies responsibilities for health promotion The hospital's stated aims and mission include health promotion [ Evidence: e.g. time- table for the action ]. 0% 25% 50% 75% 100% Minutes of the governing body reaffirm agreement within the past year to participate in the WHO HPH project [ Evidence: e.g. date for the decision or for payment of the annual fee ]. WHO 0% 25% 50% 75% 100% 39

46 1.1.3 The hospital's current quality and business plans include health promotionhpfor patients, staff and the community [ Evidence: e.g. health promotion is explicit in the plan of action ]. 0% 25% 50% 75% 100% The hospital identifies personnel and functions for the coordination of HP [ Evidence: e.g. staff member nominated for the coordination of HP ]. 0% 25% 50% 75% 100% 1.2 The organization allocates resources for the implementation of health promotion. There is an identifiable budget for HP services and materials [ Evidence: e.g. budget or staff resources ] % 25% 50% 75% 100% Operational procedures such as clinical practice guidelines or pathways incorporating HP actions are available in clinical departments [ Evidence: e.g. check guidelines ]. 0% 25% 50% 75% 100% 40

47 1.2.3 Specific structures and facilities required for health promotionincluding resources, space, equipmentcan be identified [ Evidence: e.g. facilities to lift patients available ]. 0% 25% 50% 75% 100% 1.3 The organization ensures the availability of procedures for collection and evaluation of data in order to monitor the quality of health promotion activities Data are routinely captured on HP interventions and available to staff for evaluation [ Evidence: e.g. availability assessed in staff survey ]. ( ) 0% 25% 50% 75% 100% A programme for quality assessment of the health promoting activities is established [ Evidence: e.g. time schedule for surveys is available ]. 0% 25% 50% 75% 100% 41

48 Standard 2. Patient Assessment. The organization ensures that health professionals, in partnership with patients, systematically assess needs for health promotion activities. Objective To support patient treatment, improve prognosis and to promote the health and well-being of patients. Substandards 2.1 The organization ensures the availability of procedures for all patients to assess their need for health promotion Guidelines on how to identify smoking status, alcohol consumption, nutritional status, psycho-social-economic status are present [ Evidence: check availability ] % 25% 50% 75% 100% Guidelines/procedures have been revised within the last year [ Evidence: check date, person responsible for revising guidelines ]. 0% 25% 50% 75% 100% 42

49 2.1.3 Guidelines are present on how to identify needs for HP for groups of patientse.g. asthma patients, diabetes patients, chronic obstructive pulmonary disease, surgery, rehabilitation[ Evidence: e.g. for groups of patients specifically treated in the clinical department ]. ( COPD 0% 25% 50% 75% 100% 2.2 The assessment of a patient's need for health promotion is done at first contact with the hospital. This is kept under review and adjusted as necessary according to changes in the patient's clinical condition or on request The assessment is documented in the patients' record at admission [ Evidence: for all patients. Identified by patient records audit ]. 0% 25% 50% 75% 100% % 25% 50% 75% 100% There are guidelines / procedures for reassessing needs at discharge or end of a given intervention [ Evidence: guidelines present ]. 0% 25% 50% 75% 100% 43

50 2.3 The patient's needs-assessment reflects information provided by others and ensures sensitivity to social and cultural background Information from referring physician or other relevant sources is available in the patient's record [ Evidence: for all patients referred from physician ]. 0% 25% 50% 75% 100% The patient's record documents social and cultural background as appropriate [ Evidence: religion that requires special diet or other specific attention. Social conditions indicating that the patient is at risk ]. 0% 25% 50% 75% 100% 44

51 Standard 3. Patient Information and Intervention. The organization provides patients with information on significant factors concerning their disease or health condition and health promotion interventions are established in all patient pathways. Objective To ensure that the patient is informed about planned activities, to empower the patient in an active partnership in planned activities and to facilitate integration of health promotion activities in all patient pathways. Substandards 3.1 Based on the health promotion needs assessment, the patient is informed of factors impacting on their health and, in partnership with the patient, a plan for relevant activities for health promotion is agreed. Information given to the patient is recorded in the patients record. [ Evidence: random review of patient records for all patients ] " "" "" "" "" " 0% 25% 50% 75% 100% 45

52 3.1.2 Health promotion activities and expected results are documented and evaluated in the records [ Evidence: e.g. patient records' audit ] % 25% 50% 75% 100% Patient satisfaction assessment of the information given is performed and the results are integrated into the quality management system [ Evidence: e.g. various assessment methods: survey, focused group interview, questionnaire. Time schedule ]. 0% 25% 50% 75% 100% 3.2 The organization ensures that all patients, staff and visitors have access to general information on factors influencing health General health information is available [ Evidence: e.g. availability of printed or online information, or special information desk ]. 0% 25% 50% 75% 100% Detailed information about high risk/diseases is available [ Evidence: e.g. availability of printed or online information, or special information desk ]. / 0% 25% 50% 75% 100% Information is available on patient organizations [ Evidence: e.g. contact-address is provided ]. 0% 25% 50% 75% 100% 46

53 Standard 4. Promoting a Healthy Workplace. The management establishes conditions for the development of the hospital as a healthy workplace. Objective To support the development of a healthy and safe workplace, and to support health promotion activities of staff. Substandards 4.1 The organization ensures the development and implementation of a healthy and safe workplace Working conditions comply with national/regional directives and indicators [ Evidence: e.g. national and internationaleuregulations are recognized ]. 0% 25% 50% 75% 100% Staff comply with health and safety requirements and all workplace risks are identified [ Evidence: e.g. check data on occupational injuries ]. 0% 25% 50% 75% 100% 47

54 4.2 The organization ensures the development and implementation of a comprehensive Human Resources Strategy that includes training and development of health promotion skills of staff New staff receive an induction training that addresses the hospital's health promotion policy [ Evidence: e.g. interviews with new staff ]. 0% 25% 50% 75% 100% Staff in all departments are aware of the content of the organization's health promotion policy [ Evidence: e.g. annual performance evaluation or staff participation in the HP programme ]. 0% 25% 50% 75% 100% A performance appraisal system and continuing professional development including health promotion exists [ Evidence: e.g. documented by review of staff files or interview ]. 0% 25% 50% 75% 100% Working practicesprocedures and guidelinesare developed by multidisciplinary teams [ Evidence: e.g. check procedures, check with staff ]. 0% 25% 50% 75% 100% Staff are involved in hospital policy-making, audit and review [ Evidence: check with staff; check minutes of working groups for participation of staff representatives ]. 0% 25% 50% 75% 100% 48

55 4.3 The organization ensures availability of procedures to develop and maintain staff awareness on health issues Policies for awareness on health issues are available for staff [ Evidence: e.g. check for policies on smoking, alcohol, substance misuse and physical activity ]. 0% 25% 50% 75% 100% Smoking cessation programmes are offered [ e.g. Evidence on availability of programmes ]. 0% 25% 50% 75% 100% Annual staff surveys are carried out including an assessment of individual behaviour, knowledge on supportive services/policies, and use of supportive seminars [ Evidence: check questionnaire used for and results of staff survey ]. 0% 25% 50% 75% 100% 49

56 Standard 5. Continuity and Cooperation. The organization has a planned approach to collaboration with other health service levels and other institutions and sectors on an ongoing basis. Objective To ensure collaboration with relevant providers and to initiate partnerships to optimize the integration of health promotion activities in patient pathways. Substandards 5.1 The organization ensures that health promotion services are coherent with current provisions and regional health policy plans The management board is taking into account the regional health policy plan [ Evidence: e.g. regulations and provisions identified and commented in minutes of the meeting of management board ]. 0% 25% 50% 75% 100% The management board can provide a list of health and social care providers working in partnership with the hospital [ Evidence: e.g. check update of list ]. 0% 25% 50% 75% 100% The intra and intersectoral collaboration with others is based on execution of the regional health policy plan [ Evidence: e.g. check congruency ]. 0% 25% 50% 75% 100% 50

57 5.1.4 There is a written plan for collaboration with partners to improve the patients' continuity of care [ Evidence: e.g. criteria for admittance, plan for discharge ]. 0% 25% 50% 75% 100% 5.2 The organization ensures the availability and implementation of health promotion activities and procedures during out-patient visits and after patient discharge Patientsand their families as appropriateare given understandable follow-up instructions at out-patient consultation, referral or discharge [ Evidence: e.g. patients' evaluation assessed in patient surveys ]. 0% 25% 50% 75% 100% There is an agreed upon procedure for information exchange practices between organizations for all relevant patient information [ Evidence: e.g. check availability of procedure ]. 0% 25% 50% 75% 100% The receiving organization is given in timely manner a written summary of the patient's condition and health needs, and interventions provided by the referring organization [ Evidence: e.g. availability of copy ]. 0% 25% 50% 75% 100% If appropriate, a plan for rehabilitation describing the role of the organization and the cooperating partners is documented in the patient's record [ Evidence: e.g. review of records ]. 0% 25% 50% 75% 100% 51

58 Self-assessment Forms for Implementing Health Promotion in Hospitals and Health Services (Modified by Taiwan HPH Network) 1 2 : 3,

59 1. Groene O ed. Implementing Health Promotion in Hospitals: Manual and Self-assessment Forms. Copenhagen: WHO Regional Office for Europe;

60 Introduction: The role of health promotion in hospitals is changing. It is no longer restricted to providing additional lifestyle-related information to the patient after the clinical procedures have been completed. Health promotion is becoming an integral part of the health care process and is related to clinical, educational, behavioural, and organizational issues 1. In order to improve the quality of care for patients with chronic diseases and long-term conditions, health promotion activities in hospitals need to become better embedded in the larger health systems framework. With the expanded scope of health promotion activities, questions are raised regarding the quality assessment and improvement of these activities. Among the prominent tools to improve quality in health care, such as professionally c o n s e n t e d g u i d e l i n e s, s t a n d a r d s a n d performance indicators, there is little focus on health promotion issues. We therefore developed a self-assessment tool for health promotion in hospitals that addresses the following issues: the hospitals' management policy; the patients' assessment with regard to risk factors and health needs, patients' health promotion information and -intervention; promoting a healthy workplace and continuity and cooperation of the hospital with other health, social and informal care providers 2. This document provides a self-standing tool to assess, monitor and improve health promotion activities in hospitals. In detail, this document should facilitate: assessing health promotion activities in hospitals; developing the capacity of health care organizations in improving health promotion activities; formulating recommendations for the improvement of health promotion activities in hospitals; involving all professionals and the patient in improving health promotion activities; improving the coordination of care with other providers of care; improving the health and safety of staff and patients; assisting with modernizing and changing healthcare practice and service delivery to make it more efficient and effective. Health promotion covers conceptually a broad range of activities, interventions, methods and approaches, some of which were too broad for the scope of this document. A decision was taken to address in this self-assessment tool only those issues that are most easily recognized by professionals working with patients, and for which the strongest evidence base is available. Consequently some health promotion activities that were included in previous guiding documents of the Health Promoting Hospitals' N e t w o r k a r e n o t f u l l y r e f l e c t e d 3,4. A comprehensive framework to guide strategic 54

61 implementation of health promotion in hospitals and to guide the further development of health promotion standards is summarized in the Eighteen Core Strategies for Health Promotion in Hospitals 5. Some of the standardslike patient assessment or information and interventionare directly linked to patient safety issues 6 ; however, this document provides additional tools for a wider approach to empower patients and staff and to complement existing quality and safety activities. This document was developed for all hospitals and quality agencies interested in improving health promotion. Organizations working in the field of quality improvement are encouraged to review and incorporate the standards and indicators for health promotion in hospitals into their existing systems. hp.pdf, accessed 08 May The Vienna Recommendations on Health Promoting Hospitals. Copenhagen, WHO Regional Office for Europe, publications/ _1, accessed 08 May Pelikan J, Dietscher C, Krajic K, Nowak P. Eighteen core strategies for Health Promoting Hospitals. In: Groene O, Garcia-Barbero M, eds: Health promotion in hospitals. Evidence and quality management. Copenhagen, WHO Regional Office for Europe, 2005: accessed 08 May Forward Programme World Alliance for Patient Safety. Geneva, World Health Organization, pdf, accessed 08 May References 1. Groene O, Garcia-Barbero M. eds. Health promotion in hospitals. Evidence and quality management. Copenhagen, WHO Regional Office for Europe, accessed 08 May Standards for Health Promotion in Hospitals. Copenhagen, WHO Regional Office for Europe, accessed 08 may Ottawa Charter for Health Promotion. Geneva, World Health Organization,

62 Standard 1. Management Policy. The organization has a written policy for health promotion. The policy is implemented as part of the overall organization quality improvement system, aiming at improving health outcomes. This policy is aimed at patients, relatives and staff. Objective To describe the framework for the organization's activities concerning health promotion as an integral part of the organization's quality management system. Substandards 1.1 The organization identifies responsibilities for health promotion The hospital's stated aims and mission include health promotion [ Evidence: e.g. time- table for the action ]. 0% 25% 50% 75% 100% Minutes of the governing body reaffirm agreement within the past year to participate in the WHO HPH project [ Evidence: e.g. date for the decision or for payment of the annual fee ]. WHO 0% 25% 50% 75% 100% 56

63 1.1.3 The hospital's current quality and business plans include health promotionhp for patients, staff and the community [ Evidence: e.g. health promotion is explicit in the plan of action ]. 0% 25% 50% 75% 100% The hospital identifies personnel and functions for the coordination of HP [ Evidence: e.g. staff member nominated for the coordination of HP ]. 0% 25% 50% 75% 100% 1.2 The organization allocates resources for the implementation of health promotion. There is an identifiable budget for HP services and materials [ Evidence: e.g. budget or staff resources ] % 25% 50% 75% 100% Operational procedures such as clinical practice guidelines or pathways incorporating HP actions are available in clinical departments [ Evidence: e.g. check guidelines ]. 0% 25% 50% 75% 100% 57

64 1.2.3 Specific structures and facilities required for health promotionincluding resources, space, equipmentcan be identified [ Evidence: e.g. facilities to lift patients available ]. 0% 25% 50% 75% 100% 1.3 The organization ensures the availability of procedures for collection and evaluation of data in order to monitor the quality of health promotion activities Data are routinely captured on HP interventions and available to staff for evaluation [ Evidence: e.g. availability assessed in staff survey ]. ( ) 0% 25% 50% 75% 100% A programme for quality assessment of the health promoting activities is established [ Evidence: e.g. time schedule for surveys is available ]. 0% 25% 50% 75% 100% 58

65 Standard 2. Patient Assessment. The organization ensures that health professionals, in partnership with patients, systematically assess needs for health promotion activities. Objective To support patient treatment, improve prognosis and to promote the health and well-being of patients. Substandards 2.1 The organization ensures the availability of procedures for all patients to assess their need for health promotion Guidelines on how to identify smoking status, alcohol consumption, nutritional status, psycho-social-economic status are present [ Evidence: check availability ] % 25% 50% 75% 100% Guidelines/procedures have been revised within the last year [ Evidence: check date, person responsible for revising guidelines ]. 0% 25% 50% 75% 100% 59

66 2.1.3 Guidelines are present on how to identify needs for HP for groups of patientse.g. asthma patients, diabetes patients, chronic obstructive pulmonary disease, surgery, rehabilitation[ Evidence: e.g. for groups of patients specifically treated in the clinical department ]. ( COPD 0% 25% 50% 75% 100% 2.2 The assessment of a patient's need for health promotion is done at first contact with the hospital. This is kept under review and adjusted as necessary according to changes in the patient's clinical condition or on request The assessment is documented in the patients' record at admission [ Evidence: for all patients. Identified by patient records audit ]. 0% 25% 50% 75% 100% % 25% 50% 75% 100% There are guidelines / procedures for reassessing needs at discharge or end of a given intervention [ Evidence: guidelines present ]. 0% 25% 50% 75% 100% 60

67 2.3 The patient's needs-assessment reflects information provided by others and ensures sensitivity to social and cultural background Information from referring physician or other relevant sources is available in the patient's record [ Evidence: for all patients referred from physician ]. 0% 25% 50% 75% 100% The patient's record documents social and cultural background as appropriate [ Evidence: religion that requires special diet or other specific attention. Social conditions indicating that the patient is at risk ]. 0% 25% 50% 75% 100% 61

68 Standard 3. Patient Information and Intervention. The organization provides patients with information on significant factors concerning their disease or health condition and health promotion interventions are established in all patient pathways. Objective To ensure that the patient is informed about planned activities, to empower the patient in an active partnership in planned activities and to facilitate integration of health promotion activities in all patient pathways. Substandards 3.1 Based on the health promotion needs assessment, the patient is informed of factors impacting on their health and, in partnership with the patient, a plan for relevant activities for health promotion is agreed. Information given to the patient is recorded in the patients record. [ Evidence: random review of patient records for all patients ] " "" "" "" "" " 0% 25% 50% 75% 100% 62