It's all too common to see groups of healthcare workers smoking together outside a medical facility. According to data from the Centers for Disease Control, 17.9 percent of healthcare workers smoke1, just slightly under the national average of 18.1 percent2. And they're doing worse than the nation as a whole when it comes to managing their weight. The Gallup-Healthways Well-Being Index® reports that 27.7 percent of Americans are obese3, compared with 32 percent of healthcare workers, as cited by the American Journal of Preventive Medicine.4
The high incidence of obesity and tobacco utilization are just two examples of behaviors that are taking a toll on health systems by driving increased employee healthcare utilization and costs. In an analysis of more than 12 million healthcare claims, a recent survey reported some disturbing trends when comparing hospital employees to workers in other industries:
- Healthcare costs for hospital employees and their dependents were 9 percent higher than other industries.
- They and their dependents had a 5 percent higher hospitalization rate.
- They were more likely to use the emergency department.
- They had higher admission rates for chronic conditions.
- They were less likely to comply with preventive services such as mammograms and colorectal cancer screenings.5
Poor health habits obviously lead to poor health outcomes, but what's underlying these habits? Could organizational culture be the culprit behind the alarming statistics?
Research from Gallup and Healthways has shown that five elements influence individual well-being:
- A sense of purpose
- Social connections
- Financial stress
- Community connection
- Physical health
The elements work together and can have profound impact on one another.6 The easiest example is stress — about finances, family issues, work performance — causing someone to light up a cigarette or eat an unhealthy meal. But the interplay between the elements is nearly infinite.
Health systems that turn an analytical eye inward and focus on creating a culture of well-being in their employee populations can gain significant advantage from addressing the five elements in concert. This is an increasingly important goal for employers of all types because of the link between high well-being and both lower healthcare costs and greater productivity.7 At the same time, a culture of well-being can help employees attain greater job satisfaction and model healthy behaviors.
What drives unhealthy behaviors?
Why do healthcare professionals, tasked with shepherding others on their journeys to improved health and well-being, struggle to maintain their own well-being? The answer is complex, but environment and culture are clear contributors. Long shifts, stressful workloads, eating on the run – all of these factors could be contributing to the contradiction of the unhealthy healthcare professional. And when environment and culture engender or reinforce unhealthy habits, employees may be more likely to seek out a very accessible but temporary fix than to address the root causes. For example, a technician who works on his feet all day may find it easier to get a prescription for addressing his back pain than to attend a yoga class once a week.
Another potential reason healthcare professionals are struggling is that the very environments in which they work and spend much of their time are traditionally preoccupied with addressing primarily their patients' physical well-being, which may sustain a culture that downplays or ignores other contributing elements.
Why transform a culture?
When health systems adopt strategies to create a culture of well-being and drive improved well-being among their employees, the benefits are very tangible: lower rates of healthcare utilization, reduced overall healthcare costs, better workplace performance, enhanced productivity, talent attraction and retention, and fewer days of work missed. The combined effect of lowered healthcare costs and improved workplace outcomes can help to "bend the cost curve" and create demonstrable benefits for health systems.
Research has shown that, when compared to their colleagues with high well-being, employees with low well-being are five times more likely to have high medical claims costs, seven times more likely to miss work and self-report low performance, and nearly 29 times more likely to have high presenteeism (low productivity). Hospital employees who are more engaged and perform better can in turn create positive impacts such as improved clinical outcomes, fewer readmissions, reduction in unnecessary costs, and perhaps even mitigated exposure to fines and penalties.
Creating and sustaining a culture of well-being can also work on a powerful symbolic level, helping employees "live the brand" and model ideal behavior. It helps mitigate the mixed messages of, for instance, a nurse administering an asthma treatment while smelling of cigarette smoke, or vending machines loaded with high-calorie, sugary snacks in patient waiting areas. Cultural transformation also means that health systems can become beacons of positive change and well-being leadership within their communities. Additionally, forward-thinking providers that create well-being cultures have the opportunity to lead (rather than follow)8 the profound transformation that's currently taking place in American healthcare, as the old fee-for-service model is replaced by an outcomes-driven model.
Where do you start a well-being journey?
Because culture is elemental for most organizations, "culture change" can sound like a difficult undertaking — a feeling that may even be more pronounced among health systems. Hospital leadership may believe that some aspects of their cultures are entrenched, a natural but unfortunate outcome of the work itself and its proximity to suffering.
But keep in mind that careful consideration of all five elements of well-being — purpose, social, financial, community and physical — can open up new insights and possibilities for addressing the historically intractable nature of a health system's culture. Additionally, health systems may have some distinct advantages over other industries when it comes to adopting a well-being culture. The improvement solutions you choose to implement are bolstered by the legitimacy and deep knowledge of your clinicians, for example. And hospitals tend to have environments where employees work very closely in smaller areas — ideal for culture building.
So where is a health system to start its well-being journey? Perhaps the most effective place to begin is with an honest evaluation of your organization's culture, which requires involving as many members of leadership as possible. Because leadership is such a foundational part of a well-being culture, their participation from day one is essential. It is also wise to include input from front-line employees, who sometimes have very different perspectives than hospital management. Garnering insight from every level within the organization strengthens buy-in and helps ensure a successful outcome.
The self-evaluation process should determine whether your organization exhibits characteristics shared by many successful well-being cultures. For example:
- Do we define well-being in a consistent way? Determine whether you incorporate all five elements of well-being into your definition, and, if not, start the conversation to expand it.
- Are our leaders actively engaged in our well-being culture? The role of leadership in creating and supporting a culture of well-being can't be understated. Leaders should fully understand the business case for well-being and also model good well-being behaviors for employees. Take a close look at what your leaders are saying and doing on a regular basis to better gauge whether they're strengthening or undermining your culture of well-being.
- Do we offer a variety of well-being improvement initiatives that address all five elements, are structured to appeal to various levels of interest, and help people participate at their own pace? For example, someone who is not all that interested in attending a seminar on financial well-being may be thrilled at the opportunity to join an after-work book club, bolstering their social well-being.
- Do we have meaningful incentives in place to encourage participation? Behavior change is not easy for most people — employees may need to be urged or incentivized to participate in activities and programs that enhance their well-being. Remember that not everyone is motivated by the same thing, so a variety of options that encourage positive behaviors should exist. These can include challenges, financial rewards and employee recognition.
- Do we have a way to measure well-being? An accurate measurement of well-being helps establish a baseline, determine how successful initiatives are, and supports overall program momentum by giving you ongoing benchmarks to match or exceed.
With the self-evaluation completed, health system leadership should then agree on what your culture change objectives are. Is anything less than a complete transformation acceptable, or will you be content with a more moderated and slow-paced approach? By forming a consensus around objectives, you have now performed two critical tasks: You have determined the starting point for your well-being journey, and you have identified how your organization is defining success. It's also important to realize that your definition of success can change as your culture evolves.
Your action plan for moving you from point A to point Z would benefit from a healthy dose of realism about what your organization can actually achieve. If the budget allocated to the initiative is small, it would not be reasonable, for example, to have "install an on-site fitness center" as a tactic. Remaining practical doesn't mean that you have to jettison any hope of a culture makeover, however. In fact, all change has to start somewhere -— little actions can add up to big transformations.
Consider the following steps that don't require a significant financial or physical investment but can make a grand impact:
Ask head nurses to start shifts by asking employees to share their recent well-being activities, which helps cultivate an environment where well-being is always top of mind.
Replace high-calorie sodas and snacks in vending machines with healthier options, which helps make the healthy choice the easy choice.
Place a white board in a well-traveled area where employees can share well-being improvement anecdotes and encourage each other, which helps foster mutual support among your employees.
What's next for a well-being culture?
Recognizing that health is more than physical is a great first start for your organization. Once your culture of well-being gathers momentum and your employees see the impact both in themselves and across the organization, what's next?
Energized by a broader definition of health and a deeper understanding of how to effect the lifestyle changes that result in true well-being, your employees can more easily connect with the their original purpose in pursuing healthcare as a profession: helping people live more longer, better lives. Not only does cultivating higher well-being among your employees improve their performance and therefore positively impact patient outcomes, but similar programs can be offered to patients.
Your employees' direct experience with and endorsement of such programs will both strengthen the offerings and help your employees meet patients where they are in their own well-being journeys. Starting with your own employees is also a great opportunity for experimenting with and fine-tuning approaches that work in your specific environment, so that when you do offer them to your patients, the solutions will have maximum effectiveness.
Therefore, driving culture change within your health system and sparking well-being improvement among your own employees is a stepping stone to a more comprehensive effort to improve overall population health — an effort than can help establish your organization as a symbol of well-being leadership within the communities in which you operate.
David Ellwanger is the President of Health Systems and Physicians with Healthways, Inc. based in Franklin, TN. He has almost 30 years of healthcare industry experience, including 10 years of building, acquiring, and operating HMOs and PPOs for Aetna, and operating physician practices for InPhyNet Medical Management and BMJ Medical Management.Ellwanger has also served as a senior executive at Baptist Hospital and President and COO of HealthSpring and Windsor Health Plans, respectively. He was part of a Senior Management Team responsible for taking three separate companies public.
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1 Centers for Disease Control and Prevention's National Institute for Occupational Safety and Health. (2014, April). "Current tobacco use: Estimated prevalence by current industry, U.S. working adults, aged 18 and over, 2010." National Center for Health Statistics Health Interview Survey 2010. http://www2a.cdc.gov/drds/worldreportdata/FigureTableDetails.asp?FigureTableID=2628&GroupRefNumber=T18-01
2 Centers for Disease Control and Prevention. (2014, January 17). "Current Cigarette Smoking Among Adults—United States, 2005–2012." Morbidity and Mortality Weekly Report, 63 (02), 29–34. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6302a2.htm?s_cid=mm6302a2_w#tab
3 McCarthy, J. (2014, May 22). "In U.S., Adult Obesity Rate Now at 27.7%". Retrieved from http://www.gallup.com/poll/170264/adult-obesity-rate.aspx
4 Luckhaupt, S. E., Cohen, M. A., Li, J. and Calvert, G. M. (2014, March). "Prevalence of Obesity among U.S. Workers and Associations with Occupational Factors." American Journal of Preventive Medicine, 46 (3), 237-248. http://www.ajpmonline.org/article/S0749-3797%2813%2900617-X/fulltext
5 Taylor, M. and Bithoney, W. (2012, October). White Paper: 10 Steps to Developing a Culture of Health for Hospital and Health System Employees. Retrieved from http://interest.truvenhealth.com/forms/EMP-20120910StepsWhitePaper
6 Gallup-Healthways. (2014, August 5). "Gallup-Healthways Well-Being 5™ Delivers Next-Generation Population Health Measurement to Individuals and Organizations Worldwide: Research Validates a New Diagnostic for Health-Related Costs and Productivity". Retrieved from http://www.businesswire.com/multimedia/home/20140805005244/en/#.VCwZ0havGE4. Also see Rath, T. and Harter, J.K. (2010). Wellbeing: The Five Essential Elements, New York, NY: Gallup Press.
7 Harrison, P.L., Pope, J.E., Coberley, C.R., and Rula, E.Y. (2012, December). "Evaluation of the Relationship between Individual Well-Being and Future Health Care Utilization and Cost." Population Health Management, 15 (5), 325-330. http://online.liebertpub.com/doi/abs/10.1089/pop.2011.0089. Also see Sears, L.E., Shi, Y., Coberley, C.R., and Pope, J.E. (2013, December). "Overall Well-Being as a Predictor of Health Care, Productivity, and Retention Outcomes in a Large Employer". Population Health Management, 16 (6), 397-405. http://online.liebertpub.com/doi/abs/10.1089/pop.2012.0114
8 Yuyan, S., Sears, L., Coberley, C.R., and Pope, J.E. (2013, April). "Classification of Individual Well-Being Scores for the Determination of Adverse Health and Productivity Outcomes in Employee Populations." Population Health Management, 16 (2), 90-98. http://www.ncbi.nlm.nih.gov/pubmed/23013034
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