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Introduction
The North Broward Hospital District is a public, non-profit, tax-assisted hospital system with a network of more than 35 health care facilities. They offer a full spectrum of services to meet virtually any medical need of Broward County residents in its service area.
Broward General Medical Center is part of the North Broward Hospital District System. BGMC is a full-service hospital with 716 beds and a full level I Trauma Center and a Liver Transplant Program. Also, the affiliation with Nova Southeastern University School of Osteopathic Medicine and ongoing involvement in medical research and clinical drug trials place Broward General at the forefront of medical care today.
The North Broward Hospital District is governed by a Board of Commissioners that are appointed by the state governor. The governing body is composed of seven individuals, and they all serve a four-year term. The administration has ten persons to run the hospital’s day-to-day operations. They are Chief Executive Officer, Chief Nursing Officer, Chief Operating Officer, Chief Finance Officer, Director of Products Lines Services, Director of Facility Planning and Developing, Chief Patient Safety Officer, Director of Human Resources, Director of Media Relations, and Director of Ambulatory Physician Services. Each of these administrators also has direct reports of department heads to ensure smooth operations. Each department head is allowed certain leeway in running his department, with oversight from the administration.
Moreover, the market is very competitive when it comes to the paying patient base. There are currently 25 other hospitals within the County. Furthermore, many ambulatory service facilities are competing for part of the market. Equally important, these facilities are constantly upgrading their technology to keep up with the growing pace of the health care industry.
Broward County is a net explorer of labor, meaning that there are more working adults living in the county than there are jobs. Census 2000 showed 801,772 residents aged 16 and over in the labor force, which represented a 63% of labor force participation rate. Most were paid employees (717,821); 83% worked in the private sector and 12 % in federal, state, and local government. The largest percentage of Broward County population was employed in the educational & health services, leisure and hospitality services, and retail trade.
In 2000, the County’s population was 1,623,018 residents and continues to become more racially diverse. In 2000, the number of minorities (non-white population) almost doubled to 42%. The Hispanic and Black groups have seen the largest growth increase. The Asian population doubled over 10 years. In 2000, people of two or more races represented 17% of the County’s population (University of Florida).
Broward County’s health care funds are split in two ways: one-quarter of the County’s Property Tax Assessment is received by Memorial Regional Health Care Systems located in Hollywood; the other three quarters are received by the North Broward Hospital District. As a result, the County’s Health Care System receives 8.75% of the County’s Property Tax Assessment. According to the Sun-Sentinel, “Broward’s average tax rate remains the third highest in Florida, the State Department of Revenue reports. Only two of the state’s 67 counties (Alachua and St. Lucie) have higher tax rates” (Wyman, Wallman & Milarsky, 2005).
The North Broward Hospital District has three major competitors:
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Holy Cross Hospital is a non-profit organization, a member of Catholic Health East-sponsored Sisters of Mercy of America. Currently, they have 580 beds and are providing many services including bariatric services, comprehensive cancer care, emergency services, heart, and vascular services, home health care, maternal/child health, orthopedics, a fitness/wellness center, diagnostic and preventive services, and even a nursing home;
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Hollywood Memorial Regional Hospital is a non-profit organization and a tax-assisted institution. The hospital provides 732 beds along with a variety of services like Vascular Institute and Cancer Institute. Florida’s only sickle cell hospital is placed in this hospital which has also a level 1 trauma center, one of the six in the state.
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The Tenet South Florida group has a for-profit hospital in the Florida Medical Center. It is a 459-bed acute care hospital located in the central west part of the County. The Heart Institute of Florida is a center for cardiac services included in the hospital. Medical and surgical services are offered at the hospital. Patients can avail themselves of 24-hour emergency services. Bariatric surgery, comprehensive psychiatric services, and cancer care are other services for the needy.
Broward General Medical Center has a staff of approximately 2,900 employees. This includes 936 clinical, 770 non-clinical, and 1187 nursing staff. In addition, BGMC has over 800 physicians as staff. These comprise physicians from all specialties including residents through Nova Southeastern University’s DO Program. The workforce is extremely diverse and mirrors the community it serves, reflecting a rich, cultural and ethnic population. BGMC employs people ranging from posts of environmental service workers to physicians. The cultural diversity of the employees matches that of the community they serve.
The facilities include many state-of-the-art technologies. One example of such advanced technological systems is “PACS” (Picture Archive Communicating System). PACS is a Digital Imaging System that eliminates the use of X-ray film.
Problem/Issue/Improvement Project
The preservation and maintenance of health are of paramount importance to everyone. What do we mean by health? Is it a social value, or a concept that relates solely to the individual? These questions have been part of our intellectual heritage for centuries, and they are just as relevant today. Medical professionals increasingly encounter opportunities to assist patients in achieving disease prevention. Unfortunately, the vast majority needs substantial reorientation to a situation for which they received inadequate training. Their education is focused on the need for response and treatment of an illness.
The problem for many professionals, however, lies in not knowing how to help their patients effectively achieve healthful behaviors. Many people around the world are dying or have become disabled by chronic illnesses. Health prevention can reduce or at least delay the onset. Offering a set of strategies, values, attitudes, and behaviors to remedy these grievances, prevention perhaps is the most valuable benefit to someone’s healthy lifestyle. The clinicians at North Broward Hospital District have a place in the fight for health, but too much attention is paid to the treatment and too little to prevention.
From a historical perspective, patterns of health and illness have undergone extensive change. In contrast to earlier centuries, people are living longer and are afflicted by quite diverse types of illnesses. Whereas in earlier times people died of infectious diseases (e.g., smallpox, diphtheria, yellow fever, and influenza), today’s deaths are more commonly due to non-infectious and sometimes chronic degenerative illnesses, particularly heart disease, cancer, and stroke. The types and causes of modern illnesses have also been expanded with the advent of new viruses, toxic, substances, and problematic lifestyles.
Whether health and illness are quantitatively different, or qualitatively different, can be debated. An alternative concept emphasizes that although biological, psychological, and environmental factors play a role in both health and illnesses, the specific types and patterns of factors that increase or maintain healthy states are different from those that produce illness. (Kovner & Knickman, 2008) The impact that these various determinants have on health and illness changes in profound ways across the lifespan as the population grows older.
A life-span approach to the study of human development is no longer as novel a conception as it was several decades ago. Psychologists have been slow to adopt this framework for studying and understanding health and illness. As Peterson (2005) pointed out, “too little attention has been directed toward development as a dynamic force that shapes behaviors.” She suggested that health psychologists have viewed age as a static variable, like gender and ethnicity, rather than shifting the background against which illness and interventions are placed (Lucas & Lloyd, 2005).
Analysis of Problem/Issue improvement Data
According to Kovner & Knickman (2008), “chronic diseases like coronary heart disease, diabetes, asthma, and cancer are the leading causes of death and disease.” With each of these factors, there is a leading role for health promotion in the improvement of the health of the population. Firstly, studies have shown a marked increase in coronary heart disease as well as elevated all-cause mortality among obesity, even when such other factors as smoking are controlled for. Such facts underscore the complexity of the behaviors that must be altered if people are to achieve and maintain weight loss, nonsmoking status, and other desired health outcomes.
According to the American Heart Association (2009): “Preliminary mortality data for 2006 shows that coronary heart disease accounted for 34.2% (829 072) of all 2 425 900 deaths in 2006, or 1 of every 2.9 deaths in the United States.” Secondly, type 2 diabetes has become more prevalent. Besides being called non-insulin-dependent diabetes, it has also been known by many other names, such as maturity-onset diabetes, insulin-resistant diabetes, non-ketosis-prone, ketosis-resistant, and even MODY or Maturity Onset Diabetes in the young (Saudek, Rubin, and Shump, 1997). Ninety to 95 % of the diabetes population is diagnosed as having type 2 diabetes.
Of these, 95 % or so are overweight. Many of the so-called borderline diabetes Type 2 have been mislabeled. (American Diabetes Association, 2007). Lastly, some illnesses are not preventable but can be detected at a sufficiently early stage to permit medical treatment that can reduce overall morbidity and mortality. Some types of cancer fit this picture. Thus, in many cases, acute recurrences, complications, and exacerbations can be avoided or ameliorated. According to the National Cancer Institute (2009):
Cancer prevention can be accomplished by avoiding a carcinogen or altering its metabolism; pursuing lifestyle or dietary practices that modify cancer-causing factors or genetic predispositions; medical intervention (e.g., chemoprevention); or early detection strategies that can result in removal of precancerous lesions, such as colonoscopy for colorectal polyps.
The emphasis is on the fact that health has many dimensions: physical, social, psychological. Health is not just a medical issue but one which is relevant to all health care professionals, and the public at large. Therefore, health-risk behaviors are concerned with the vocabulary of health promotion and how the words are used by the public, the philosopher, the doctor, the educationalist, and others. Moreover, the same concept is sometimes called by a different name by different groups (Lucas & Lloyd, 2005). Life skills, self-esteem, empowerment, and autonomy might be examples of such words.
Nationally and internationally, there has been increasing recognition among policy planners, researchers, professionals, and the public that successful disease prevention and health education require more than effective clinical and medical services. There are examples of effective prevention strategies based in clinical environments such as prenatal care, well-baby care, and immunizations (Jerath, 2001). However, examples where the care systems have not adequately seized prevention opportunities also are readily evident: behavior changes like eliminating smoking or alcohol abuse, improving nutrition, or early detection and prevention of chronic illnesses like hypertension, cervical or breast cancer. (Centers for Disease Control and Prevention, 2009).
Malnutrition is known to lead to death or disability. Stunted mental and physical growth can cause poor national socioeconomic development. Obesity is a global problem involving children, adolescents, and adults. Increasing death rates from illnesses of the heart, hypertension, cerebrovascular illnesses, and diabetes are occurring due to obesity (Weiner, Helfrich, Savitz, & Swiger, 2007). The chronic disease epidemic takes a disproportionate toll on poor and underserved populations, and the nation has failed in its efforts to reduce chronic mortality among these populations.
Prevalence and risk of chronic disease are consistently higher for many populations. For example, while cancer rates for White adults have remained relatively stable during the past 25 years, rates among African-Americans males have increased by 18 % and among, African-Americans females by nearly 10 % (Center for Disease Control and Prevention, 2009). Diet is a major causative factor in many types of cancer. Recent research indicates not only do those young children have risk factors associated with cardiovascular disease, but that atherosclerosis is also occurring in preschool children. (Centers for Disease Control and Prevention, 2009).
Lastly, people with serious mental illnesses die an average of 25 years sooner than other Americans. According to a study conducted by the National Association of State Mental Health Program Directors (2006), three out of every five people with serious mental illnesses die from preventable, co-occurring chronic illnesses. The situation in South Florida is even more complex: Florida remains the 48th of 50 states in per capita mental health spending. (Nami, 2006).
The purpose of the search for resilience mechanisms in life is not to find qualities that make people feel good but to identify processes that protect individuals from adverse situations. From the perspective of prevention, a favorable circumstance for promoting resistance is not necessarily a life without adversity, but more likely it is a life with graduated challenges that enhance the mastery of skills, flexible coping strategies, positive self-concept, and feelings of efficacy.
As life involves unavoidable encounters with all types of illnesses, it is unrealistic to assume that individuals who age “successfully” have led a life without adversity (Callahan, 2007). More possibly, protection probably lay in the safeguarding qualities that accrued from successful coping with health prevention when the exposure is of a degree that is manageable in the context of the individual’s capacities and social situation.
The process by which resilience mechanisms promote more optimal outcomes in life is important for intervention strategies as well. Some risk factors for disease are preventable (e.g., cigarette smoking) or modifiable (e.g., through diet or exercise), but others might not be (e.g., stressful events). People age differently; however, not all prevention strategies will work for all people. Rather than trying to change specific behaviors, enhancing feelings of self-concept through strategies aimed at life review or selecting an appropriate comparison group might be more advantageous. For some individuals, providing support from a variety of sources (e.g., family, friends, or community) might be important; for others, however, encouraging reciprocity of support may be the key to a successful intervention (Callahan, 2007).
The United States spends more on health care than any nation in the world, yet it continues to have some of the poorest health outcomes in the industrialized world. In part, this disparity is due to an overemphasis on treatment, technology, and health services rather than primary prevention and action to improve social conditions and reduce inequities that cause ill health. Current funds for health prevention programs are limited.
The Center for Disease Control’s Division of Nutrition and Physical Activity has an annual budget of $ 16 million compared to $ 100 million that CDC is given for programs to reduce the use of tobacco (which kills about the same number of Americans), unhealthy eating and physical activity (Center for Disease Control and Prevention, 2009).
To move beyond the simple creation of a list of characteristics of health prevention education, three basic principles for developing a definition and model of health prevention education should be anticipated. First, one must keep up-dates with current trends and think in the field of promoting health education to individuals in general. Second, one must develop a comprehensive approach to conceptualization and measurement of health prevention education by looking at many interrelated aspects of a person’s life as possible. Third, one must incorporate the value of personal control by everyone over his/her life, while keeping in mind the limits on freedom imposed.
The claim that spending on health prevention education is cost-effective by improving health suggests that the valued outcome is not monetary savings, but improved health status. There is a tremendous amount of evidence on the efficacy and effectiveness of health prevention education. For example, research conducted by the Centre for Prevention and Health Services Research, National Institute of Public Health and the Environment in the Netherlands (2007), has demonstrated that quitting smoking improves health, and health education such as physicians’ advice to quit, nicotine replacement therapy and behavioral programs have all been demonstrated to be effective in helping people to quit smoking.
Proposal Solution
The clinicians at the North Broward Hospital District need to identify target groups for intervention and to know who is at greatest risk or who can benefit most from specific interventions. Optimal health outcomes may result from the goodness of fit among the attributes of each and aspect of the environment. Knowing how best to promote change requires knowledge of the developmental health prevention process linking risk and protective factors with optimal versus pathological aging. Furthermore, the acquisition of specific knowledge and skills is essential to the efficiency and effectiveness of health promotion efforts in its community.
Designing and implementing comprehensive strategies for disease prevention and health education involves both thoughtful translations of the science base that supports modern public health and active participation and appropriate actions by the public (Kovner & Knickman, 2008). Two decades ago, the Surgeon General’s report entitled Healthy People succinctly stated the change in the patterns of leading health threats and emphasized the social and behavioral determinants of health risks.
Subsequently, a major consensus development approach, jointly led by the office for Health Promotion and Disease Prevention and the Centers for Disease Control, resulted in a report, Promoting Health/Preventing Disease: Objectives for the Nation. Widely known as “the 1990 Objectives,” this report identified specific objectives with each of the important areas of health actions identified in Healthy People (Saudek, Rubin, & Shump, 1997).
Three general approaches should be outlined by the North Broward Hospital District management when applying health prevention education: social policy, community-based, and individual-based. While the pendulum of popularity might swing back and forth among these approaches, it is clear that each employee of the District has a role in promoting health prevention education.
First, social policy approaches should be defined as ecological in perspective, multi-sectional in scope, and participatory in strategy. Among seniors, for example, dental care becomes more important at a time of life when many are not able to afford it. These issues are relevant for adolescents whose families may not be able to afford a quality of care.
Secondly, community mobilization should address the target and organize members of a common geographical, social, or cultural unit for heath prevention education activities. Community-development approaches place a greater emphasis upon strengthening communities through community members’ identification and solution of self-defined problems. The connectedness of individuals with their environments is an important focus of both these community-level approaches.
Being a non-profit tax-based organization that receives three-quarters of the County’s Property Tax Assessment and has a large number of unnecessary emergency room visits yearly, one solution to promote health education will be to create workshops and provide literature on the prevention of chronic illnesses. Management must decide to promote the education of prevention of one type of disease at a time, such as heart disease, diabetes, cancer, AIDS. The idea is to select a disease and promote the education of preventing it during an entire month. Furthermore, the suggestion would be for management to have all employees wearing promotional materials.
One example would be to create health promotion educational buttons, T-shirts, or other forms of communication such as advertising. Providing education to all employees on the topic of the month and emphasizing the importance of their assistance in helping the organization’s health promotion campaign is necessary. This must be directed to those employees who are the patients’ first contact like those in registration, information desk, and secretaries. Connectedness with environments should be an important part of this organization’s model. An individual’s lack of sense of physical, social, and community belonging can indicate need; improved belonging resulting from activities can be an indicator of program success.
Lastly, all heath service educators must continue to work individually with patients. As individuals are treated for illnesses or disabilities, physicians continue to see patients one at a time. Such one-on-one opportunities can be used to inquire into health promotion education. Patients can be provided with information and knowledge which can enhance health promotion education. In any specific health campaign, it will often be far harder to change environments and contexts than to mount educational programs directed at individual behavior modification. A health promotion education focus thus includes the identification of a range of issues that impacts a person’s life and the interaction with the person on these issues to improve one’s quality of life.
The management at North Broward Hospital District should not look at health prevention education to reduce medical care costs. Focusing on prevention, early intervention, treatment, and management of chronic health conditions should be the main aim of quality health care. If a healthy population is the goal of our society and maintaining and improving health is valued, then expenditures on health education interventions, for which there is scientific evidence of effectiveness measured in terms of improved health as well as relative cost-effectiveness, will move the organization closer to achieving their goals and demonstrating their values.
Subsequently, the goals of controlling health care costs and educating the populations’ health need to be separated and pursued independently. If the organization’s goal is to reduce medical care costs, one needs to ask how one can reduce costs without harming health. Instead of assuming that HMOs have an incentive to promote the health of their members, one needs to ask how one can best hold HMOs accountable for improving the health of their members. Continuing to make over-generalizations that proclaim the economical medical benefits of health education prevention, could serve one’s interests in the long run. However, it may ultimately produce more harm than good by calling into question the credibility and intellectual integrity of those who should care most about preventing and protecting public health.
In summary, health prevention education may be the determinant of health among individuals and may well help differentiate between healthy and non-healthy functioning individuals. Since health prevention education can be improved through social policy, community-based or individual levels activities, health prevention education provides a useful way to conceptualize domains of functioning and identify targets of health prevention activities.
Subsequently, it is essential to point out that self-responsibility must be nourished by helping people to develop health-related life skills, such as the ability to make decisions and to be assertive, rather than expecting them simply to take responsibility for their health. Similarly, the behavior of powerholders, such as politicians and vested business interests, must be fully considered. In other words, combining these two points, victim-blaming must be avoided. Thus, the health prevention education program must be integrated by the North Broward Hospital District with other programs within the community levels to achieve the greatest impact. The more that consistent health prevention education messages are reinforced across programs, the greater is the chance that the consumer will implement behavior change.
References
American Diabetes Association (2007). National Diabetes Fact Sheet. Web.
American Heart Association (2009). Heart Disease and Strokes Statistics. Web.
Callahan, D. (2007). Promoting Healthy Behavior. How Much Freedom? Whose Responsibility? Washington, DC: Georgetown University Press.
Centers for Disease Control and Prevention (2009). Healthy Weight – it’s not a diet, it’s a lifestyle! Web.
Center for Disease Control and Prevention (2009). Nutrition Resources for Health Professionals. Web.
Center for Disease Control and Prevention (2009). Disease Burden and Risk Factors. Web.
Center of Prevention and Health Services Research, National Institute of Public Health and the Environment in the Netherlands (2007). Cost-Effectiveness analyses of health promotion programs: a case study of smoking prevention and cessation among Dutch students. Oxford University Press. Web.
Nami (2006). Grading the States 2006: Florida. Web.
National Association of State Mental Health Program Directors (2006). Morbidity and Mortality In People with Serious Mental Illnesses. Web.
National Cancer Institute (2009). Descriptive of Evidence. Web.
Jerath, N. (2001). The Effect of Health and Prevention on Emergency Rooms Visits and Its Implication for Increasing Health Care Costs. Web.
Kovner, A. & Knickman, J. (2008). Health Care Delivery in the United States (9th ed.). New York, NY: Springer Publishing Company.
Lucas, K. & Lloyd, B. (2005). Health Promotion Evidence and Experience. Thousand Oaks, CA: Sage Publications Inc.
Marlatt, G. (2002). Harm Reduction: Pragmatic Strategies for Managing High-Risk Behaviors. New York, NY: The Guilford Press.
Saudek, C., Rubin, R., & Shump, C. (1997). The Johns Hopkins Guide to Diabetes for Today and Tomorrow. Baltimore, MD: The Johns Hopkins University Press.
University of Florida. Broward County Census. Web.
Weiner, B., Helfrich, C., Savitz, L., & Swiger, K. (2007). Adoption and Implementation of Strategies for Diabetes Management in Primary Care Practices. Web.
Wyman, S., Wallman, B., & Milarsky, J. (2005). Property values, not tax rates, feed government’s hunger. Sun-Sentinel, p.B2.
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