Abstract
Purpose:
To measure the impact of tying adoption of evidence-based worksite health promotion (WHP) interventions to annual organizational strategic objectives, as measured by the Centers for Disease Control and Prevention (CDC) Worksite Health ScoreCard (ScoreCard).
Design:
A prospective cohort study following Johns Hopkins Medicine (JHM) affiliates against industry-specific and large employer benchmarks from 2016-2020.
Settings:
JHM, the largest private employer in Maryland with facilities in Florida and the District of Columbia.
Subjects:
Twelve JHM affiliates representing over 40,000 employees.
Intervention:
A strategic objective was established annually based on the ScoreCard and organizational priorities.
Measures:
JHM affiliates measured their WHP efforts annually using the ScoreCard. CDC industry-specific and large employer benchmarks were collected for comparison.
Analysis:
ScoreCard data was assessed annually to measure deviations from CDC benchmarks, determine whether strategic objectives were met, and inform additional annual objectives.
Results:
JHM demonstrated improvement from 8.9 percentage points above industry-specific and 3.4 percentage points below large employer benchmarks in 2016, to 26.4 percentage points above industry-specific and 21.8 percentage points above large employer benchmarks in 2020.
Conclusion:
Large employers face unique challenges in implementing WHP programs. Our study suggests embedding health promotion in annual strategic objectives may alleviate these challenges by prioritizing the goal and ensuring adequate resources to be successful. There are however, some limitations on using benchmarking data for comparison.
Keywords
Purpose
Traditionally, actions of employers have implied employee health and well-being rests largely on the shoulders of the employees. A traditional approach has been to summon completion of a health assessment, along with participation in biometric screening, followed by some form of education. While most employees feel employers should play a role in improving their health, less than half feel their current work environment is conducive to maintaining good health. 1 The socio-ecological model explains this gap by demonstrating that individual decisions are only one part of the complicated milieu that must exist for successful adoption of healthy lifestyle habits. 2,3 Our behaviors are influenced across individual, interpersonal, organizational, and environmental levels, and thus to be effective, worksite health promotion (WHP) programs must supply the necessary resources, relationships, polices, and supports for employees to have a healthy workday. 2,3
Johns Hopkins Medicine (JHM) sought to leverage these socio-ecological influences to make it easier for employees to make healthier choices. We pursued this study to test whether tying implementation of evidenced-based health promotion practices to annual strategic business objectives would accelerate organizational change and facilitate ongoing improvement to WHP programs. We hypothesized that worksites in which health promotion was consistently embedded in annual strategic objectives would see a greater adoption compared to a benchmarking cohort of similar size and similar industry employers.
Methods
Design
We conducted a prospective cohort study following JHM affiliates over a 5-year period as they measured their WHP efforts using the Centers for Disease Control and Prevention (CDC) Worksite Health ScoreCard (ScoreCard).
Sample
All 12 affiliates participated in the annual ScoreCard process, representing more than 40,000 full-time employees.
Measures
Each affiliate completed the ScoreCard annually from 2016 to 2020 to measure changes in the number and/or level of impact of evidence-based WHP interventions in place from baseline to subsequent years. Affiliate scores were validated annually upon ScoreCard submission via a combination of documentation review and on-site resource certification. Documentation review confirmed the presence and contents of written policies and resources. On-site validation meetings provided an opportunity to ask clarifying questions and tour the campus to certify the presence of visible resources, such as available food options and self-measuring blood pressure monitors. ScoreCard measures collected in 2016 were used as baseline, with subsequent years providing year-over-year points of comparison. Industry-specific and large employer benchmarks reported annually by the CDC provided points of comparison to like employers.
Intervention
Each year, JHM leadership choose strategic objectives to match elements in JHM’s five year plan. Affiliate leaders are held accountable to achieving these objectives as part of their annual performance evaluation. In Fiscal Year (FY) 2016, a strategic objective was established based on the ScoreCard to match the organizational priority of supporting a healthy workforce. The first year, FY2016, served as a baseline. Objectives since then set goals for improvement. In FY2017 the goal was to improve the total score (specific goals were set based on baseline numbers). The same approach was used in FY2018.
In FY2019, affiliates were asked to achieve at least 12 points in the Nutrition category. This strategic objective was selected because nutrition was one of the lowest scoring categories across affiliates, and because food was a very visible symbol of health and well-being due to its presence in staff meetings, cafeterias, and vending machines across campuses. In FY2020, affiliates were asked to achieve all 16 points in the High Blood Pressure (HBP) category. This strategic objective was selected because it was one of the lowest scoring categories across affiliates, and because over half of JHM employees in a voluntary blood pressure screening demonstrated elevated or HBP. Subsequent review of affiliate accomplishments determined total ScoreCard points and whether affiliates received a zero, check minus, check, or check plus on their annual ScoreCard report (Table 1).
Example of Scoring Based on FY2020 Strategic Objective.
a163 was the Calendar Year 2018 industry benchmark for health care and social assistance organizations.
b If affiliate gets less than 16 points in the HBP section, they will get a
Analysis
JHM analyzed ScoreCard data annually to determine year-over-year changes in points, deviations from CDC industry-specific and large employer benchmarks, and achievement of strategic objectives. The team also reviewed the percentage of total points achieved by category to help identify strategic objectives for subsequent years. Scores, comparisons, and considerations were documented annually in enterprize and affiliate-specific reports. JHM leadership was briefed on enterprize-level results, and informed discussions ensued regarding subsequent strategic objectives. Affiliate-specific reports were shared with each affiliate to drive discussions for their specific worksite. Affiliate leadership performance evaluations were updated annually to include their ScoreCard results.
Results
Ninety-two percent of the affiliates participated in the annual ScoreCard process in each of the five years. All 12 affiliates participated in each year except for FY2020. In FY2020, one affiliate did not participate due to organizational changes. JHM demonstrated improvement from 8.9 percentage points above industry-specific and 3.4 percentage points below large employer benchmarks in 2016, to 26.4 percentage points above industry-specific and 21.8 percentage points above large employer benchmarks in 2020 (Figure 1). JHM improved against benchmarks in all years except for FY2020.
JHM average, industry-specific benchmark, and large employer benchmark as a percentage of total available ScoreCard points over a 5-year period. a Since the CDC’s reporting period follows a calendar year cycle, which conflicts with JHM’s July to June fiscal year, JHM measured our fiscal year averages against CDC benchmarks from the previous calendar year.
Across the 5-year period, JHM affiliates achieved the maximum strategic objective 90% of the time. In FY2019, for example, 83% of affiliates achieved the strategic objective of improving their total score and earning at least 12 points in the Nutrition category, thus earning them a check plus on their annual ScoreCard report. Two affiliates lost points in the Nutrition category due to their vending machine contractors failing to meet the criteria for vending machine specific questions on the ScoreCard. Despite two affiliates falling short of the strategic objective for FY2019, JHM saw its largest category-specific improvement of FY2019 in the Nutrition category: a 16.3 percentage point improvement in the percent of total points achieved in the Nutrition category from FY2018 to FY2019.
In FY2020, 91% of affiliates achieved the strategic objective of earning more than 240 total points and all 16 points in the HBP category, thus earning them a check plus on their annual ScoreCard report based on criteria specified in Table 1. One affiliate lost points in the HBP category by failing to offer self-monitoring blood pressure devices, thus earning them a check minus based on criteria specified in Table 1. While the affiliate did offer blood pressure screenings at their on-site clinic, the Healthy at Hopkins team counseled them that offering employees the option to measure their blood pressure in private is important in removing barriers to personal blood pressure management. All affiliates were held to the same expectation to ensure consistent scoring. Despite the one affiliate falling short of the strategic objective for FY2020, the HBP category still became JHM’s highest scoring category in FY2020, with JHM affiliates achieving an average of 98.3% of total available points in the HBP category.
Discussion
Summary
JHM encountered variable leadership buy-in, especially in early stages of the ScoreCard process. JHM decided to embed the ScoreCard in annual strategic objectives and affiliate leadership team performance evaluations to enhance adoption of the ScoreCard. In year 1, affiliates simply had to complete the ScoreCard. The results of year 1 informed JHM executives of areas of weakness and shaped future goals. In following years, affiliates were asked to complete the ScoreCard and improve their previous score. In years four and five, they were asked to improve their score and achieve a category-specific target. Most importantly, each strategic objective was informed by the ScoreCard and by an understanding of the current environment and organizational needs.
For example, looking forward to FY2021, JHM chose to lower the total point goal and require all managers complete training on identifying and reducing workplace stress (Stress Management Category, Q6) 4 to achieve a check plus in the strategic objective. We did so recognizing JHM would be continually stressed by the pandemic response. In JHM’s experience, organizations are likely to benefit most when strategic objectives are flexible to the societal context and in line with organizational needs.
Limitations
A few limitations should be considered in interpreting these results. First, employers contributing to CDC benchmarks vary each year, with some using the ScoreCard only once, and others using the tool for two or more years. It is unlikely other employers used the tool for the same 5-year period as JHM, as this is not noted in the literature. This variability means we are not comparing to the same employers every year. It may also explain why greater improvement is not seen in benchmarks over time. Second, it is possible there are other like employers contributing to CDC benchmarks that similarly tied the ScoreCard to annual strategic objectives. Therefore, CDC benchmarks present an imperfect comparison in representing like employers outside of the intervention cohort. Future studies may benefit from matching cohort groups more closely.
Significance
The ScoreCard provides a valid and reliable tool for measuring and guiding improvements to the implementation of evidence-based WHP interventions. 5,6 However, its 18-category, 154-question scope can be daunting for a large employer lacking uniformity of structure, culture, priorities, and resources across the organization. Compared to the average size employer using the ScoreCard, JHM is very large. 7 -14 In 2019, 78% of employers who completed the ScoreCard were very small (1-100), small (101-250), and mid-sized (251-750). 14 Only five% of employers who submitted data to the CDC in 2019 have more than 5,000 employees (Jason E. Lang, MPH, MS, e-mail communication, August 2020). Many fewer are near JHM’s 42,000 employees. Our study addresses this gap in understanding the unique challenges large employers may face, and how to overcome them. Our study suggests an early and sustained focus on the Organizational Supports Category, and specifically on Question three (“Have a strategic plan that includes goals and measurable organizational objectives for the health promotion program”) 4 may help employers build capacity for organizational change and position them to provide a greater level of support to employees in making it easier for them to have a healthy workday.
So What?
What is already known on this topic?
The ScoreCard provides a valid and reliable tool for measuring the number of evidence-based WHP interventions. 5,6 The ScoreCard can be used as a framework for guiding improvements to the number and level of impact of evidence-based WHP interventions. 11,12,15
What does this article add?
This study adds considerations for large, complex employers looking to build capacity for sustained organizational change.
What are the implications for health promotion practice or research?
Employers may see greater improvement to their WHP programs by establishing an early and sustained focus on organizational supports. In particular, tying WHP to annual strategic objectives may improve leadership buy-in and help an organization to grow more appreciative of employee health and well-being, thus unlocking greater capacity for change.
Footnotes
Acknowledgments
The authors would like to acknowledge Wendy Bowen for her many years of service on this project and the Employee Health and Well-being team.
Declaration of Conflicting Interests
The author(s) declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
