Implementing public health services in health care settings: ALPHA-2 VERSION standards & selfassessmentforms

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Implementing public health services in health care settings: ALPHA-2 VERSION standards &

self-assessment forms

Contact persons:

Professor Hanne Tønnesen and Technical Officer Jeff Kirk Svane, WHO-CC for Evidence-based Health Promotion in Hospitals & Health Services, Bispebjerg-Frederiksberg Hospital, University of Copenhagen

ALPHA-2 VERSION

(Dec2015+May20

16)

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Introduction

The standards consist of 5 domains and 46 measurable elements. They have incorporated the two documentation models for clinical health promotion needs and related activities as indicators.

The pilot test Winter 2015/16.

The pilot test included 10 clinical settings from 8 countries/regions (Austria, Catalonia, Denmark, Estonia, Germany, Japan, Kenya, Slovenia), representing general practitioners, specialist practitioners, university hospitals and rural hospitals. The results were promising regarding usefulness, understanding, applicability and sufficiency.

Results

Standard Understandable Applicable Sufficient

1) Policy & Leadership 100% 90% 90%

2) Patient Assessment 100% 80% 80%

3) Patient Information & Intervention 100% 70% 90%

4) Promoting a Healthy Workplace and ensuring capacity

for clinical health promotion 100% 90% 90%

5) Implementation & Monitoring 100% 90% 100%

Summary of comments included (no. of pilot centres in brackets):

1. Annual updating of guidelines is too short. Wanted every 3 years (x1)

2. Yes and no answers are too simplistic. Scale from “not implemented” to “totally implemented”

recommended (x1)

3. Separate between small and larger clinics (x2)

4. Recommended to be implemented in national accreditation programs (x2)

5. The updated version of the standards and indicators is clearer, easier to work with and better (x2) 6. More complementary indicators and specific aspects of risk profiles wanted (x2), but further

expansion would impede implementation (x1).

7. More information and instructions on how to fill out is needed (x2) 8. HP budget often included in other budgets (x1)

9. Native language preferred (x1)

10. 5-day readmission period is too short. 30 days recommended (x1)

The project team has included comments 1 (compromise: every 2 years), 2 (is scaled in standard 2 and 3 per percentages. For issues like documents, yes and no answers suffice), 3+6 (this is a balance, however the updated standards should be a basic minimum level for all working on implementation of CHP), 4+5+9 (agree), 7 (will be expanded in instruction chapters preceding the actual standards text chapters), 8 (it is important to make the HP budget visible, either as part of adjacent budgets or on its own), 10 (according to international definitions, 5 days is standard, however, 30 days could be relevant as supplementing

timeframe).

Expert hearing:

Pre-hearing from WHO Europe completed. Comments included need for extra clarification, extra clarification of limitations of the scope, lowering evidence level from high to middle/low, extra work on incorporating equity issues and measurable elements on environmental issues, extra consideration of implementation issues and extra clarification of quality assurance measures.

Full expert hearing will be conducted in early summer 2016.

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Short instruction on using the standards manual:

Step 1: The fulfilment of measurable elements for standards regarding policy, strategy and other

documents is evaluated through availability of needed documents and existence of facilities and structures.

Step 2: The fulfilment of measurable elements for standards regarding patient information and

intervention is evaluated by medical records audit of 20-50 consecutive patients per department, if the setting is a hospital, or in total for minor clinics.

STANDARD 1) Policy and Leadership

The organization has a written policy for clinical health promotion (CHP) - aimed at patients, relatives and staff.

Objective: to describe the framework for the organization’s CHP activities.

Substandards:

1.1. The organization prioritizes CHP.

Y N Action Plan

1.1.1 The organization has a policy for CHP - aimed at patients,

relatives and staff.

1.1.2. The policy is reflected in the organization’s aims and mission [Evidence: e.g. time- table for the action].

1.1.3. The commitment to CHP is made visible (Evidence: e.g. the policy is available on web or in brochure)

1.1.4. The organization is a current member of the WHO HPH

Network [Evidence: e.g. date for the decision or for payment of the annual fee].

1.1.5. Working practices (procedures and guidelines) are developed by multidisciplinary teams [Evidence: e.g. check procedures, check with staff].

1.1.6. Staff are involved in policy-making, audit and review [Evidence:

check with staff; check minutes of working groups for participation of staff representatives].

1.2. The organization prioritizes continuity and coordinated patient pathways.

Y N Action Plan

1.2.1. The management takes the regional health policy plan into account [Evidence: e.g. regulations and provisions identified and commented in minutes of the meeting of management board].

1.2.2. The management can provide a list of health and social care providers working in partnership with the organization [Evidence: e.g.

check update of list].

1.2.3. The intra- and intersectoral collaboration with others is based on execution of the regional health policy plan [Evidence: e.g. check congruency].

1.2.4. There is a written guidelines or procedure for collaboration with partners to improve the patients’ continuity of care [Evidence:

e.g. criteria for admittance, plan for discharge].

1.2.5. There is an agreed upon procedure for information exchange practices between organizations for all relevant patient information [Evidence: e.g. check availability of procedure].

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Complementary indicators

a) ________________________________% of patients (and relatives) aware of policy b) Do you have a policy for :

Tobacco Alcohol Overweight/malnutrition Physical inactivity

Y/N/U Y/N/U Y/N/U Y/N/U

c) Additional indicators

(local indicators you may want to consider for the action plan) -

- - - -

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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 assesses the needs for health promotion of all patients at first contact.

Y N Action Plan

2.1.1. The organization has guidelines/procedures for how to identification of smoking status, alcohol consumption, physical activity level, nutritional status, psycho-social-economic status at admission or first contact [Evidence: e.g. check availability].

2.1.2. Guidelines/procedures have been revised within the last year [Evidence: e.g. check date, person responsible for revising

guidelines].

2.1.3. The assessment on needs for CHP is documented in the patient’s record [Evidence: e.g. identified by patient records audit].

2.1.4. The patient’s record documents socio-culturally determined

special needs as appropriate [Evidence: needs for translation, social conditions indicating that the patient is at risk, special dietary needs or other issues requiring specific attention. ].

2.1.5. Information from referring physician or other relevant sources is available in the patient’s record [Evidence: for all patients referred from physician].

2.2.The assessment of a patient's need for health promotion is kept under review and adjusted as necessary according to changes in the patient's clinical condition or on request.

Y N Action Plan

2.2.1. The organization has guidelines / procedures for reassessing needs at discharge or end of a given intervention [Evidence: e.g.

guidelines present].

guidelines].

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Complementary indicators

a) ________ % of patients assessed for risk factors

b) ________ score on survey of patients’ satisfaction with assessment procedure c) HPH DATA Model for documentation of patient risk factors

HPH Data Model: Document risk in medical records Yes/No Risk?

A. Risk of malnutrition

A1. Does patient have a BMI < 20.5 ?

A2. Has patient suffered from weight-loss in the past month?

A3. Has patient suffered from decreased food intake in the last wk.?

A4. Is patient severely ill (sepsis, burns, etc.)?

B. Overweight

B1. Does patient have a BMI > 25 ?

B2. Is patient’s waist-measure > 80 cm (W) or 94cm (M) ?

C. Physical inactivity

C1. Is patient physically active < 1/2 hour / day ?

D. Smoking

D1. Does patient smoke daily ?

E. Drinking

E1. Does patient drink > 14 drinks/wk (W) or 21 (M) ?

(NB: Please fill out the form above for EACH of the 10 – 20 medical

records you have retrieved from your system or files, as described in

“Step 1” on page 1. You can just copy/paste the form as many times as needed, and then enter in your answers based on the information in each medical record).

d) Additional indicators

- - - -

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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 where relevant and via coordinated 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 needs assessment, the patient is informed of factors impacting on their health and motivational activities or brief intervention is offered as needed.

Y N Action Plan

3.1.1. General health information is available [Evidence: e.g.

availability of printed or online information, or special information desk].

3.1.2. Detailed information about high/risk diseases is available [Evidence: e.g. availability of printed or online information, or special information desk].

3.1.3. Information is available on patient organizations [Evidence: e.g.

contact-address is provided].

3.1.4. The organization has guidelines/procedures on how to deliver motivational activities and brief intervention regarding smoking status, alcohol, physical activity, nutrition and psycho-social- economic issues [Evidence: e.g. check availability].

guidelines].

3.1.6. Motivational activities or brief intervention given is recorded in the patient’s record [Evidence: e.g. random review of patient records for all patients].

3.1.7. Motivational activities or brief intervention and expected results are documented and evaluated in the records [Evidence: e.g.

patient records’ audit]

3.2. Based on the needs assessment, the patient is offered intervention, rehabilitation or after-treatment as needed.

Y N Action Plan

3.2.1. The organization has guidelines/procedures on how to deliver intervention, rehabilitation and after-treatment regarding smoking status, alcohol, physical activity, nutrition and psycho-social- economic issues [Evidence: e.g. check availability].

guidelines].

3.2.3. Intervention, rehabilitation or after-treatment given is recorded in the patient’s record [Evidence: e.g. random review of patient records for all patients].

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3.2.4. Intervention, rehabilitation or after-treatment and expected results are documented and evaluated in the records [Evidence: e.g.

patient records’ audit]

3.2.5. Patients (and their families as appropriate) are given understandable follow-up instructions at out-patient consultation, referral or discharge [Evidence: e.g. patients’ evaluation assessed in patient surveys].

3.2.6. 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].

3.2.7. 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].

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Complementary indicators

a) HPH Doc-Act Model for documentation of clinical health promotion services

HPH Doc-Act Model:

Document CHP activities in medical records DRG Code

Counselling or motivational interviewing done regarding:

Smoking BQFS01

Alcohol BQFS02

Nutrition BQFS03

Physical activity BQFS04

Psycho-social relation BQFS05

Other risk factors BQFS06

Integrated counselling (consisting of several factors) BQFS19 Intervention, rehabilitation or after-treatment done regarding:

Tobacco cessation BQFT01

Alcohol intervention BQFT02

Nutrition BQFT03

Physical activity BQFT04

Psycho-social support BQFT05

Medicine after-treatment BQFT06

Patient education BVDY04

Integrated rehabilitation (consisting of several elements) BQFT19

Note: DRG codes from Danish National Board of Health used here for illustration purposes.

In Denmark, the reimbursement for each resembles ordinary visit to primary care or out-patient clinic.

www.medinfo.dk

b) ________ % of discharge summaries sent to GP or referral clinic within two weeks or handed to patient on discharge

c) ________ Readmission rate for ambulatory care sensitive conditions within 5 days d) ________ Score on patient discharge preparation survey

e) Additional indicators

- - - -

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STANDARD 4) Promoting a Healthy Workplace and ensuring capacity for CHP

The management establishes conditions for the development of the organization as a healthy workplace and ensures adequate capacity for delivering CHP.

Objective: to support the development of a healthy and safe workplace, health promotion activities for staff and needed staff skills for delivering CHP.

Substandards

4.1. The organization protects the health of staff and ensures the development and implementation of a healthy workplace.

Y N Action Plan

4.1.1. Working conditions comply with national/regional directives and indicators [Evidence: e.g. national and international (EU) regulations are recognized]

4.1.2. Staff comply with health and safety requirements and all workplace risks are identified [Evidence: e.g. check data on occupational injuries].

4.1.3. CHP programmes for staff are offered regarding smoking cessation, alcohol intervention, nutrition and physical acticvity [e.g.

Evidence on availability of programmes].

4.1.4. Annual staff surveys are carried out including an assessment of individual behaviour,Quality of life, knowledge regarding avaliable supportive services/policies, and use of CHP programmes [Evidence:

check questionnaire used for and results of staff survey].

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.

Y N Action Plan

4.2.1. Staff training and professional development programs for CHP are avaliable [Evidence: e.g. check avaliability, review of staff files, interviews with new staff].

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Complementary indicators

a) ________ Score of survey of staff experience with working conditions b) ________ % of short-term absence

c) ________ % of work-related injuries d) ________ Score on burnout scale

e) _________ % aware of health promotion policy f) Staff questionnaire

Do you comply with the health and safety regulations of your workplace?

I comply completely I mostly comply I comply partly I comply a little I don't comply at all

Are you aware of the risks at your workplace?

I am completely aware I am mostly aware I am partly aware I am a little aware I am not at all aware

How do you rate your working conditions?

Excellent Very good Good Fair Poor

Have you received introductory training, which addressed the health promotion policy of your workplace?

Yes No

Are you aware of the content of the health promotion policy of your workplace?

Yes No

Has your workplace asked you about your health and lifestyle risks (such as smoking status) within the last year?

Yes No

Within the last year, has your workplace informed you of any supportive services, such as smoking cessation courses, which are offered to staff?

Yes No

How many days per week are you physically active? (Moderate intensity with pulse increase, e.g. walking, cycling, training)

0 1 2 3 4 5 6 7

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For the above days, how many minutes on average are you physically active?

Minutes (per day with physical activity):

________________ minutes

How many days per week do you smoke/use tobacco? (see tobacco conversion table in appendix)

0 1 2 3 4 5 6 7

Grams of tobacco (per day with smoking/tobacco usage):

________________ grams

How many days per week do you drink alcohol?

0 1 2 3 4 5 6 7

For these days, how many units of alcohol do you drink on average? (see unit conversion table in appendix) Units of alcohol (per day with drinking):

Alcohol unit conversion table:

If you are a current or previous smoker have you received advice to quit smoking by your workplace?

Yes No Never smoker

Have you ever been absent from your current job for 7 days or more in a row? (for any reason, except for holidays, pregnancy, education, planned leave etc.)

Yes No

Have you ever been absent from your current job for 30 days or longer? (for any reason, except for holidays, pregnancy, education, planned leave etc.)

Yes No

Within the last year, have you been injured at work? (including injuries such as needlestick, cuts from sharp devices etc.)

Yes No

How burned-out from work are you?

Not at all A little bit Moderately Quite a bit Extremely

g) Additional indicators

- - -

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STANDARD 5) Implementation and monitoring

The organization implements and monitors its policy for CHP as part of the overall quality improvement system.

Objective: to implement and monitor the framework for the organization’s CHP activities.

Substandards:

5.1. The organization implements CHP.

Y N Action Plan

5.2.1. The organization’s current quality and business plans include CHP [Evidence: e.g. health promotion is explicit in the plan of action].

5.2.2. The organization identifies personnel and functions for the CHP [Evidence: e.g. staff member(s) coordinating/providing CHP].

5.2.3. There is an identifiable budget for CHP services and materials [Evidence: e.g. budget or staff resources].

5.2.4. Specific structures and facilities required for health promotion

(including resources, space, equipment) can be identified [Evidence:

e.g. facilities to lift patients available].

5.2.5. Operational procedures such as clinical practice guidelines or pathways incorporating CHP are availables [Evidence: e.g. check guidelines].

5.2. The organization monitors effect of CHP.

Y N Action Plan

5.2.1. Data are routinely captured on HP interventions and available to staff for evaluation [Evidence: e.g. availability assessed in staff survey].

5.2.2. A programme for quality assessment of the health promoting activities is established [Evidence: e.g. time schedule for surveys is available].

5.2.3. The organization performs research and development in CHP [Evidence: e.g. published articles, internal reports etc.].

5.2.4. Patient satisfaction assessment of CHP services 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].

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Complementary indicators

a) ________________% budget dedicated to staff HP activities b) Score on survey of patients’ experience with CHP services

c) Do you have info to patients on lifestyle risks (e.g. on web or in brochures) for:

d) To what degree does it have practical consequence for patients, such as referral to smoking cessation etc?

ca. % ca. % ca. % ca. %

e) Do you have systematic follow up for effect of offered HP for?

f) Additional indicators

- - - -

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APPENDIX

TOBACCO GRAM CONVERSION TABLE (av. For practice) 1 cigarette = 1 gram

1 cheroot = 3 grams 1 cigar = 4 grams 1 pipe = 3 grams 1 snuff = 10 gram

(nicotine content of 1 gram snuff = content of 10 cigarettes) ALCOHOL UNIT CONVERSION TABLE (av. For practice) BEERS

1 light beer (33 cl., 1.5 – 2.5% vol) = 0.5 unit 1 small light beer (25 cl., 1.5 – 2.5% vol) = 0.25 unit 1 ordinary beer (33 cl., 3.5 – 4.5% vol) = 1 unit

1 small ordinary beer (25 cl., 3.5 - 4.5% vol) = 0.75 unit 1 strong beer (33 cl., 4.5 – 6% vol) = 1.25 units 1 small strong beer (25 cl. with 4.5 – 6% vol) = 1 unit 1 extra strong beer (33 cl., 7 – 10% vol) = 2 units

1 small extra strong beer (25 cl., 7 – 10% vol) = 1.25 units

WINES

1 glass of wine (12.5 cl., 11 - 16% vol) = 1 units 0.5 bottle of wine (37.5 cl., 11 - 16% vol) = 3.25 units 1 bottle of wine (75 cl., 11 - 16% vol) = 6.5 units

FORTIFIED WINES

1 glass of fortified wine (5 cl., 17 – 22% vol) = 0.5 unit 0.5 bottle of fortified wine (37.5 cl., 17 – 22% vol) = 5 units 1 bottle of fortified wine (75 cl., 17 – 22% vol) = 10 units

SPIRITS

1 ordinary serving of spirits (4 cl., 35 – 40% vol) = 1 unit 1 small serving of spirits (2 cl., 38% vol) = 0.5 unit 1 bottle of spirits (75 cl., 35 – 40% vol) = 19 units

Implementing public health services in health care settings: ALPHA-2 VERSION standards & selfassessmentforms