Hospital Learning Network

State: MA Type: Model Practice Year: 2013

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Boston has a population of 625,087 (2011) with the median age of 31 years. The median household income for a family is $44,151. According to the 2010 U.S. Census, Boston is racially diverse with White (53.9%), Black (24.4%), and Latino (17.5%) residents. Over one-third of U.S. adults and approximately 17% of children and adolescents are obese placing them at an increased risk for a multitude of chronic diseases. Overweight and obesity are the cause for $190 billion in medical spending every year in the US. The increased consumption of sugar-sweetened beverages (SSBs), the largest single source of added sugar to the American diet, has been shown to be a unique contributor to weight gain and Type 2 diabetes, in addition to an association with, heart disease, metabolic syndrome, hypertension, and gout. In Boston, statistics mimic the national trend with nearly 60% of the population either overweight or obese.

The target population of the Hospital Learning Network is Boston’s health care sector. The unhealthy beverages provided by hospital patient meals, vending, catering, and retail services model unhealthy consumption habits and have a significant impact on human health. Due to its massive buying power (18% of GDP), moral authority, and its mission-driven interest in health, the healthcare sector can help shift the `economy towards healthier product purchasing and consumption trends.

Boston is renowned for the quality of its hospital system which employ over 50,000 people and provide care for over 1 million patients each year. Because of this substantial impact on the Boston community the hospital setting represents a unique opportunity for promoting healthy behaviors. Two separate studies done in Boston hospitals have demonstrated that a decrease in sales of unhealthy beverages is achievable by implementing strategies such as changing beverage product placement and pricing, These promising findings suggest that there is opportunity for interventions made within hospital food environments to be an effective strategy for shifting individual beverage choices. LHD can easily adopt this practice assuming the role as a convener of the network and advocate to hospital upper management. The technical assistance partners utilized in this practice have national range and outreach and are able to support the adoption of this practice by LHD nationally.

As part of the CPPW efforts to reduce consumption of SSBs across key sectors, in April of 2010, the BPHC created a SSB “hospital learning network” (HLN), to provide a forum for Boston hospitals to address access to SSBs in the healthcare setting. Hospital representatives participated in HLN standing meetings, through which they received technical assistance (TA) and resources on making SSB policy, systems, and environmental (PSE) changes; shared progress and best practices; and addressed challenges and obstacles . Health Care Without Harm (HCWH), and the American Heart Association (AHA were strategically selected to serve as TA providers and partners for this initiative.

 

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Boston Public Health Commission
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Hospital Learning Network
Is there sufficient stakeholder commitment to sustain the practice? Describe how this commitment is ensured.Our technical assistance partners HCWH and the AHA maintained working relationships with all the participating health care facilities prior to the development of the HLN and will continue those relationships after the BPHC ceases to host the HLN meetings. HCWH continues with multiple synergistic initiatives with these hospital to foster the development of healthy food and beverage environments as well as the initiation of policies to support them. The AHA will continue to engage the clinical staff and management within these facilities providing access to resources and education that guides them in the development of a healthy beverage program.Describe plans to sustain the practice over time and leverage resources.As a result of the success of the Boston hospitals through this learning network, national interest has emerged within the health care sector to engage in similar efforts to implement healthy beverage strategies in their facilities. HCWH with their national network has created the Healthy Beverage Program housing tools, resources, case studies, and the noted Health Care Professional Pledge on their website. This Program also informed the development of the National Healthier Hospital Initiative’s Healthy Beverage Goal charging hospital management to commit to achieve a sector standard where 80% of all beverages purchased by health care facilities will be healthy (i.e. only 20% of all beverages offered can be SSBs) This structure in place allows us to tap into the national momentum and resources that will continue to be developed to support facilities with minimal staffing.
Responsiveness The public health issue that this practice addressesOver one-third of U.S. adults and approximately 17% of children and adolescents aged 2—19 years are obese placing them at an increased risk for a multitude of chronic diseases such as Type-2 diabetes, heart disease, stroke, arthritis, gall bladder disease, and certain cancers. Overweight and obesity are the cause for $190 billion in medical spending every year in the US. The increased consumption of sugar-sweetened beverages (SSBs), the largest single source of added sugar to the American diet, has been shown to be a unique contributor to weight gain and Type 2 diabetes, in addition to an association with, heart disease, metabolic syndrome, hypertension, and gout. In Boston, Massachusetts, statistics mimic the national trend with nearly 60% of the population either overweight or obese. According to BMI data collected at Boston Public Schools on children in first, fourth, seventh, and tenth grade, during the 2004-2005 school year 27% met BMI percent-by-age criteria for “overweight” and 19% were at risk of becoming overweight. Process used to determine the relevancy of the public health issue to the communityObesity, diabetes and other diet-related disease are national health crises, and CDC data shows the City of Boston mimics national trends. . In Boston, Massachusetts, statistics mimic the national trend with nearly 60% of the population either overweight or obese. According to BMI data collected at Boston Public Schools on children in first, fourth, seventh, and tenth grade, during the 2004-2005 school year 27% met BMI percent-by-age criteria for “overweight” and 19% were at risk of becoming overweight. The City of Boston is taking this epidemic seriously and has initiated policy and programs to combat these trends. Boston Mayor Thomas M. Menino’s issued an executive order prohibiting the use of City funds for the purchase or sale of sugar-sweetened beverages on city property. Mayor Menino called upon leaders across other major sectors to follow suit, creating a supportive political environment and precedence for future efforts to reduce access to SSBs. How the practice addresses the issueThe Hospital Learning Network addresses obesity and diet-related chronic disease by targeting a principle source of added calories and sugar in the diet; sugar sweetened beverages (SSB) while leveraging the power of the healthcare sector as the change agent. The healthcare sector is recognized as a respected source of health information and interfaces with the community on a regular basis. Hospitals also have a broad reach in the community as employers and as a provider of health care services. Health care facilities serve beverages daily in multiple areas; patient trays, cafeteria, vending, and catering offering numerous opportunity to model healthy choices. The practice aims to reduce incidence of diet-related disease directly by changing the offerings within hospital facilities, and more broadly by engendering behavior change outside the hospital setting through healthy choice modeling and education. Innovation Evidence based strategies used in developing this practiceTwo separate studies done in Boston hospitals have demonstrated that a decrease in sales of unhealthy beverages is achievable by implementing strategies such as changing beverage product placement and pricing. http://www.ncbi.nlm.nih.gov/pubmed/22390518, http://www.ncbi.nlm.nih.gov/pubmed/20558801 These promising findings suggest that there is opportunity for interventions made within hospital food environments to be an effective strategy for shifting individual food choices. Currently there is not an effective model to implement similar types of interventions throughout a diverse community of hospitals, and the HLN work aims to develop that model. This practice is new to the field of public health Process used to determine that the practice is new to the field of public healthThe development of sector-based workgroups or taskforces to collaborate on program development is not a new one. We recognize the existence of on-line discussion boards and listservs centered around specific topic areas that tend to be multi-sector. Historically, there is also a recognized practice within institutions to form committees to develop and roll-out a program. Regarding strategies and methods utilized within the health care sector in particular, Health Care Without Harm, with their national network is engaged in leading multiple hospital leadership teams where multiple hospitals come together to work on overcoming challenges to local, sustainable food purchasing within their individual settings. However, we are unaware of any instance of a multi-health care facility learning network in place that addresses obesity nor one that addresses the purchase, provision, education, and policies surrounding sugar-sweetened beverages. When initiated, this topic had only been addressed in municipal and school settings. Since the initiation of this practice there has emerged interest from communities and organizations nationally to replicate it recognizing the innovative nature of the model. How this practice differs from other approaches to address the public health issueWhen initiated, this topic had only been addressed in municipal and school settings . Health care settings were not being utilized in strategies to reduce access to SSBs and model healthy beverage policies other than reducing bottled water policies. Also, the implementation of SSB reduction programs within hospitals was a voluntary effort by large organizations to address the issue of obesity without funding to do so. They were under no specific obligation or governmental mandate to meet any criteria. It is also a creative use of an existing tool or practice Process used to determine that the practice is a creative use of an existing toolThe practice of collaborative efforts between organizations forming for the purpose of achieving a health or other community goal has been an effective process utilized past. For example, in Boston there have been various collaborative formed to share best practices and set strategic goals to address community health issues, such as the Boston Collaborative for Food and Fitness, the Violence Intervention and Prevention Coalitions, and the Steps Consortium. We used the same concept of learning collaborative to bring hospitals together to tackle the issue of SSB availability in the health care sector. Tool or practice used in a creative wayThroughout the HLN process, two tools were developed and used to support the progress of set goals. First, an SSB toolkit was created to help agencies make organizational policy, systems and environmental changes. In reviewing existing tool-kits we concluded that there were no existing toolkits which thoroughly supported the implementation of key elements necessary for achieving SSB PSE changes across various sectors including the health care sector. Various existing tool kits were referenced to obtain ideas of what works well in the creation of our own SSB toolkit, all of which can be found in our reference page of our toolkit http://www.bphc.org/programs/cib/chronicdisease/healthybeverages/Forms Documents/toolkit/HealthyBeverageToolkitFinal.pdf Secondly, point-of-purchase signage was created which we labeled “Rethink Your Drink” Stoplight Signs which can be found at http://www.bphc.org/programs/cib/chronicdisease/healthybeverages/Pages/Home.aspx These signs were placed at different points of purchase of beverages in the hospitals to encourage healthier beverage choices. The stoplight sign used red to indicate beverages that should be consumed on a very limited basis if at all, yellow to indicate beverages that should be consumed in moderation, and green to indicate beverages that can be consumed freely. The red, yellow, green lighting system has been used in the past as an educational tool. IN particularly, our stop light sign was developed and modified from Harvard’s How Sweet Is it? Nutrition handout www.hsph.harvard.edu/nutritionsource/healthy-drinks/ which used this same system to define the different types of beverages based on sugar and calorie content. Health Care Without Harm also housed the Health Care Professionals Pledge to support reducing SSBs in health care on their website at http://org2.democracyinaction.org/o/5140/p/dia/action/public/?action_KEY=8358 As mentioned this topic had only been addressed in municipal and school settings prior to this programs initiation. The hospital setting is a unique one with many different outlets where SSBs can be offered such as retail or cafeterias, vending often with 24 hour access, catering service, patient trays and floor stock by clinical staff as well as on-site contracted venue. The creation of the above toolkit noted strategies for each and the point of purchase signage could be used at each location. There was also the opportunity to engage clinicians in educating those they encountered as patients with information on the impacts of SSB consumption and health. This unique opportunity to provide our educational brochure and healthy messaging was unique to the sector we worked with. The use of the health care professional pledge offered us a way to first bring awareness to the clinical community about these efforts so that a shift in messaging could be provided.
Primary StakeholdersThe Boston Public Health Commission served as the convener of this initiative. Health Care Without Harm (HCWH), and the American Heart Association (AHA) were strategically selected to serve as technical assistance providers and partners for this initiative. The ten Boston hospitals participating in the learning network included Massachusetts General Hospital, Brigham and Women’s Hospital, Boston Children's Hospital, Faulkner Hospital, St. Elizabeth Medical Center, Carney Hospital, Boston Medical Center, Tufts New England Medical Center, Dana Farber Cancer Institute, Beth Israel Deaconess Medical Center LHD RoleThe Boston Public Health Commission served as the convener and co-organizer of this practice. As the local health department they served as a central connecting factor linking the broader city-wide obesity prevention initiative to the Hospital Learning Network. They served to provide educational resources which included the point-of-purchase stoplight education poster and brochure to hospitals that assisted in shaping the consistency and roll-out of the 10 hospitals programs. Health Care without Harm served as a co-organizer and technical assistance provider to the facilities. Their expertise and existing networks in the health care sector served to foster program development and outreach to key health care contacts. They provided resources and guidance on contract modifications, procurement strategies, educational program development, tracking, and overcoming barriers. HCWH assisted with the development of the meeting agendas. The American Heart Association also provided technical assistance in the form of on-the-grounds support at meetings and virtual assistance through the provision of resources. The AHA existing clinician networks and positive reputation within the health care sector also assisted in leveraging momentum within the facilities. The BPHC maintains an on-going collaboration with the city of Boston’s initiatives building off momentum at the municipal level and progress in sectors such as schools and community health centers. This was particularly the case when leveraging momentum built from the Mayors executive order to prohibit the sale of SSBs on city property. BPHC engaged other health care partners such as community health centers in sharing best practices and educational opportunities. The Public Health Law Center in addition to the American Heart Association were utilized in developing a policy training provided to Bostons’ community health centers and faith-based organizations in addition to the learning network facilities. BPHC worked to maintain awareness of synergistic efforts by other organizations such as one led by the local youth led Sociladad Latina organization. BPHC supported and attended a presentation to engage hospitals in the Longwood Area of Boston by this group with follow-up communication to support future efforts. Lessons learned The collective gathering of hospitals together in a competitive/learning environment proved to be an optimal way to foster progress towards a common goal with the use of limited on-the-ground resources for technical assistance. The partnering with organizations; one with a strong reputation in research and outcomes ( American Heart Association) and another with a strong history of environmental change work in the health care sector (Health Care Without Harm) assisted us in building our capacity in this sector to not only promote the change we sought but also develop our own relationships. The path was not without barriers. We found varying levels of commitment within the hospitals based on upper management support and interest. Many of the facilities were challenged with competing campaigns such as the effort to promote a smoke-free campus. We found that those facilities that maintained a structured internal taskforce comprised of interdisciplinary members from throughout the hospital were more successful at overcoming barriers. Elimination of SSBs was taken on by only one facility as the other 9 facilities felt the budget challenges they encountered would not warrant this step. Facilities with on-site contracted vendors that competed with their own retail operations such as Dunkin Donuts or CVS were reluctant to move forward with a program unless these entities would also comply. We provided guidance on opportunities for intersecting in contract language and found that the need to engage upper management in the roll-out of their programs was essential to assure the budget implications would be recognized. Tasks taken that achieve each goal and objectiveThe BPHC engaged Health Care Without Harm (HCWH) as a technical assistance partner to leverage their existing network within the health care sector and develop a strategy to engage this group. The Commission formulated a strategic sugar-sweetened beverage education campaign in collaboration with the Boston Health Commissioner that included the development of the stoplight point-of-purchase poster and brochure to be given to any organization in Boston for use for free. The BPHC Executive Director sent a formal letter of request to participate to the hospital leadership of Boston’s acute care hospitals calling on them to identify a member of their organization to participate in the newly forming Hospital Learning Network. HCWH provided outreach to food and beverage operational staff within Boston’s health care institutions alerting them of the formation of this workgroup. Standing meetings of the HLN were held every 6 weeks convened by the BPHC with support from HCWH and new partner AHA providing resources, speakers, case studies from facilities nationally, and input on challenges hospitals faced. In the time between meetings, HCWH served as the TA partner maintaining communication with the health care facilities, assisting with individual program development, providing resources and guidance and serving as a liaison to the BPHC. A national Health Care Professional Pledge was implemented through the HCWH website as a way to engage the clinicians within the facilities and motivate individual hospitals to move forward. The media was engaged at the Capstone Event to provide a goal point for facilities to work towards. TimeframeThe timeframe was that of the CPPW grant initiated in March of 2010 through March of 2012 a 2 year span. The first meeting of the HLN was initiated in April of 2010 and the Capstone event held on February 2012.Please provide a succinct outline of some basic steps taken in implementing your practice. The BPHC engaged Health Care Without Harm (HCWH) as a technical assistance partner to leverage their existing network within the health care sector and develop a strategy to engage this group. The Commission formulated a strategic sugar-sweetened beverage education campaign in collaboration with the Boston Health Commissioner that included the development of the stoplight point-of-purchase poster and brochure to be given to any organization in Boston for use for free. The BPHC Executive Director sent a formal letter of request to participate to the hospital leadership of Boston’s acute care hospitals calling on them to identify a member of their organization to participate in the newly forming Hospital Learning Network. HCWH provided outreach to food and beverage operational staff within Boston’s health care institutions alerting them of the formation of this workgroup. Standing meetings of the HLN were held every 6 weeks convened by the BPHC with support from HCWH and new partner AHA providing resources, speakers, case studies from facilities nationally, and input on challenges hospitals faced. In the time between meetings, HCWH served as the TA partner maintaining communication with the health care facilities, assisting with individual program development, providing resources and guidance and serving as a liaison to the BPHC. A national Health Care Professional Pledge was implemented through the HCWH website as a way to engage the clinicians within the facilities and motivate individual hospitals to move forward. The media was engaged at the Capstone Event to provide a goal point for facilities to work towards. Lessons LearnedThe format of the learning network provided a successful forum for troubleshooting, resource sharing, and healthy competition among facilities. Hospitals individualized the path to achieving PSE changes but adhered to one common goal set forth by the BPHC. Having a common goal with flexibility in the implementation proved to be a good strategy. Hospital noted the need to individualize their programs. Engaging upper management was a key factor in the ability of facilities to implement changes as often times those from the Learning Network facilities working in operations were hesitant to move forward with any purchasing changes without hospital leadership consent. The support of a interdisciplinary internal hospital taskforce gathered at each hospital to encourage communication among facility departments was a key strategy that assisted facilities in overcoming the unique barriers they faced within their institutions. The dissemination of point-of-purchase education and general education to staff and visitors on the health impacts of sugar and SSB consumption was the strategy most frequently used by all the facilities. This proved to be the case because it had minimal impact on budget and the current purchasing practices in place within the facility. Providing facilities with the stoplight educational tool for use provided an easy implementation tool and guided their program development. Perceived hurdles and hospital staff concerns over healthy beverage program implementation were overcome through the internal work of the individual hospital taskforces with support and guidance from the larger Hospital Learning Network. Some of the main concerns were common throughout all facilities and included; Concerns about elimination of beverages/personal choice argument, hydration concerns for patient services, and economic impact. Time proved to be a limiting factor for the development of an internal beverage policy. Hospitals were resistant to develop written policy language until they had rolled out a successful program and hospital management expressed full support. Cost to implement Funding was made possible by the Communities Putting Prevention to Work Obesity Prevention Grant, a stimulus funded CDC grant from the US Office of Health and Human Services. Major expenses consisted of staff time contributed by the sub-contracted partner organization Health Care Without Harm at 10 hours per week and in-kind staff time contributed by BPHC intern at 10 hours per week for the length of the grant period. Additional costs included start-up staff time from the BPHC, in-kind participation by the American Heart Association as technical assistance partner provided through the CDC, minor on-the-grounds travel expenses, printing costs for meeting handouts, and in-kind printing costs for the resources developed as part of the broader obesity prevention campaign.
Objective 1: (375 word limit plus 375 word overflow): Activate the collective economic and social power of Boston’s’ acute-care facilities to reduce access to sugar sweetened beverages and increase access to public drinking water Performance measures 1) Number of hospital learning network facilities that: 1a) Reduced access to SSBs in their facilities 1b) Increased access and promotion of public drinking water 2) Number of health care professionals signed on to the pledge in support of reducing the provision of SSBs and increasing access to public drinking water in their facility Data HLN participants were asked to complete a baseline assessment that collected information on all of the noted performance measures. We encouraged facilities to complete this assessment with assistance from TA partner HCWH. 5 facilities chose to do so, 4 completed the assessment independently, and participating facility did not complete a baseline assessment. Midpoint progress data was collected via a survey created by BPHC and HCWH that was disseminated and collected electronically by BPHC. A final progress report of PSE changes was collected from HLN participants via email from TA partner HCWH and summarized into a fact sheet of accomplishments to be distributed at the capstone event held in February 2012. The Health Care Professional Pledge was managed and tracked by Health Care Without Harm and collected 422 signatories by the capstone event. Evaluation results The BPHC and partners provided suggested strategies for achieving the noted objective with particular emphasis on the MAPPS strategies. Hospitals reported using a wide variety of the MAPPS strategies in innovative ways that were unique to each facility. The individuality of each program roll-out was integral to the ownership of the program within each facility. 7 out of the 10 facilities implemented programs that reduced access to SSBs within their facilities. 6 out of 10 facilities increased access to or the promotion of public drinking water. Feedback We recognized that standardized tracking of beverage purchases and sales was challenging to obtain from each facility and required continual TA and prodding. Even with the increased attention, the response to tracking was poor. This challenged our ability to measure the impact outcome.   Objective 2: Establish a Learning Network of Boston-area acute-care hospitals to address obesity and diet-related disease by implementing policy, systems, and environmental changes that promote healthy beverage choices in their facilities Performance measures Process strategies used to support PSE changes that included healthy beverage program implementation PSE changes implemented Purchasing practice shifts Sales shifts Data: HLN participants were asked to complete a baseline assessment that collected information on all of the noted performance measures. We encouraged facilities to complete this assessment with assistance from TA partner HCWH. 5 facilities chose to do so, 4 completed the assessment independently, and participating facility did not complete a baseline assessment. Midpoint progress data was collected via a survey created by BPHC and HCWH that was disseminated and collected electronically by BPHC. A final progress report of PSE changes was collected from HLN participants via email from TA partner HCWH and summarized into a fact sheet of accomplishments to be distributed at the capstone event held in February 2012. Evaluation results We learned that obtaining information from health care facilities is challenging due to the competitive environment with which they operate as well as their concern for public perception. They prefer to implement their programs in an independent manor due to the unique culture of each facility and therefore the continuity of tracking becomes troublesome. Budget is a strong deciding factor in whether or not a program is implemented. We successfully provided a forum, supportive TA, seminars, educational tools and resources that promoted the success of hospitals to implement PSE changes that promote a healthy beverage environment. All facilities engaged in the HLN implemented PSE changes. Feedback An evaluation was performed after February 2012’s Capstone event but we continue to work with the HLN to track and measure the impact of the this group as well as the individual facilities through their healthy beverage program implementation. Our preliminary evaluation informed our current work indicating that impact data was needed and a consistent method of tracking needed to be adopted by all the members of the HLN.
Stakeholder CommitmentOur technical assistance partners HCWH and the AHA maintained working relationships with all the participating health care facilities prior to the development of the HLN and will continue those relationships after the BPHC ceases to host the HLN meetings. HCWH continues with multiple synergistic initiatives with these hospital to foster the development of healthy food and beverage environments as well as the initiation of policies to support them. The AHA will continue to engage the clinical staff and management within these facilities providing access to resources and education that guides them in the development of a healthy beverage program. SustainabilityAs a result of the success of the Boston hospitals through this learning network, national interest has emerged within the health care sector to engage in similar efforts to implement healthy beverage strategies in their facilities. HCWH with their national network has created the Healthy Beverage Program housing tools, resources, case studies, and the noted Health Care Professional Pledge on their website. This Program also informed the development of the National Healthier Hospital Initiative’s Healthy Beverage Goal charging hospital management to commit to achieve a sector standard where 80% of all beverages purchased by health care facilities will be healthy (i.e. only 20% of all beverages offered can be SSBs) This structure in place allows us to tap into the national momentum and resources that will continue to be developed to support facilities with minimal staffing.
 
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