Table 2 The 5 WHO standards for health promotion in hospitals: Compliance to the 40 measurable elements (ME) of the intervention and control group, presented as median and range

Measurable elements:

 1. Stated aims and mission include HP

 2. Minutes of governing body reaffirms agreement within the past year to participate in the WHO HPH Network

 3. The current quality and business plans include HP for patients, staff and the community

 4. Personnel and functions for the coordination of HP are identified

 5. There is an identifiable budget for HP services and materials

 6. Operational procedures such as practice guidelines or pathways incorporating HP are available in clinical departments

 7. Specific structures and facilities required for HP (including resources, space, equipment) can be identified

 8. Data are routinely captured on HP interventions and available to staff for evaluation

 9. A programme for quality assessment of HP activities is established

Measurable elements:

 1. Guidelines on how to identify smoking, alcohol consumption, nutritional and psycho-social-economic status are present

 2. Guidelines/procedures have been revised within the last year

 3. Guidelines are present on how to identify needs for HP for groups of patients (e.g. asthma patients, diabetes patients etc.)

 4. The assessment is documented in the patient’s medical record at admission

 5. There are guidelines/procedures for reassessing needs at discharge or end of a given intervention

 6. Information from referring physician or other relevant sources is available in the patient’s record

 7. The patient’s record documents social and cultural background as appropriate

Measurable elements:

1. Information given to the patient is recorded in the patient’s records

2. Health promotion activities and expected results are documented and evaluated in the records

3. Patient satisfaction assessment of the information given is performed and the results are integrated into the QM system

4. General health information is available

5. Detailed information about high-risk diseases is available

6. Information is available on patient organizations

Measurable elements:

1. Working conditions comply with national/regional directives and indicators

2. Staff comply with health and safety requirements and all workplace risks are identified

3. New staff receive an introductory training that addresses the hospital’s HP policy

4. Staff in all departments are aware of the content of the organization’s health promotion policy

5. The performance appraisal system and continuing professional development include HP

6. Working practices (procedures and guidelines) are developed by multidisciplinary teams

7. Staff are involved in hospital policy-making, audit and review

8. Policies for awareness on health issues are available for staff

9. Smoking cessation programmes are offered

10. Annual staff surveys are carried out including an assessment of individual behaviour, knowledge on supportive services/policies, and use of supportive seminars

Measurable elements:

 1. The management board is taking the regional health policy plan into account

 2. The management board can provide a list of health and social care providers working in partnership with the hospital

 3. The intra- and intersectoral collaboration with others is based on execution of the regional health policy plan

4. There is a written plan for collaboration with partners to improve the patients’ continuity of care

5. Patients/families are given understandable follow-up instructions at out-patient consultation, referral or discharge

6. There is an agreed upon procedure for exchange practices between organizations for all relevant patient information

7. The receiving organization gets a written summary of condition, health needs and interventions already provided

8. If appropriate, a plan for rehabilitation describing roles of the organization/collaborators is documented in the record