Creating a Culture of Health and Uniting a Complex Health System: Johns Hopkins Medicine

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On his first day at Johns Hopkins Medicine in 2012, Dr. Rich Safeer took a walking tour of the East Baltimore campus. Outside, he noticed a soft drink truck. Inside, he saw long lines of visitors and staff waiting for pizza and burgers in the hospital cafeteria. Other temptations included chocolate, chips, and sugary drinks in vending machines.

The disconnect between the medical center’s business goal and the actual environment bothered Safeer, who is now Chief Medical Director of Employee Health and Well-Being.

“It was discouraging that our health system was not more proactive in supporting a healthy environment and workplace. After all, health is the business purpose of the industry. Unfortunately, health care workers are generally less healthy when compared with those in other sectors,” Safeer said in reference to “Sicker and Costlier: Healthcare Utilization of U.S. Hospital Employees,” a 2011 study by Thomson Reuters.

Safeer took on the challenge of leading efforts across Johns Hopkins Medicine’s large, complex structure to provide a healthier culture for all employees. The result was a 5-year strategic plan that included active support for a healthy workforce.

Johns Hopkins Medicine is an academic medical center that brings together the Johns Hopkins Health System
and Johns Hopkins University School of Medicine. It has 12 organizational units—six hospitals, the largest primary care network in Maryland, a home-care company, and four health insurance plans.

To help each organizational unit work independently while also moving toward an overall healthy culture, Johns Hopkins Medicine used the Worksite Health

ScoreCard (CDC ScoreCard) created by the Centers for Disease Control and Prevention. The CDC ScoreCard helps employers assess their efforts to improve the health and well-being of their employees.

CDC ScoreCard Can Help Employers Reach Health Goals

Social networks play a big role in influencing behavior at work. A supportive environment helps employees make healthier choices to improve their lives.

The CDC ScoreCard helped Johns Hopkins Medicine establish a foundation for its mission to improve employee health. This evidence-based tool helps employers assess their efforts to address many health topics, such as physical activity, diabetes, depression, vaccines, and tobacco cessation. Each topic includes questions about the employer’s health promotion programs, policies, and practices. Point values are assigned on the strength of the evidence provided for each question.

Since 2013, Johns Hopkins Medicine has set strategic objectives for promoting the health of its employees in multiple areas. Specifically, the medical center:

• Created a 5-year strategic plan to support a healthy workforce in 2013.
• Piloted use of the CDC ScoreCard by focusing on the tobacco cessation topic area in 2014.
• Started collecting baseline data across all CDC ScoreCard topic areas for all 12 of its organizational units in 2015. The data provided a snapshot of the organization as a whole and laid the groundwork for accountability and uniformity.
• Added an element to the annual performance evaluation of each organizational unit’s executive team that measured improvement of the CDC ScoreCard total score.

How Johns Hopkins Medicine Helps Employees Be Healthier

Dry erase boards at work spur employee peer support

Cultures are webs of social influences that shape workers’ behavior. Health and well-being efforts can be most effective when supported by these social influences.

For instance, coworkers can encourage one another to drink more water, take a walk during lunch, or join a softball game after work. Executives at Johns Hopkins Medicine help by participating in one health promotion activity each quarter. They include employee health as a topic on meeting agendas, and regularly attend health promotion committee meetings.

The goal for 2017 was for all 12 organizational units to increase their scores on the CDC ScoreCard by offering more policies, environmental changes, benefits, and other resources. The ScoreCard helped the organizational units assess their health promotion programs, identify gaps, and prioritize high-impact strategies to promote employee health and well-being.

Each organizational unit could choose which topic areas they wanted to work on and how they would do it. Leaders based their decisions on employee needs and available budgets. Options included adopting the Healthy at Hopkins website, opening lactation support rooms, and offering live webinars. This approach helped each unit’s subculture to flourish. For instance, clinicians are a subculture of employees. Doctors and nurses often have high stress and fatigue levels that result in burnout and early retirement. Resources such as resilience training and mindfulness-based stress reduction tools help them cope with stressful activities, such as time-consuming electronic medical records entries.

The CDC ScoreCard also helped Johns Hopkins Medicine in its efforts. Eleven of the 12 organizational units improved their overall score in one year, and the overall organization surpassed CDC ScoreCard benchmarks by the second year.

Health Promotion Strategies Featured at Johns Hopkins Medicine

Organizational units across Johns Hopkins Medicine (in addition to Johns Hopkins Bayview Medical Center, below) used a variety of strategies to promote employee health, including the following:

Howard County General Hospital, Columbia, Maryland

• Offered a 6-week chronic disease self-management program.
• Promoted online courses on nutrition, physical activity, blood pressure, and cholesterol.

Johns Hopkins All Children’s Hospital, St. Petersburg, Florida

• Won the Race the Globe steps challenge, in which worksites compete to record the highest number of steps and level of employee participation. Employees walked a total of 86,629,893 steps, the equivalent of walking from St. Petersburg to Chicago 36 times.
• Offered a Hold the Stuffing weight management challenge during the holidays to help employees maintain their weight.

Johns Hopkins Community Physicians, Maryland and the Greater District of Columbia area

• Held area breakfasts with the Johns Hopkins Community Physicians President to collect employee feedback on the work environment.
• Offered a seminar on Deadlines, Distractions and Dinner: Managing Your Work-Life Effectiveness.

Johns Hopkins HealthCare LLC, Hanover, Maryland

• Offered lactation support rooms with breast pumps for employees.
• Created a quiet room for stress management activities.

Johns Hopkins Home Care Group, Baltimore, Maryland

• Offered resiliency training to managers as part of a yearly retreat.
• Partnered with a produce truck to offer employees fresh produce for purchase weekly.

Johns Hopkins Hospital, Baltimore, Maryland

• Offered a seminar titled Recognizing and Responding to Depression in the Workplace.
• Distributed flyers on the signs and symptoms of heart attack and stroke during a Leader’s Agenda meeting and asked all leaders to post the flyers in their work areas.

Johns Hopkins Medicine International, Baltimore, Maryland

• Offered various on-site exercise classes, like yoga and Zumba, for employees.
• Had a staff member deliver an educational seminar on breastfeeding.

Johns Hopkins Medical Management Corporation, Lutherville-Timonium, Maryland

• Partnered with a software company to make it easy for administrative staff to order food for company events that meets Johns Hopkins Medicine’s nutrition guidelines.
• Created a flex time and telecommuting policy for employees.

Johns Hopkins University School of Medicine, Baltimore, Maryland

• Gave free subscriptions to the Calm app, which provides stress management tools and resources.
• Offered a wide variety of physical activity classes, including yoga, cardio fusion, and muscle toning and conditioning.

Sibley Memorial Hospital, District of Columbia

• Partnered with a local farmer to offer employees fresh produce for purchase throughout the summer.
• Offered boot camp and yoga classes to employees and family members.

Suburban Hospital, Bethesda, Maryland

• Added self-monitoring blood pressure devices to the Occupational Health Clinic for employees to easily access.
• Offered a Depression in the Workplace training for managers and supervisors that helps identify and address employee depression.

Spotlight on Bayview Medical Center

A Push for Healthier Foods

RN Latanya Harrison (right) buys two salads each day in the cafeteria at Johns Hopkins: one for lunch and one for dinner. She says eating more vegetables helps her lose weight, lower her cholesterol, and have more energy.

Across Johns Hopkins Medicine, the lowest scoring topic on the CDC ScoreCard was nutrition. Johns Hopkins Bayview Medical Center sought to improve its score in this area by focusing on improving the food options in its cafeteria and vending machines.

A nutrition subcommittee of representatives from Bayview’s food services, marketing, and executive leadership worked together to develop a marketing and communication campaign called Your Choices: Choose Green, Eat Well. The campaign used proven behavioral strategies to encourage employees to make healthy food choices at work.

In Bayview’s cafeteria, all healthy choices are now marked by a green leaf symbol and discounted in price. Discounts encourage employees to choose foods that are low in sodium, saturated fats, and calories, which may help them manage chronic conditions such as high blood pressure and heart disease.

The cafeteria also added more healthy choices and made them more visible—for example, the salad bar is located in the direct flow of traffic.

Bayview also added more healthy choices to its vending machines. These items are marked by the green leaf symbol and are less expensive. They are also at eye level in the vending machine, making them easier to see and choose.

By guiding employees toward green leaf foods, Bayview increased the purchase of healthier choices in its cafeteria by 12%. It also improved its CDC ScoreCard score for the nutrition topic from a baseline of 7 out of 21 points in 2016 and 2017 to 8 of 21 points in 2018—and then to 21 of 21 points in 2019. Overall, Bayview had the highest score of any organizational unit at Johns Hopkins Medicine—263 out of 264 possible points in 2019.

The Greens Project is Johns Hopkins Bayview Medical Center’s new salad station. A green leaf symbol indicates healthy choices and discounts. The more green leaf items chosen, the more money saved.

A Smoking Success

Bayview also increased its tobacco control score from 14 out of 19 points in 2016, 2017, and 2018 to 19 of 19 points in 2019. Changes that helped raise the score included:

• Tobacco cessation group classes and counseling with a health coach.
• Low out-of-pocket costs for prescription and over-the-counter tobacco cessation medications.
• Health insurance premium reductions for nonsmokers.
• Campus ban on the use of tobacco products and smoking devices. To reinforce the message, Bayview Medical Center added “smoke-free campus” signs around the property.

A Physical Activity Boost

Bayview employees have several options for being physically active. For example, an on-site gym offers diverse fitness classes—from aerobics to strength training—at a discounted price for employees and their families. The gym features:

• Cardio area with treadmills, bikes, and elliptical and rowing machines.
• Cybex circuit and weight-training area.
• Weight room, group fitness studio, locker room, and shower area.
• Onsite fitness professionals who offer free assessments and equipment orientation, as well as a free class each month to promote the benefits of physical activity.

Bayview also provides bike racks and marked walking routes on campus. “Walk to Wellness. Take the Stairs” signs are posted near elevators and doorways to encourage physical activity.

Communication Helps Foster a Sense of Connectedness

Across the board, Johns Hopkins Medicine found the CDC ScoreCard to be an effective way to measure and increase health promotion strategies in the workplace.

Beyond the numbers, it’s also about feeling good—literally. Delivering health is the purpose of Johns Hopkins Medicine, not only for consumers but also for employees. Healthy employees cost less because they have fewer medical and pharmacy claims, as well as lower rates of short- and long-term disability, absenteeism, and worker’s compensation incidents.

“We were often so intent on helping patients that we weren’t focused enough on helping ourselves,” said Safeer.

Although Johns Hopkins Medicine has made significant progress, communicating effectively across multiple organizational units and executive teams in different locations has been a challenge. The CDC ScoreCard provided a way to work toward a common goal, but still allowed each organizational unit to choose which strategies to use to address its individual health culture and employee needs.

Because of its complex structure, Johns Hopkins Medicine must meet the needs of many different subcultures, including clinicians, nurses, office staff, and maintenance workers. Subcultures may develop around multiple factors, including work shifts, teams, educational and income level, age, and job responsibility. A new Office of Well-Being was set up to help coordinate efforts to create a productive, joyful, and healthy workplace.

Johns Hopkins Medicine also developed an educational campaign called Keep the Pressure Down. It emphasizes healthy eating, more sleep, more movement, and less stress to help employees lower or maintain their blood pressure. Employees receive rewards for participating in blood pressure screenings, coaching, classes, and activities like walking.

In the future, Johns Hopkins Medicine plans to continue integrating topics from the new CDC ScoreCard into its strategic objectives and offer employees online resources, like Healthy at Hopkins.

Recommendations for Action

• Invest in worksite wellness programs by providing financial incentives for participation. Invest time in identifying resources and partners to support wellness activities.
• Assess your organization using tools such as the CDC Worksite Health ScoreCard.
  • Use the initial results to identify strengths and set priorities for developing your program.
  • Repeat the assessment process after changes are made to monitor and improve your program.
• Reach out to state government workplace health-related programs for resources. Your local health department can also become a partner to guide your effort.