BUILDING A HEALTHIER WORKFORCE UPHS HR Benefits + UArts MiD Thesis Project by Alaina Pineda & Sara Hall Spring 2012
ABOUT THIS DOCUMENT This document is a final report divided into three parts, demonstrating our work with the UPHS Human Resources Benefits Department. From January to April of 2012, we worked on developing a healthy cafeteria initiative. The first part of this report provides a project overview. The second part details our research process and synthesizes the data we collected. The third part outlines our final recommendations. This report is meant to serve as the starting point for further development and implementation of healthy workforce initiatives for UPHS employees.
CONTENTS PROJECT OVERVIEW The Team 8 Human Centered Design Process 10 Project Goal + Approach 12
PROCESS Cafeteria Observations Nurse Focus Groups Support Staff Interviews Employee Profiles Health Fair Table
16 20 26 30 36
SUMMARY & RECOMMENDATIONS Summary 44 Themes 46 Recommendations 51
PROJECT OVERVIEW In this section, we include an explanation of our project, an introduction to our design process, and our project statement. This provides a description of our work and approach to designing a healthy cafeteria initiative for UPHS employees.
THE TEAM We are graduate students from The University of the Arts working towards our Masters in Industrial Design. We partnered with the University of Pennsylvania Health System Human Resources Department to create a healthy workforce culture at UPHS, specifically geared towards developing a healthy cafeteria initiative. We worked with and reported to Rosemary Ossman-Koss, Director of Benefits; Jennifer Brady, Employee Health Advocacy Manager; and Lauren Johnson, Program Specialist, Talent Acquisition. Our work focused on the Hospital of the University of Pennsylvania, the largest of the three UPHS hospital entities. With over 6,000 UPHS employees, HUP provided the opportunity to learn about various employee demographics and design effective intervention ideas based on the real health needs of UPHS employees.
HUMAN CENTERED DESIGN PROCESS Our design process includes several general phases that lead to discovering design opportunities and producing results. The process is organic and applied based the specific needs of the user population. We learn by involving all stakeholders. This is done with various techniques, such as contextual interviews and observations of the userâ€™s environment, to identify opportunities for design interventions. Focused on the user, our work identifies unmet needs and emphasizes rapid prototyping for testing and implementing ideas. Through our design methodologies, we gain a detailed understanding of the users and their needs. This allows us to create a better platform for success.
PROJECT OVERVIEW 11
PROJECT GOAL AND APPROACH Beginning in the HUP cafeteria, our goal was to effectively design the support UPHS employees need to lead healthier lives, aligned with UPHSâ€™ commitment to building a culture of health. Through analyzing the cafeteria space at HUP, observing how individual interact in the space, and interviewing employees outside the cafeteria, we will design a sustainable cafeteria initiative that will positively impact the health of UPHS employees. This research will serve as part of the building blocks for constructing a culture of health throughout the organization. By engaging employee stakeholders early in our research process, we will design effective strategies to encourage healthy behaviors based on the needs of the employee population. Over time, this can result in healthier, more productive employees, in a work environment supportive of healthy behaviors, and ultimately, in a drop in health care benefits costs for both UPHS and its employees. PROJECT OVERVIEW 13
PROCESS In order to understand what kind of design interventions to implement, we had to build a solid understanding of the current behaviors. We developed a series of strategies to learn about the existing food culture for various employee groups at HUP. In this section, we will explain our research that included observations, contextual interviews, and several data gathering tools to aid us in gaining insight into current employees behaviors and opportunities for health-focused initiatives.
CAFETERIA OBSERVATIONS We began our research in the public space of our focus, the Spruce Street Café located on the 2nd floor of Founders Building. Our intention was to observe in order to gain a deep understanding of the space—to see what is offered in the space, how individuals currently operate in the space, and what behaviors enabled by the space were not considered healthy. Our observations consisted of a month-long endeavor broken into three phases. We chose to focus our observations on lunch time, roughly from 11:30am-1:30pm, because it is the cafeteria’s busiest time of day and because the most employees are present in the hospital during the day time shift.
Full Cafeteria Space and Seating Spruce Street Cafe Observation
Food Options in Cafeteria Path Observation
Friday | 01.20.2012 |12:00-1:30pm
Visitor 1 | Male | 50-65 years old
Ate alone for 25 minutes. Meal: 1. BBQ Chicken Wings 2. Mac & Cheese 3. Fountain Soda
HOW LONG description
time (in minutes)
Waited in line for both items. Ate rather slowly, very reserved.
3 1 WHO
Action Station Grill
Staff 1 | Female | 30-35 years old Ate alone for 20 minutes. Meal:
patients and visitors
group (+3 people)
Cafeteria Seating Observations
1. Grilled Cheese 2. Raw Vegetables 3. Fountain Soda
Grill Salad Bar
Debated on choosing soup, seemed not to be interested in any of the available options. Waited in grill line for grilled cheese.
Individual Path Observations
CAFETERIA OBSERVATION RESEARCH TOOLS We divided our observations into three phases, and used the various tools depicted on the left to record our observations. The first phase of the observation process focused on becoming familiar with the cafeteria space itself, including the types of food for sale, the process of finding and purchasing foods, and the employees present during lunch. The second phase included a detailed focus on the employees and guests eating in the adjoining seating space. This was to gain a greater understanding of the food culture at the hospital, focusing on how employees treat their meal breaks. Our third phase further analyzed the interactions employees and guests had with the cafeteria space. This included specific path observations and touch points between hospital employees, cafeteria employees, food and the cafeteria space itself. These three phases were used to create a comprehensive understanding of the current behaviors practiced in the cafeteria.
NURSE FOCUS GROUPS The significant absence of primary care workers in the cafeteria led us to focus on the eating patterns of employees not present in the cafeteria. At most, we saw around 300 individuals in total during the lunch time rush, nowhere near the total number of UPHS employees working the day shift at HUP. By learning more about the eating patterns of various employee populations, we argued we could better identify opportunities that could encourage healthier behaviors and change existing unhealthy behaviors. We searched for the ability to see firsthand the hospital culture in action. Partnering with Jean Romano, Director of the Nursing Network at HUP, we secured times and locations for nurse focus groups in the breakrooms of several hospital units.
NURSE FOCUS GROUP RESEARCH TOOLS We developed a series of tools and a plan for the focus groups. We asked for 20-minute sessions with 5 nurses present at each session. We divided the sessions into two partsâ€”one of us would have a one-on-one interview with a nurse to deeply understand his or her food behaviors and the other one of us would lead a group discussion where we would use maps of the cafeteria, its seating space, and the food options available around HUP to encourage dialogue. This portion was planned to facilitate a discussion about the needs and struggles of the nursing staff when it comes to eating throughout the day. Our execution was not nearly as smooth as we had planned for, but we did facilitate rich conversations and incentivized them to talk to us with free lunch and snacks.
NURSE FOCUS GROUP RESULTS
90% PACK FOOD
10% ORDER OUT
95% PACK FOOD
75% 25% PACK FOOD
SUPPORT STAFF INTERVIEWS Using the tools developed for the nurse focus group interviews, we were able to interview another demographic, Support Staff. After meeting with Mia Gonzales-Dean, we set up 15-minute interview sessions for around10-15 employees. These one-on-one interviews would be based around the cafeteria but could evolve into a conversation about the current food state. The execution of this portion was fast paced and very informative. The individuals interviewed provided a very informative insight into the culture of Support Staff.
INTERVIEWEE DEPARTMENT COMPOSITION
HUP EMPLOYEE PROFILES Part of our design process involves building character profiles that generalize the many voices of individuals we met through our research. The following profiles come from our nurse focus groups and support staff interviews, two groups we spoke with extensively. The goal of the profiles is to provide a united voice of the work culture at HUP and obstacles to healthy eating that many UPHS employees face while at work.
Registered Nurse, Medical Unit Typical Shift: 7:00am-7:00pm | 3 days a week Medical unit nurses frequently can take their full lunch breaks because of the nature of the unit. They enjoy spending their lunches off their feet. Lunch often falls at various points in the day, sometimes as late as 4pm. They tend to pack their lunches because they would rather take their breaks to rest instead of traveling to the cafeteria or elsewhere to get food. Where he gets his food: outside food
cafeteria 5% pack
Where he eats his food:
“There is time for me to go off the unit to pick up food, but I would much rather pack and be able to spend the time off my feet. Lunch is the only opportunity to relax, and I’d rather sit than spend my entire break picking up food.”
Registered Nurse, Surgical Unit Typical Shift: 7:00am-7:00pm | 3 days a week Surgical unit nurses must remain flexible and eat food whenever they can. They often graze on foods throughout the day instead of sitting down to a large meal. They pack their lunches because they have no chance to leave the unit. Their patients often require more immediate care, so nurses snack whenever they get a chance because it is never certain exactly how the day might go. Where she gets her food: outside food 2% cafeteria 3% pack
Where she eats her food:
“If I don’t bring my lunch, I have such anxiety about how I’m going to get food and when I’m going to manage to eat. I often graze throughout the day because you never know when your patient will need you. I rarely leave the unit.” PROCESS 33
Registered Nurse Typical Shift: 7:00pm-7:00am | 3 days a week Night shift nurses on both medical and surgical units order food more often than day shift nurses. Their biggest obstacle is a lack of availability of foods during their shift. They call themselves “the forgotten shift” because very little is available for them by the time they start thinking about food, often well after midnight.
Where she gets her food:
outside 25% pack 75%
Where she eats her food:
“I can’t imagine thinking about food until around midnight when the shift slows down, and by then, the cafeteria is closed. CHOP closed our McDonald’s so now we have to walk up the street to Wawa or eat out of a vending machine if we don’t bring our own food.”
Materials Management, Support Staff Typical Shift: 7:00am-3:30pm | 5 days a week Most support staff have a similarly structured work day. The beginning and ends are busy and workload slows down around lunch time. Lunch time typically falls between the hours of 12:00pm and 1:00pm, but some days the rate of work does not allow this. Many support staff do not frequent the cafeteria, mainly because of its busyness during their lunch hour. Where she gets her food: outside food 25% cafeteria 16% pack
Where she eats her food: cafeteria 24% breakroom 76%
“When you work for HUP, you know its going to be demanding. Sometimes, there’s not enough time for lunch. That or I don’t want to waste my time waiting in the cafeteria.” PROCESS 35
HEALTH FAIR TABLE We were offered the opportunity to have a table at the UPHS health fairs. There were 7 health fairs where we were offered a table, and we chose to focus our efforts on the three hospitalsâ€”Hospital of the University of Pennsylvania, Penn Presbyterian Medical Center, and Pennsylvania Hospital. Since a significant number of the 15,000 UPHS employees work out of the three hospitals, we honed our efforts on understanding them. Additionally, the three hospitals are the only three UPHS buildings with cafeterias to be the focus in the development of a health cafeteria initiative.
Questionnaire Voting Activity
What is your biggest obstacle for eating healthy at work?
you are... RN
Voting Activity at PPMC
Prompt Activity Card
HEALTH FAIR TABLE RESEARCH TOOLS Our intention for the health fair tables was to continue our research and gather more data to inform the next steps and possible recommendations for a healthy cafeteria initiative. We designed a series of tools that could provide us with quantitative data quickly and efficiently. We wanted to utilize another tactic for gathering the employee perspective and showcase yet another method that can be used to inform more meaningful and more effective initiatives in the future.
HEALTH FAIR TABLE RESULTS
RECOMMENDATIONS Our design intervention recommendations are rooted in and created from our research, including observations and direct conversations with UPHS employees. The ideas address the healthy eating needs of employees and possible points of entry for designing and implementing success initiatives. Many recommendations were created by employees, based on their wishes to change their current struggles with healthy eating while at work. The following recommendations voice the employee perspective and the support they would like to have in eating healthy at work.
SUMMARY Our work over the course of the semester led to a deep understanding of the existing behaviors of various groups at HUP and more generally at PPMC and PAH, especially in regards to food. From our research with the various employee stakeholder groups, we developed a set of themes that were resounding within each group, some of which were also obvious from our more general cafeteria observations. The following pages describe the various themes and provide evidence from direct employee statements that best exemplify the themes.
MAIN THEMES These themes represent the biggest obstacles UPHS employees face when trying to eat healthy while at work. They were distilled directly from our research engaging employee stakeholders.
High prices of healthy food, especially in the cafeteria but also in general
Inconvenient locations and far distances to travel to purchase food, both healthy and unhealthy options
Little time to waste finding food with short lunch breaks and too long being away from work
CULTURE Work culture takes away from individual ability to take a break, relax and enjoy food
HEALTH Employees struggle with lack of access to healthy foods and with eating at work, especially if they have a chronic disease to manage
WHAT EMPLOYEES SAY These are direct quotations from our interviews, focus groups, and the health fairs with UPHS employees describing their biggest obstacles to eating healthy while at work.
COST “I try to pack my food... time wise, economically and nutritionally, it makes the most sense.” “Half the times, there’s not enough food anyway or any good food or you are going to spend $12.” “I can’t pay $7 for a healthy lunch. $3.50 for a hot dog is more like it.”
LOCATION “By the time you can get down to the cafeteria and wait in line, it takes 20 minutes and then you only have 5 minutes left to be off your feet and eat your food.”
TIME “Any time you leave the floor, it takes away from the time we have to relax.” “I got an admission today at noon, so I did that instead of going to get food.” “I wolf down food at my desk and end up snacking on junk food because there is no time to eat a meal.”
“If I don’t bring my lunch, I have such anxiety about how I’m going to eat food and when I’m going to eat.”
“It’s just when you go to the cafeteria near midnight, there’s only junk food to eat. Anytime after 8pm there’s nothing to eat.”
“Since I’m a new nurse, I don’t like leaving the unit. I’m always concerned about my patients, and want to be there to answer any questions, even if I am taking a break.”
“It is very hard to eat healthy here if you don’t bring your own lunch.”
“Everyone brings junk food into the breakroom.”
“There is too much salt in the foods at the cafeteria.” “Why does the cafeteria make healthy foods unhealthy? Like putting brie in the mushroom soup.” RECOMMENDATIONS 49
RECOMMENDATIONS We propose three types of recommendations for moving forward to develop a healthy cafeteria initiative and for creating and implementing future HR Benefits health initiatives.
Step To begin, we have developed a series of Steps that could adjust the environment and individual perceptions enough to begin changing eating at the hospital cafeteriaâ€”by making it easier to eat healthy foods while at work. Portion Size The research shows that we consider what we have on our plate to determine when we are done eating, meaning when the plate is clear than we are finished with our meal. We do not eat until we are not hungry anymore but instead conquer whatever is on our plates. By serving food on smaller plates so that people do not get as much food at one time or by training employees on the number of scoops and grabs to include in a single serving, we can serve the appropriate sized portions to employees in the cafeteria. Food Labeling: Stickers This method provides a quick visual cue to individuals who have little time to make food decisions or those who want an easy way to recognize pre-approved healthy choices without the hassle of making decisions. Criteria for healthy choices must be established so that employees know the exact rubric with which foods were graded in order to receive the Well Balanced branded sticker. Food Labeling: Calories While studies show that this method has mixed results, it does provide individuals with a full understanding of how the food was good and its nutritional value. This could help highlight that food in the cafeteria is cooked with olive oil instead of butter, that 5: RESULTS
the produce is organic, and an understanding of portion sizes. This education is helpful to anyone counting calories or in need of knowing the exact ingredients in various foods.
Cafeteria Flow A study and a better understanding of the arrangement of food in the space could lead to nudging employees to make better decisions about what they eat, while still remaining in the cafeteria to purchase their food. For example, the healthier food options, such as the salad bar, are located at the far end of the cafeteria space. Some of the foods available close to the door include Tastykakes, pretzels and cereal to the left of the door and ice cream, the grill and a rotating action station to the right. By making healthier choices like the salad bar and fresh fruits more immediate upon entry into the cafeteria, the purchasing habits of employees can be altered. Employees can be nudged in the direction of buying healthier foods. Tactics such as these have been successfully implemented in various cafeterias across the country, including Googleâ€™s. Information Station The current location of the information station is not a spot where people choose to stand and linger. It is operating as a barrier that forces individuals to veer either to the left or right of it. Instead of trying to engage individuals in stopping in the space, what if it became a wall full of fruit or healthy options to grab and go? The colors of the fruit accompanied with a message of making sure to eat the daily recommended amount could increase the sale of fruit and the healthy food intake of employees.
Wing Friday Wing Friday is a huge seller at HUPâ€™s cafeteria, but through our research, we heard employees say that if there was no Wing Friday that they would be upset but learn how to live without it because they did not need to eat wings every week. By actions like decreasing the frequency of Wing Friday to every other week or by expanding the menu of meatless protein options and encouraging employees to try another version of the wing, employees can begin altering their Friday food habits, which over time as Wansink argued in his book Mindless Eating, these small changes can add up to huge results. Improved Salad Bar This was a request from every group of nurses we spoke with and demonstrates that many indiivduals do choose to eat healthy foods, and would enjoy greater variety and low fat options when eating salads. Not only variety was requested but also better presentation of foods. Employees often cited that the salad bar begins to wilt and look unappealing at certain times during the day. With improved presentation and increased options, the salad bar could become a healthy option that employees want to choose.
Jump Our Jump recommendations involve more planning to implement and involve operational stakeholders outside of the cafeteria space. They alter the hospital environment and address the needs of users both inside and outside of the cafeteria. These recommendations begin to shift the focus. Food Cart A major issue that is faced with HUP employees is lack of time. In particular, this plagues nurses who are frequently unable to leave their units at all. One solution proposed by several groups is the use of a food cart to bring food to them on the hospital floors. HUP is comprised of several buildings and can take up to 20 minutes to make the roundtrip between the unit and the cafetria. A food cart that offers for purchase healthy meals and snacks would alleviate stress added on busy days when employees forget to pack their lunches and provides comfort to the employees because they know they can get something to eat during their shifts. Nutrition Classes at the Nursing Renewal Center While many nurses argued that they know what is best for them, many also shared that nutrition classes could serve as a reminder for those who may have forgotten. The Nursing Renewal Center is a resource for nurses that provides a space of reprieve for nurses to enjoy before and after shifts as well as on their days off. It could become the sight of additional aid by offering classes that could answer specific questions for individuals. Instead of relying on online tools to learn about nutrition, classes could facilitate conversations about healthy eating and provide helpful tips that 5: RESULTS
could more easily translate into actionable steps that can change into more permanent behaviors. Employee Meal Card Many employees we spoke with complained of the long lines in the cafeteria, not just in waiting for food but also in purchasing food. We observed many doctors and residents using their ID badges to pay for food in the cafeteria, and so we propose an employee meal card that would make it much easier to pay for food. Employees could save time in making their purchases with a meal card embedded in their ID badges. In combination with changes like an employee line or the ability to call in an order for pick up, employees could save themselves time and stress by having tools make getting food much easier.
Mobile Application Our idea for a mobile application would provide a level of education that could synchronize with the cafeteriaâ€™s menu. In essence, employees could use this application to learn about what foods that can and should be eating based on their unique health needs. Many employees voiced their inability to eat certain foods due to various chronic diseases, so this application could facilitate food decisions for employees as they visit the cafeteria to make their decisions. The education could also begin to affect decisions being made outside of the cafeteria and away from work. By emphasizing what someone can eat instead of what not to eat, the application provides a positive outlook on making food choices. Healthier Food Options Many of the food choices available in the cafeteria, both meals and snacks, are not very healthy. In fact, many of the most appealing and most popular foods are the poorest in terms of nutrional value. For example, the half chicken and plate of macaroni and cheese looks delicious and sells out often. Many nursing employees complained of
not having enough healthy food options to choose from, including an often unappetizing salad bar with very few options. By increasing the fresh and healthy foods that are available, especially quick grab and go items, this would impact the quaility of foods employees enjoy while eating at the cafeteria. Organized Competition We heard musings on various health competitions at the different hospital entities, but they did not seem very organized. While conducting our focus groups, some nurses noted that they did not realize they had missed the final weigh-in. There is interest in organized competitions like this, and there is even significant promise in challenges between day and night shift nurses. We learned of a kind of rivalry between the two groups, and a friendly health competition could engage both parties in uniting against one another to improve their health. This fosters a sense of ownership over what you can contribute to the group to help beat the competition, a favorite practice 59 for creating change. Altered Hours A major struggle faced by nurses is that the cafeteria hours are not condusive to their shift hours. For example, when day nurses can begin taking a break and think about food, the cafeteria is closed to set up for lunch. By the late afternoon when many nurses eat their lunches, there is no fresh food options available. Night nurses have no food options past midnight because the cafeteria is closed, and midnight is the earliest they can imagine taking a break. Hours could be altered to better fit the schedules of nurses, the largest UPHS employee population at the hospital.
Leap Our Leap recommendations focus on a much larger challenge currently facing UPHS. These recommendations address the decision making process that has resulted in unsuccessful initiatives without making significant impact on increasing health or avoiding the 2018 excise tax. Workshops The value we see in workshops is the ability to bring various stakeholders into the same room to brainstorm and prototype various solutions that could impact much larger problems faced by the health system. This would continue to engage participants and provide an opportunity to become part of solution creation. This would enable successful solutions to be created by those who experience those particular problems, and in this way, real change could happen. These facilitated workshops could be used to engage stakeholders across the health system on various problems and opportunities for continuing to improve on the success and notoriety of Penn Medicine. Alignment of Environment and the Mission: The Bacon Intervention The current struggles with having to encourage health care workers to be healthy reveals a problem with the environment that does not facilitate healthy behaviors for employees. While employees also spend a significant amount of time away from work, their work environment can shape their behaviors and can translate to actions away from work. In particular, the example we are using to explain the misalignment of the hospital environment and the healthy systemâ€™s mission is bacon. We learned that bacon is a best selling 5: RESULTS
item at the cafeteria in Pennsylvania Hospital. The environment that exists now enables unhealthy behaviors and does not promote healthy food choices. By continuing to offer foods like bacon, the cafeteria and by extension UPHS are enabling poor employee behaviors by making it easy to eat poorly. To better align with the health system’s mission of health, this strategy highlights UPHS’ need to acknowledge the existing disconnect and work to remedy it by making strategic changes in the way things are done—for example, with bacon.
Non-Survey Based Engagement Currently, UPHS employees suffer from survey fatigue and burnout. This is the standard form for communicating and evaluating experiences, challenges and more. We are proposing a new strategy that utilizes on the ground engagement that makes employees feel that they are part of something meaningful. As an example, we offer our health fair table design. By borrowing principles from play theory, we engaged employees in a fun and colorful activity that also yielded important and meaningful results. Instead of a standard survey to collect data, designing various tools that are more exciting can lead to increased participation and perhaps more thoughtful responses.and more. Unfortunately it leaves no room for… Feedback Loop Currently, UPHS has an excellent track record at asking employees about what they think and keeping track of that data; however, improvements could be made in terms of how that information is communicated back to employees in terms of the actions the information informed. Value in participation is not created and must be in order to continue to learn about the most important areas of concern and opportunities for change.
Change in Culture Most importantly, we recommend that there be a shift in culture to adopt new processes for engaging employees and implementing change across the system. While it is important to respect the time of all employees, the greatest change comes as a result of bringing various voices to the table to pilot change and create meaningful actions. Our project highlights how a change in process can uncover real opportunities to create impactful changes--the changes necessary to implement as we move closer to the 2018 health care reform deadline. This shift in perception can lead to successful changes that address true problems faced by employees and even patients and their families 63 across the health system, and will continue to improve upon the incredible work done by all UPHS and Penn Medicine employees.