Designing Health

DESIGNING HEALTH fostering the growth of a healthy

workforce within corporate culture Alaina Pineda & Sara Hall | Spring 2012

Sara Hall Alaina Pineda

Designing Health fostering the growth of a healthy workforce within corporate culture

Published by

Master of Industrial Design at The University of the Arts 302 South Broad Street Philadelphia, PA 19102 http://mid.uarts.edu

Copyright © 2012 by Alaina Pineda & Sara Hall and Master of Industrial Design at University of the Arts Photography credits: All photography by Alaina Pineda & Sara Hall unless otherwise noted.

Some rights reserved. No portion of this book may be reproduced– mechanically, electronically, or by any other means, including photocopying–without written permission of the publisher.

Cover design by Alaina Pineda & Sara Hall Book design by Alaina Pineda & Sara Hall Master of Industrial Design at The University of the Arts 302 South Broad Street Philadelphia, PA 19102 http://mid.uarts.edu First printing July 2012

Submitted in partial fulfillment of requirements for degree of Master of Industrial Design at The University of the Arts, Philadelphia, PA

by Sara Hall and Alaina Pineda

Approved by

committee chair

Monica Gilbert

advisor

Sherry Lefevre

advisor

Neil Kleinman

director Jonas

Milder

Dedication To my mother, who listened to me day after day as I fumbled my way through something new and who believed I could make it every step of the way. To my father, who gave me an example of what can happen when you find something you are truly passionate about. To my classmates, who inspired me in so many ways during my time in Philadelphia. I could not have done it without you. –Alaina To my family, friends and cat. Thank you for all of the support and guidance. –Sara

Acknowledgements Thank you to our committee chair Monica Gilbert, whose perspective helped us make sense of a truly complex problem.

Thank you our advisors Neil Kleinman, Sherry Lefevre, and Jonas Milder, whose guidance has been invaluable in making our project stronger with every conversation, email, and meeting.

Thank you to Rosemary Ossman-Koss, Jennifer Brady, and Lauren Johnson. You all supported our ideas and our process, and we thank you a million times over for welcoming us into your culture.

Thank you to all UPHS employees who allowed us to come into your workspaces, to ask questions, and to listen. Your willingness to openly share ideas with us made this project possible.

Abstract

Designing Health: Fostering the Growth of a Healthy Workforce within Corporate Culture describes our work in partnership with the University of Pennsylvania Health System [UPHS] to design a work environment that promotes and values employee health. Through our discovery process, we also identified the need to affect the decision-making process of our client and the much larger health system in order to reach those impactful outcomes. To try to make a good thing even better at the health system, we developed and implemented a series of design interventions to address the current challenges within the UPHS environment. Our work was rooted in various methods of behavior change. We hosted focus groups, had interviews, and developed various data gathering techniques based on play, to learn about the current environment and design recommendations for effective change.

Our process was iterative, based on qualitative data, and user-centered—a process unfamiliar to this corporate culture.

This design driven model for organizational learning can produce meaningful insights that will facilitate positive changes in less time and with fewer resources. Our process empowers change from within an organization. Ultimately, we provided our client with a series of tools and abilities to enable them to implement sustainable and successful initiatives for their employees.

This book outlines how the organization is currently working, to showcases strategies for successful deployment of sustainable healthy initiatives at UPHS, and highlights how Human Centered Design [HCD] can create value for organizations seeking important and meaningful change.

Sara Hall “You can never learn less, you can only learn more.”

—R. Buckminster Fuller

I want to know more, more about everything. Design influences everything everyone interacts with, subconsciously and consciously. Many of my studio projects during my undergraduate program in Architecture dealt with designing for humans but the scale and time constraints prevented me from getting to the actual user group. This is where I began to shift my thoughts from Architecture to designing for people.

The MID program allowed me to interact with the actual user.

I can see the change that is implemented and through the process, I am able to evaluate and react to the results. The skills that I am learning and using in real situations now will provide me with the capabilities to create change.

This thesis project, surving as the culmination of our degree program, allowed us to apply and utilize the human-centered design process to UPHS. The thought that my profession will allow me to create change excites and motivates me.

Alaina Pineda “I can never feel that information learned by heart that can be looked up in a book is learning. Real learning is about thinking and putting new things together with old things…”

—Michael Ann Holly

My ultimate goal has always been to learn. As an art historian, as a pastry chef, and now as a designer, I have been in the fortunate position to learn something new, to listen intently, to ask difficult questions, and to take a stab at solving interesting problems. Problem solving is my life’s passion. MiD offered me the opportunity to explore new technologies, meet fascinating people, and work on problems for the social good.

Our thesis has been the ultimate exploration for a constant learner. Getting to know the employees of UPHS and using their thoughts to inform necessary change makes learning all that much sweeter. I am hopeful of the positive growth and impact our design process can bring to any industry—big or small. I look forward to learning more about the work of my peers and the great changes I’m sure we will all make in the world.

CONTENTS

CONTEXT

14

THE PROBLEM

24

KEY PLAYERS

54

ACTIONS 66 APPENDIX 170

CONTEXT

16

The Inciting Incident

Health care reform threatens to impose a severe tax on businesses and large corporations if they do not decrease their health care costs by 2018. Known as the “Cadillac Tax,� it is a tax levied on insurance companies that offer premium benefits packages, a tax that will be passed on to employers like our client UPHS. The purpose of the tax is to cut back on the increased use of superfluous treatments and reduce the high costs that are set by insurance companies. It is a 40 percent fee imposed on employersponsored health care benefits premiums with plans whose price tags exceed the defined threshold. Currently, the threshold is set at $10,200 for individual coverage and $27,500 for family coverage1.

The hope is that these changes will allow the insurance market to become more competitive with its rates and grow to allow more Americans to have access to health insurance. The tax is meant to penalize the current health care trajectory and create change that will make health care more affordable.

Our client, the University of Pennsylvania Health System, partnered with us to take steps to address the 2018 threat of the Cadillac Tax, by implementing a healthy cafeteria initiative to get UPHS employees healthier.

1: CONTEXT

17

Disease Management

18

Disease Management aims to manage a disease by keeping conditions from worsening9. Most health care has been operating on the level of disease management, treating a disease once it has already affected the body. Employer benefits programs, such as online tools and disease management hotlines, were popular in the past and are still used even today to help employees monitor their stats and keep them in check. These programs generally targeted “at risk� individuals and worked with them to manage their health problems with medication and other treatments. Often the programs were used to encourage employees to adhere to their medications and manage their disease before it escalated and caused complications and hospitalizations.

Disease Prevention Growing in popularity, disease prevention seeks to achieve and to maintain a level of health so that there is never an onset of disease10. Such employer sponsored programs and initiatives encourage employees to take ownership over their health and make choices that will keep them healthy. Often these programs use incentives to encourage employee participation, including discounts on gym memberships and discounts on health insurance premiums11. Larger organizations have gone as far as to drastically change the work environment to support healthy choices and behaviors12. Other employer-driven disease prevention programs have introduced the concept of “wellness,� devoting a portion of their efforts to treating the whole person—mind, body, and spirit13.

1: CONTEXT

19

20

Times Magazine Disease Prevention Cover8

The Shift As a result of not only health care reform tax and the Cadillac Tax but also general health over several decades, there has been a growing trend both in the US and abroad of a shift from disease management to disease prevention2. This can be seen in various ways, from the methods companies have taken to improve employee health to the increase in vitamin sales3 to prevention care content in popular magazines4.

This shift is a result of two factors: the prevalence of chronic disease and skyrocketing treatment costs5. The majority of health care costs are associated with managing chronic diseases. In fact, “Chronic diseases cause 70 percent of deaths in America and are responsible for three-fourths of health-care spending6.� Most all chronic diseases, including cardiovascular disease and diabetes to name a few, can be managed if not prevented with a change in lifestyle including diet and exercise. Additionally, the rising cost of health care is due in part to the availability of new technologies to diagnose and monitor disease as well as new drugs to manage diseases7.

1: CONTEXT

21

Some History

22

The current practice of medicine relies heavily on new technologies and pharmaceutical drugs. Both are expensive and continue to be the go-to tactics of the medical field, making it harder for individuals to afford their plans and for employers to provide benefits for their workers. Newer technologies increase the quality of medical care, leading to more expensive bills and often many more bills in order to diagnose and treat patients.

Insurance companies have increasingly shifted these higher costs to employers by charging more for health benefits. In turn, employers have shifted these higher costs to their employees, resulting in a rise in out-of-pocket expenses in the form of monthly premiums, co-pay fee, and co-insurance fees and much more14. The only way these costs can be avoided is by preventing disease from the beginning.

To place the problem of poor health and high cost into context, here are some facts and projections based on our current statistics. “In 2008, 107 million US adults—that is 1 out of every 2 adults 18 years and older—had at least 1 of the 6 most common chronic diseases. These include cardiovascular disease, arthritis, diabetes, asthma, cancer, and chronic obstructive pulmonary disease15.” At the current pace, obesity rates will account for more than $860 billion in health care costs in 203016. According to the American Heart Association, cardiovascular disease costs, including treatment and loss of productivity, will exceed $1 trillion per year by 2030. At this rate, Type 2 Diabetes could cost $500 billion per year by 202018. While our country pays top dollar for health care, it

23

Graphic of growth in insurance premiums17

is currently ranked thirty-seventh by the World Health Organization in terms of outcomes. We are currently on par with Serbia19, which shows that the health care industry is in desperate need of reshaping if we want to change our outcomes.

For more information on the shift of the medical model, turn to Appendix B: What Experts are Saying.

1: CONTEXT

THE PROBLEM

26

Clinical Care Practices of HUP

Hospital of the University of Pennsylvania

Penn Presbyterian Medical Center

Pennsylvania Hospital

Clinical Care Associates

Primary Health Care & Home Services

Penn Medicine Organizational Structure

The University of Pennsylvania Health System

The University of Pennsylvania Health System (UPHS) is one part of the large umbrella organization of Penn Medicine. Penn Medicine is comprised of the School of Medicine and UPHS, which is the practicing health care branch. UPHS Corporate oversees the three hospitals, Hospital of the University of Pennsylvania, Penn Presbyterian Medical Center, and Pennsylvania Hospital as well as Clinical Care Associates and Penn Home Care and Hospice Services.

It also shares responsibility with the School of Medicine over the Clinical Practices of the University of Pennsylvania, which includes specialists who have their own practices but also teach for the University. UPHS employs over 13,000 employees across its various entities.

Penn Medicine and UPHS practice a hierarchical model of decision-making, with the seat of power residing with the Board of Directors—removed from the challenges and needs of frontline employees.

Our client was the University of Pennsylvania Health System, specifically the Department of Corporate Benefits. Our direct contacts were Rosemary Ossman-Koss, Director of Benefits, and Jennifer Brady, Employee Health Advocacy Manager. We initially learned about the challenges facing the entire health system from Michele Fletcher, Associate Vice President of Human Resources.

She related to us how proposed health care reform is forcing UPHS to create wide changes to their employee health care benefits packages and to rethink how they address employee health throughout the organization. At $12 million per year, the Cadillac Tax is an incredible financial burden that the health system cannot and will not support.

2: THE PROBLEM

27

28

Health Education Example: Healthy Vending Machine

Their Proposed Solution

UPHS has been introducing healthy initiatives over the last seven years, but their efforts have resulted in little progress and virtually no change to their health care costs throughout the health system.As a result of the immediate need for measureable change, UPHS chose to install initiatives across the health system to combat high costs and to support employees in making healthier choices that will affect their overall health. MiD was specifically engaged to address poor eating habits and design the details of a “healthy cafeteria initiative� for the health system. They have started to realize a greater need to shift their focus from controlling diseases to preventing them in the first place and feel the pressure to make change happen more quickly.

Recent initiatives implemented in the last year include a healthy vending machine campaign to educate employees on making healthy snack and drink choices by visually demonstrating what they should and should not eat.

2: THE PROBLEM

29

30

Research on Disease Prevention

Current research and literature support the notion that health-focused initiatives provide the mechanisms for improving employee health in order to drive down the cost of health care plans and to combat the drastic increase of chronic diseases.

Understandably, healthy employees do not require as much medical care as sick employees, so the current trend in businesses and large organizations is to support employees’ health by spending more resources on preventative care efforts instead of disease management after they are already sick.

Because of the increased cost of health care, many organizations have been actively trying to reduce these costs by creating healthy work environments to improve the quality of health and of life of their employees. It has become in vogue to offer superb incentives and resources to maintain a level of health. This is a departure from the more traditional use of premium benefits packages. Now employer health driven initiatives have started to become standard ways in which employers take care of the health of their employees.

2: THE PROBLEM

31

What Other Organizations are Doing

A review of what other large medical systems and large corporations are doing to improve overall employee health allowed us to understand and gauge the success of available models. We looked at Kaiser Permanente, Cleveland Clinic, and Pitney Bowes.

While these organizations are sizably larger than our partner organization, they are examples within the industry and a good place to begin understanding the general climate and specific tactics of similar organizations.

32

While using various tactics specific to their unique organizational needs, all three organizations stress providing an environment that supports health and makes it difficult to be unhealthy. For example, Cleveland Clinic banned all sugared beverages from their campus in 200520. Pitney Bowes’ cafeteria offers carrots and celery sticks as the default side for a sandwich. Chips are available, but only upon request21. Kaiser Permanente has a course catalog of classes they offer not only their employees but the entire community as well. These classes include nutrition, cooking, exercise, yoga, and many more22. Each organization is working to take down the barriers that prevent their employees from leading healthy lives and thinking strategically about the long-term benefits of their efforts. They see the value of addressing the whole human being through their health and wellness efforts.

For example, the timeline of Cleveland Clinic’s initiatives demonstrates the efforts the organization has adopted to ensure the health of their employees. Beginning in 2005, Cleveland Clinic has allocated the resources to provide several services for their employees, including free yoga, free gym memberships, and classes

33

Cleveland Clinic Intiative Timeline

offered at the Wellness Institute. Additionally, they have done drastic work to improve the health of the environment for their employees.

They made their campus smoke free, stopped serving foods with trans-fats, and also, in 2010, banned all sugared beverages from their cafeterias and vending machines. In 2011, it was reported that Cleveland Clinic workers have collectively lost more than 25,000 pounds since 200523. Delos Cosgrove, President and CEO of Cleveland Clinic Health System, once stated “Traditionally, medical care has focused on treating and curing disease. We need to focus more on keeping people healthy24.� Cleveland Clinic’s initiatives are 2: THE PROBLEM

on-going to provide the support and motivation that employees need to be healthy.

34

In 1999, the health care costs for Pitney Bowes soared 13%, which encouraged them to analyze employee health trends and the causes for the increased costs25. Through taking a series of steps to predict future health care costs and by targeting employee areas of their greatest concern, they provided additional health resources to avoid an imminent cost increase. They focused their efforts on the New York area, and “introduced additional health education initiatives in the region, as well as free or low-cost on-site immunizations and screenings. The firm also encouraged staff to seek regular care at nearby clinics instead of relying on the ER.” “The firm estimated that in aggregate, its health benefits programs had saved $39.8 million in 200726.” With the success of their initiatives, overtime Pitney Bowes continued to increase their health and wellness care options across their regions, dedicating $10 million in 2008 to on-site clinics and health and wellness programs.

The environments at these organizations create a sense of ownership for employees to take charge of their own health but in a way that makes the decision easy. Former CEO of Pitney Bowes, Michael Critelli, managed to capture exactly what this movement embodies: “In the old days, we were very generous in paying for people’s medical bills. Today we’d like to be very generous in helping people be healthy, but at a lower cost27.” Pitney Bowes, Kaiser Permanente, and Cleveland Clinic have all made drastic changes to their environments in an effort to make a healthy workplace for their employees, and these messages are embraced across

“Traditionally, medical care has focused on treating and curing disease. We need to focus more on keeping people healthy.”

-Delos Cosgrove, President and CEO of Cleveland Clinic

the organization. In another example, Michael Critelli paused a meeting he was in and asked employees to join him in a walk until he reached the recommended 10,000 steps per day28. Health is embraced throughout these organizations in how they run and in how their employees act throughout the workday.

Other companies have followed in their footsteps. For example, Sherwin-Williams based in Cleveland opened a fitness center about ten years ago and has reported that for every dollar that Sherwin-Williams spends on their fitness center, they “reap $3 in lower health care costs, lower workers compensation cost, lower disability costs that includes absenteeism and higher levels of productivity29.” The bottom line is that Kaiser Permanente, Cleveland Clinic, and Pitney Bowes and even Sherwin-Williams have invested significant amounts of money to get and keep their employees healthy, but they have managed to save tremendously on their health care costs while also enjoying the health, productivity, and happiness of their employees.

2: THE PROBLEM

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36

Closer Look into UPHS’s Past Initiatives

In order to design future efforts, we needed to learn more about past attempts at improving employee health. Our direct contact Rosemary Ossman-Koss shared the history of their past initiatives and provided us with some context of what her department handles. She informed us that it currently costs Penn Medicine an average of $10,000 per individual per year for a grand total $150 million in employee health benefits per year. UPHS provides benefits for its 13,000 employees and their dependents, roughly 26,000 total participants. Employees contribute about 30% to this total cost.

Beginning in 2006, UPHS has implemented various temporary, incentive-based initiatives to affect the health of its employees—many of which have not been sustainable because of the lack of resources to finance the incentives. All these initiatives were designed, funded, and implemented from within the Corporate HR Department. Ideas were generated by the need to lower the yearly increase in health care cost, particularly during the early 2000s when the average increase in cost was 10% or more.

The next few pages explore UPHS’s timeline as well as their initiatives they have done in the past.

2: THE PROBLEM

37

38

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UPHS Intiative Timeline

2: THE PROBLEM

Free Biometric Screenings Since 2005, these screenings have been offered for free. Out of the 15,000 Penn employees, only 400-800 individuals have taken advantage of the screening, which costs $60 to complete. The biometric screening measures BMI, blood pressure, cholesterol, and blood sugar. Over the program’s history, at least one person per year was sent immediately to the emergency room because their blood pressure was “off the charts.” This program has been credited with saving the lives of those individuals. They were very grateful.

Pharmacy Coupons Some employees were not getting their prescription drug refills because they thought the co-pay was too high. In order to encourage employees to adhere to their prescriptions, Benefits Department issued $5 coupons for employees to use at the in-house pharmacy.

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Cafeteria Coupons $2 coupons were given to employees after having their blood pressure taken. Each coupon provided a $2 discount off of a healthy food in the cafeteria. The problem was it was not enforced for healthy foods only and not monitored to see what employees spent the $2 on. Employees were willing to stand in a line for 30 minutes, waiting to have their blood pressure taken for the $2 reward, but eventually the cost became too high to continue the program.

Disease Management Program UPHS partnered with a 3rd party vendor who offered health coaching for employees. The vendor would call employees at their homes at night and offer their services to help them manage their health. They would ask if the employee was interesting, but would often be turned down. Employees would respond that they are registered nurses and clinicians and did not need help to manage their health, so the program did not have much traction.

Walking Program In 2009, UPHS hosted a walking program that encouraged employees to record their steps and then log them online. As long as they were giving out prizes, people were reporting their steps every week. Soon it became the same set of individuals who were winning, and the program was no longer sustainable or affecting change across the entire health system.

Success Stories The HR Department designed and mailed out postcards to each of the 13,000 employees to encourage them to share their health success stories so they could be added to the website. They received zero responses. One afternoon around 2:30, they circulated an email that employees would be entered in a drawing to win a Kindle for submitting their success stories. In two and a half hours, they received 40 stories. In the end, they purchased and gifted 5 Kindles.

Online Health Risk Assessment

41

In Spring of 2011, employees were encouraged to complete a health risk assessment that was made available online and would only take 10 minutes to complete. Some of the information that was asked for was specific and required a biometric screening. To reach a wider audience, they began offering biometric screenings at more locations than before. As long as the health risk assessment was submitted at all, employees were credited $130 over the year, which equaled $5 per pay period.

2: THE PROBLEM

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Corporate HR viewed these initiatives as successful while they lasted, because UPHS employees did participate but, unfortunately, the initiatives have yet to provide the results UPHS is looking for that can reduce their risk of facing the 2018 health care reform Cadillac Tax. They have not yet made the necessary impact in the health of their employees and their overall health care costs.

Michele Fletcher, Rosemary Ossman-Koss, and the newly hired Jennifer Brady all believe that this was a result of insufficient funds and lack of support for reinvigorating these initiatives. This was the catalyst for hiring Jen because, before October 2011, there was no dedicated staff member driving these initiatives. Instead, Rosemary designed and implemented the initiatives from within the HR Benefits Department along with all her other responsibilities.

2: THE PROBLEM

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44

This is Where Our Story Begins

In order for us to understand why past UPHS initiatives were unsuccessful, we researched current literature on behavior change to learn about successful tactics to create change. We looked at various models to compare to UPHS’ past work and future plans for their health initiatives. In this section, we will highlight a few of the methods we research. For details on these books and other resources we used, refer to Appendix D: Literature Review.

2: THE PROBLEM

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46

Behavior Change Research In Nudge30, Richard Thaler and Cass Sunstein argue that the environment is the dominant factor that affects behavior. They propose that by purposefully designing spaces, behaviors can be manipulated— for both good and for ill. Termed “libertarian paternalism,” this approach allows for the freedom of choice but encourages our automatic impulses to make better decisions. For example, by arranging a cafeteria space so that the salad bar is the first thing seen, individuals are more likely to gravitate to the greens and eat better than they might have had the burgers and fries been first. They are still available but often take a back seat to healthier and more prominent options.

Organizations like Google have adopted Nudge-like tactics to affect 47 how their employees eat in the cafeteria31.

Another behavior change approach was outlined in the book Switch: How to Change Things When Change is Hard32. Authors and brothers Chip and Dan Heath argue that behavior change is a result of changing the environment and engaging the individual in why they need to change. They propose a 3-part approach to creating change— engaging the emotional nature of the individual to create motivation, appealing to the logic of the individual by providing clear direction, and creating a path that encourages and supports the new change.

While they argue for a Nudge-like approach implemented in the environment, the Heath brothers place significant emphasis on need to encourage employee participation. Organizations like Cleveland Clinic, Kaiser Permanente, and Pitney Bowes subscribe to this approach. In creating a culture of health at their organizations, they have promoted the need for all employees to be healthy to be the best they can be at their jobs, provided concrete steps for how to become healthy through various employer-sponsored activities, and created an environment 2: THE PROBLEM

that supports healthy decisions—especially in terms of food in the cafeteria and vending machines. The employers have significantly reduced the ability of their employees to make unhealthy choices.

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In Mindless Eating33, Brian Wansink outlines a small-scale approach that individuals can adopt that can add up to produce significant results over time. This differs from the more drastic approaches of changing the environment as encouraged in Nudge and the overhaul of both the environment and employee participation as explored in Switch. Instead, Wansink explains his definition of the “mindless margin,” a handful of a few hundred calories that we can easily overeat and that easily adds up to weight gains of 10-20 pounds over the year. Wansink argues that it is just as easy to adapt our environment to keep these calories in check.

He offers various tools as mechanisms for watching these calories, including lists and daily tasks. This approach to behavior change requires the emotional motivation of the individual while providing specific methods in order to accomplish the goal. Cleveland Clinic, Kaiser Permanente, and Pitney Bowes offer resources and classes similar to these through their wellness institutions and classes. This Mindless Eating-like method is only part of their much larger Switchlike approach to improving employee health.

These three models are drastically different from the “carrot” approach that UPHS employed in their past initiatives. More recently they have begun to adopt a “carrot/stick34” model, especially in their approach to the smoking cessation program. UPHS is requiring employees to go online to their employee health records to encourage participation in the smoking cessation program if they

do smoke. If employees do not touch their health records to report whether they smoke or do not smoke, they will be charged the default fee for smoking—an additional cost added to employee health care cost. This is to encourage employees to take greater ownership of their health.

UPHS’ initiatives have primarily been rewards based— changing behavior simply by offering an incentive to complete a behavior. This can be seen with the walking program, the $2 cafeteria coupon, and the success stories to name a few. Once resources ran dry, participation dropped and the initiatives stalled.

Unlike other comparable organizations within the health care industry, UPHS has yet to adopt a culture of health that is evident in places like Cleveland Clinic and Kaiser Permanente. Employees at UPHS remained motivated at only a surface level, based solely on monetary or goods rewards.

Current trends showcase the benefits of changing the work environment and offering free services to employees to encourage them to become more knowledgeable. This enables employees to take actions that cause little damage to their wallets but also provides a supportive environment for employees seeking to make changes for their health.

2: THE PROBLEM

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Understanding Our Client’s Solution: Our Design Process

50

We listened to our client as they described their desires for future initiatives, specifically the health cafeteria initiative, in an effort to identify patterns and their decision-making process.

In meetings early in our project, ideas were often tossed back and forth across the table on ways to improve employee health.

They argued that poor health was a result of lack of education on healthy eating. They stated that their employees eat terribly, a statement they made based on the information they handle in their department, such as insurance claims and the cost of benefits packages. They focused the initiative on educating employees to make better choices. By providing education and building awareness in the cafeterias in their three hospital entities—the Hospital of the University of Pennsylvania, Penn Pennsylvania Medical Center, and Presbyterian Hospital—they argued that they would impact behavior and create a healthier workforce.

Some of their ideas included branding healthy foods in the cafeteria with Well Focused stickers, their branded health program initiative for UPHS employees, and providing nutritional information for everything offered in the cafeteria. They also had plans in mind for offering discount coupons for the purchase of healthy foods, for example by choosing the turkey burgers instead of the regular beef burger employees could enjoy a $2 discount while also consuming far less fat and calories. They were strongly inclined to hang test tubes filled with sugar from the fountain machine, deterring employees from drinking regular sodas because of the sugar content. They believed that this would greatly impact change. These were just some of their original ideas for educating employees and making them more aware of the consequences of their choices.

The focus was to change employee food-related behaviors so they can make better choices and become healthy.

Along with these strategies, they planned to address health care reform and avoid the excise tax by tweaking their benefits package just slightly and increase the health of their employees just enough to remain under the excise tax threshold, aiming to remain under a 3% increase every year. Their approach is rooted in small and varied tactics in order to avoid “Cadillac Tax D-Day.”

As we listened to their plans, we identified patterns of thinking similar to the decision-making process they employed with their past initiatives that did not result in the necessary improvements in employee health. They seemed to be falling into the same pattern of behavior change tactics—incentive-based and education-focused initiatives that did not account for the actual needs of the employee population. They were following the same steps to impose a structure on employees to alter employee behaviors.

We believe and argue that their past initiatives were unsuccessful and that their future initiatives could be unsuccessful because their top down approach to designing solutions has never been supported by a deep understanding of the problem at the employee level. Their solutions were not evidence-based and did not include a focus on their employees’ health needs and concerns. In conversations we were privileged to be part of, our client appeared to be engaging the same cycle that previously led to unsuccessful efforts and wasted investments. Their decision-making processes were internally driven and not clearly rooted in evidence.

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Our Defined Problem

We argue that UPHS’ goal-oriented top-down approach to developing and implementing healthy initiatives for their employees has resulted in costly non-effective, non-sustainable and un- engaging programs. Their strategies must change in order to successfully reverse their multi-million dollar taxable trajectory.

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As a hierarchical organization, UPHS requires the approval of leadership before actions can be taken. For example, it took two years to convince leadership to create the position of Employee Health Advocacy Manager. In terms of our specific project, there were several tiers that had to be cleared before ideas could be implemented. Jen reports to Rosemary. Rosemary reports to Michele. Michele reports to Judy. Judy reports to Kevin. Kevin reports to Ralph. And finally Ralph reports to the Board of Trustees.

This explanation does not touch on the hierarchical structure below Corporate. The process of decision-making has to travel up through the lines of the hierarchy for approval, to individuals even farther removed from the needs and concerns of front line UPHS employees. Unfortunately, even ideas that managed to receive approval from the top tier could not be guaranteed as successful because they lacked a deep and meaningful understanding of how best to make change that sticks and that results in healthy and happy employees.

In past initiatives and in our project’s context, there was no understanding of the current culture, and therefore, no hope for sustainable change necessary for avoiding the 2018 Cadillac Tax. With this looming deadline, real action had to happen that would engage the community in creating a culture shift. All successful

behavior change examples started with a united message, significant changes to the environment, and visible support from leadership.

In order to know what to change, it is necessary to know what is happening to change. Our human-centered design process is rooted in a search to develop a deep understanding of existing culture.

We argue that only then is it possible to know where interventions should take place and what barriers are currently in place that are preventing the desirable behavior and outcome. With our humancentered design process, we aimed to tackle a two-fold thesis. First, we wanted to address our client’s defined problem—designing a health cafeteria initiative to impact employee health and lessen the threat of the 2018 Cadillac Tax. Second, we needed to acknowledge our client’s existing decision-making structure and walk them through our process to see the value it could bring to impacting employee health.

2: THE PROBLEM

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KEY PLAYERS

56

Visualizing our work. in the MiD studio.

K

UArts MiD At MiD, we practice a human-centered design process that identifies the underlying needs of a target group. Our design process includes several general phases that lead to discovering design opportunities and producing results. The process is organic, iterative, and applied based on the specific needs of the user population. We learn by involving all stakeholders early in the process. This is done with various techniques, such as contextual interviews and observations of the user’s environment, to identify opportunities for design interventions. Focused on the user, our work uncovers unmet needs and emphasizes rapid prototyping for testing and implementing ideas. Through our design methodologies, we gain a comprehensive understanding of the user and their needs. This allows us to create a better platform for designing success.

The Human Centered Design Process

3: KEY PLAYERS

Current

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UPHS Human Resources: Lauren, Rosemary and Jen (L-R)

The Client Our client was the Human Resources Benefits Department of UPHS, the University of Pennsylvania Health System. The project was introduced to us because of a previously established relationship with them, a studio project where Sara had been a team member.

Because of the emphasis on our human-centered design process, her semester’s work with the team sparked excitement and a new dedication to a culture of change at the organization, so it was a natural fit to partner with UPHS once again but this time on a foodfocused initiative, a particular area of interest for both of us.

We met with them weekly throughout the semester to discuss next steps and to share our design insights with them as we worked to design a realistic healthy cafeteria initiative.

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Rosemary Ossman-Koss

Rosemary is the Director for Corporate Employee Benefits at the University of Pennsylvania Health System. She has been working at PennMedicine for 20 years. From her position, Rosemary piloted many of the past health initiatives, including the walking program, free biometric screenings, and the online health risk assessment.

She states that UPHS will not pay the $12 million excise tax they are currently facing, so she believes efforts must be explored and put into place that will increase the health of employees but also decrease the premium health care plans currently offered at UPHS. 60

Jennifer Brady

Jen was hired in the fall of 2011 as the UPHS Employee Health Advocacy Manager, the first position of its kind at UPHS. As a registered dietician and fitness specialist, she believes that there must be a culture change at UPHS in the way that employees think and act about health and wellness. She believes that by doing things the right way, healthy-focused initiatives can have a huge impact on healthcare costs for large organizations. Jen has hit the ground running in creating a smoking cessation program and a breast pump program for UPHS employees. Next on her list is to implement the healthy cafeteria initiative.

Lauren Johnson Lauren is a member of the Talent Acquisition department and an advocate for MiD’s continued work with UPHS. She served as the liaison between UPHS and MiD for our project, helping us arrange meeting times and spaces throughout the semester.

She familiarized us with the terminology of this culture and the various hierarchies we should be recognize in order to move our project forward.

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UPHS Corporate Structure, Rosemary and Jen circled

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UPHS Employees at HUP

The User We chose to focus on one hospital as our pilot. We chose UPHS’s largest entity, the Hospital of the University of Pennsylvania (HUP). With more then 6,000 employees, HUP has the highest population of UPHS employees that would be affected by a healthy cafeteria initiative. Our goal was to engage the employee population in order learn about the obstacles they face when it comes to being healthy at work. Our findings would ultimately aid in better informing decisions made by HR. The employees at HUP are only a portion of the user population targeted by HR’s health initiatives. Since we are working with Corporate HR, any initiative that we create will span all entities in the health system.

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Spruce Street Cafe at HUP

The Cafeteria Vendor

Each of the three hospital entities employs a different vendor, making the idea of a corporate-wide cafeteria initiative even more difficult. HUP contracts Morrison Healthcare Food Services, a member of the Compass Group as their vendor. This cafeteria is one of Morrison’s prize accounts and as their premiere healthcare industry food service space they work to make it the best it can be.

Throughout the semester, our interactions with the vendor were designed to help us learn about their plans and willingness to collaborate with HR and with us on a health cafeteria initiative.

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ACTIONS

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Actions Section: Client Management

In the Actions section of our book, we describe the various interactions with UPHS employees, a.k.a. the user, and our client.

As we built trust with our client, we were given more freedoms to interact with various user groups. Throughout our process of discovering the source of our client’s ineffective initiatives, we worked to provide insight into our human-centered design process and emphasize its good in uncovering meaningful data to inform the development of successful initiatives. We focused on making the information we gathered tangible. In this section of our book, we will outline the major interventions we held with our client in order to create buy-in and a shared understanding of the goal for our work with UPHS as well as our methods of data gathering from UPHS employees to inform our designs and recommendations.

We used various techniques to engage our client and walk them through our process. As we mentioned previously in the introduction to our client, their method of developing health focused initiatives in the past involved recognizing that change must be made because of health care reform, assuming reasons for employees’ poor health behaviors, and implementing plans to address those behaviors that needed to be changed through education. Our argument is that the UPHS HR Benefits Department decision-making process has resulted in poorly developed initiatives that do not address the root cause of poor health. Instead, dollars have been spent but behaviors have not been changed to counter the threat of a 2018 excise tax. This being said, we designed our interactions with our client to highlight the benefits and improve success rates by encouraging them to adopt an alternative method of decision making.

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The above timeline shows our designed interactions with the user and client throughout our 17-week project. The top interactions focused one gathering data from UPHS. The bottom interactions focus on engaging our client, educating them about the HCD process, and helping them gain a better understanding of theit employees.

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Understanding the Client We chose to interview each of our clients individually to better understand their background, motives and intentions. There was initial hesitation on the part of our client in being interviewed individually. They preferred to provide a united front, so it took a significant amount of cajoling and emphasizing its need for our thesis to finally receive a yes. Our goal walking into each interview was to provide prompts for both Rosemary and Jen. From these interviews, we developed a clearer understanding of our client’s approach to addressing the growing health problem that will severely penalize them in 2018.

Gaining a better understanding of Rosemary and Jen’s background and personalities allowed us to better interact with and engage them in our process. As we continued to understand the structure of UPHS, we began our employee research in the Hospital of the University of Pennsylvania cafeteria.

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Design Challenge: Learning through Observation Cafeteria Observations We began our research where we could in the public space of our focus, the Spruce Street Café located on the 2nd floor of Founders Building in HUP. 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.

Our first phase focused on becoming familiar with the cafeteria space itself, including the foods for sale, the process of finding and purchasing foods, and the employees present during lunch. Our 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 report of the current behaviors practiced in the cafeteria.

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Phase I

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We began our observations obtaining a general understanding of the cafeteria space. We immersed ourselves in the space observing and documenting the users and layout. The first few days were spent adjusting to the space then, we began to notice patterns. We created a map of the cafeteria and its seating area in an effort to help document these patterns. The development of this map included what type of food was served and its relationship to the other food “stations.� By the end of this first phase, we developed a greater understanding of the space and began to identify patterns in terms of busy times and popular stations. This included a schedule of the various food stations (the cafeteria is on a 5-week schedule, rotating stations every week) and an understanding that the grill is, by far, the most popular food station. The maps we created in this phase were used to help identify and record these patterns.

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Phase II

We shifted our focus to collecting specific data we could quantify. The second phase delved more deeply into the actions of individuals after purchasing their food. These categories included:

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•

What people choose (using the cafeteria floor plan)

•

ho eats there (employees, patients and visitors, contractors, W or doctors)

•

How long people eat

•

Who people eat with (alone, pair, group, or to go)

By recording this quantitative data, we were able to track trends over time and make generalizations about the information.

Through this phase, we discovered another level that would be useful: specific user tracking to analyze how the cafeteria space is navigated. We began tracking a user’s path once entering the cafeteria.

Spruce Street Cafe Observation

NOTES

Saturday | 01.14.2012 | 12:15-12:45pm WHAT

one soup

HOW LONG description

time (in minutes)

5

15

25

35

45

closed

Everyone was at their table for longer than 20 minutes.

closed

79 WHO

WITH

Majority of cafe-goers were patients and visitors.

Very few nurses and/or clinicians in scrubs.

No one was sitting in the lower level seating.

Only one or two individuals were sitting at the bar seats.

patients and visitors

alone

contractors

pair

doctors

group (+3 people)

employees

to go

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Phase III

The path observation attempted to track and identify user behavior. Our end goal was to see if there were any correlation between the data we have been recording, specifically food choice, profession, and time spent in the cafeteria. Over 50 users were tracked, but what we found was that the majority of users we could and did track were not employees of UPHS. There was a huge population of doctors present in the cafeteria, both in white jackets and in scrubs, who are not UPHS employees.

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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

Action Station Grill

3. Fountain Soda Waited in line for both items.

Ate rather slowly, very reserved.

3 1

2

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Staff 1 | Female | 30-35 years old Ate alone for 20 minutes.

Meal:

2 3

1. Grilled Cheese

Grill

2. Raw Vegetables 3. Fountain Soda

Salad Bar

Debated on choosing soup, seemed not to be interested in any of the available options. Waited in grill line for grilled cheese.

1

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Cafeteria Results

While gaining quantitative data about the cafeteria was important, we found much more than our client had expected.

We presented a report to our client to provide them our data and general cafeteria observations. What we learned most importantly is that only a small representation of UPHS day shift employees is ever present in the cafeteria during lunch. Additionally, our observations led to the following conclusions: •

urses and other clinical direct patient care employees did N not frequent the cafeteria.

• A significantly small portion of HUP employees visits the cafeteria for lunch.

• T he information station, a pillar located directly in front of the cafeteria entrance, was ignored by almost all users. Paths diverted to either the right or left. The station never received any attention.

• I n regards to layout, you must pass the grill and unhealthy stations prior to getting to the salad area or seeing anything fresh.

• T he cafeteria employees serve very large portion sizes.

Multiple servings were given, filling the plate instead of providing a single serving.

• W ater was rarely the choice beverage. Most people chose diet bottled beverages or juice.

These conclusions led us to propose interventions and opportunities that could be implemented both inside and outside the cafeteria.

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Engaging Our Client: Designing Opportunities In order to reach our goal of enabling our client to understand their employees’ needs, we needed to engage them in the design process. We designed a short presentation of our findings and proposed interventions and opportunities to them.

We then designed and conducted an activity to further engage the client and demonstrate how the design process works.

Our first strategy was to share our observations and propose various intervention ideas that could impact the eating behaviors we noted during our time in the cafeteria. We began with the synthesis of our observations. We gave a short presentation of our observation methods and the final results. We then walked them through all three phases of the cafeteria observations and passed around the documents we created to help them to visualize the various steps of our process.

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The Space: Overall

The entire cafeteria space, pages 2-3

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The Space: Food

The cafeteria plan, pages 3-4

As a comprehensive conclusion to the observations, we provided them with a document that was an easy reference to the information we gathered. The document was a compilation of the quantitative data they are familiar with as well as qualitative data, which could better inform their decisions. It was structured in three main sections: the space, the synthesis of our observations, and the general observations. We also provided a supplement that included our raw observations we derived during our synthesis process. After the presentation of these documents we began the second part of this meeting: engaging the client.

The overall goal of this meeting was to report our cafeteria findings and to engage our client in our HCD process. We began by introducing a document we titled Opportunities and Interventions that described ideas based on our research in the cafeteria. This was done to help expand their scope of possible intervention in the cafeteria and also ones outside of the cafeteria. We presented a series of ideas, which ranged from ideas that they originally proposed and sounded familiar to intervention ideas outside of the cafeteria in an attempt to showcase the range of possible interventions that could be designed and implemented to affect employee health.

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What People Choose Most people get their food from the grill, action station, or salad bar.

Who 88

Most of the people who eat in the cafeteria work at HUP.

How Long

The average time spent eating in the cafeteria is 20 minutes.

With

Most people eat in groups of 3 or more people.

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Through our observations we began to identify opportunities that could become part of our final deliverable to UPHS. To generate Opportunities and Interventions, we gathered our results and looked at what other organizations were doing while keeping our client’s goal in mind. This document was designed to provide our client with ideas that couldinspire and help them understand the scope of the project could reach further then the cafeteria. The ideas generated for this are included in the ‘Step, Jump, Leap’ section of our final client document (see page 152).

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After sharing our intervention ideas, we hosted an activity meant to engage our client in the process and involve them in designing next steps for the project. In this activity, we asked them to vote on our various intervention ideas. They were each given a set of post-its, each color representing a different category—one for most feasible, one for most impactful, and one for their favorite.

In the end, each idea had at least one vote, and the discussion opened up to imagine a series of possibilities that could impact the health of UPHS employees, not simply education and awareness-based initiatives. This was our first major step in engaging our client in our design work, and they responded tremendously well to our activity. As captured in the image, Rosemary was laughing and enjoying the activity the entire time.

Our actions at this meeting allowed us to gain access to the vendor and to HUP employees. Specifically, we argued for the need to speak with employees outside of the cafeteria to learn equally as much about what employees do if they are not visiting the cafeteria for lunch.

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Opportunities and Interventions Activity with Lauren, Rosemary, and Jen

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Design Challenge: Nurse Focus Groups

Through our cafeteria observations, we understood that a significant portion of HUP employees do not spend time in the cafeteria. The absence of many frontline, primary care workers led us to want to know more about the eating patterns of employees not present in the cafeteria. By learning more about the eating patterns of various employee groups, we argued that we could better identify opportunities that could encourage healthier behaviors and change existing unhealthy behaviors. Again, without knowing about current behaviors, it is impossible to know if and how to change them.

This section of our book outlines the process we followed for gaining support to reach out to frontline hospital employees, but we also want to emphasize how this process of engaging employees led to an incredibly rich understanding of the struggles nursing employees in particular face when it comes to eating healthy at work. This one-on-one engagement with personnel, while timeintensive, yields greater feedback than survey-based data gathering methods. The face-to-face contact highly values the contributions made by employees and allows for meaningful facilitated dialogue within the group. It avoids the problems faced with survey-fatigue, including low response rates. This approach can serve as a prototype for anyone within UPHS wanting to reach out to busy employees and also gain a deep understanding of frontline behaviors that can inform actions at various levels within the organization.

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Day (11:00am: Day A) Unit located close to the Cafeteria

Evening (4:00pm: Day B) Night (12:00am: Day C) Day (12:30pm: Day A)

Unit located far from the Cafeteria

Evening (5:30pm: Day B) Night (1:30am: Day C)

Preparation 94

In order to access busy frontline employees, we needed to have the approval and support of HUP management. We searched for the ability to see firsthand the hospital culture in action, and we chose to begin with nursing staff because they comprised the largest employee demographic in the hospital, with over 2,000 nurses out of roughly 6,000 total employees. 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.

As we worked closely with Jean Romano, Director of the Nursing Network at HUP, to secure times and locations for our focus groups, we developed a series of tools and a plan for them. We asked for 20-minute sessions with 5 nurses present at each session. We divided the sessions into two parts—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.

95 Hospital Map: Food Locations around HUP

Our tools for gathering information included hospital maps we created with the various food locations immediately around the hospital; a questionnaire for us to fill out that asked specifics about where nurses got their food from, where they ate it, and how food fit into their days; and our notebooks and a recorder to help us capture any moments or information beyond the scope of our data gathering tools. The questionnaire was a tool for us, the designers, to use as a way to facilitate conversations instead of silo-ing responses for each individual nurse. By using the guiding questions from the questionnaire, we hoped to engage them in a conversation that would yield more qualitative results as well as quantitative information. We also provided lunch or snacks as an incentive to meet with us and answer our questions. Jean Romano shared with us that all nurses love food and that by bringing free food, we would immediately become heroes and receive the full attention of the nursing staff.

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UArts + Penn Medicine Wellness Initiative Name

Date

Department and Position Shift

Contact Information

Location Where do you get your food from?

Where do you eat your food?

HUP Cafe

HUP Cafe

Food Cart

Workspace

Pack

Break Room

?

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?

Other

Other Always

Never

Time

Always

Never

Company

How long do you spend eating?

Who do you eat with?

60” 0” Alone

Pair 45”

15”

In a Group

30”

?

Other Always

Never

Intake When do you eat at work?

Beginning of shift

End of shift

Data Gathering Questionnaire

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The breakdown of nursing units we asked for included both surgical and medical during both the night and day shifts on units both far away and near to the cafeteria, as visualized in the diagram.

Surgical units provide more immediate and critical care, such as immediately after an operation. Medical units offer intermediate care, often for patients from surgical units who are transferred to medical units after their critical care has passed or patients who are in the hospital for less invasive procedures. We originally asked for 6 units with 5 nurses at each unit, adding up to a total of 30 nurse interviews.

Visualized above, our requests ballooned to include a total of 12 units, 24 focus groups, and the potential to interview 120 nurses.

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Execution

We imagined gathering 5 nurses at a time for a total of 1520 minutes for a snack and interview which could eventually lead into a discussion. Instead, we were unable to predict the number of nurses present at one time or how long they could stay and speak with us. Our first focus group was on a surgical intensive care unit where nurses are accountable for post-operation patients often in need of immediate attention. We spoke with anyone who could spare the time to sit down (or often stand) and chat with us while gleefully eating the food we provided. Some nurses did not have the time to sit but would shovel food into their mouths while nodding along enthusiastically as a fellow nurse explained their pains. Nurses walked in and out. Some were called away to tend to their patients while we were still interviewing them while others were delayed because a patient coded on the other side of the unit. We had to adapt to an environment where we had no control over the format and attention of the participants. Their breakrooms, where we most often hosted our focus groups, were almost always cramped and loud, with an intercom system to summon nurses whenever they were needed. We facilitated discussions as best we could but also encouraged participants to talk with minimal interference from us as we gathered data to build a picture of the nursing culture at the hospital.

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“They want us to be corporate, but we aren’t” -Diana, RN

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Nurse Focus Groups at HUP

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Results

In the end, we interviewed 107 individuals—83 Registered Nurses, 6 Certified Nursing Assistants, 6 Nurse Secretaries, 5 Nurse Managers, 1 Assistant Nurse Manager, 1 Nurse Support, 1 Clinical Pharmacist, 1 Doctor, and 1 Volunteer. We identified patterns from feedback from all medical staff we interviewed, but we focused on developing the voice of the Registered Nurses—the largest demographic represented in our focus groups.

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We began synthesizing our pile of data by listening to the audio clips and reading through our notes to identify important quotations, including obstacles and opportunities. We created quote cards in order to keep track of all the voices we were hearing. {Picture of Quote Cards} They were a helpful resource in making sense of key things we heard from nursing employees, especially as we began to identify patterns.

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A major undertone we began to hear was an “us” versus “them” mentality—frontline employees versus corporate employees.

Generally, there appeared to be a misunderstanding on the part of corporate employees of what frontline employees want and need.

In terms of health and food, we generally observed that most all nursing staff had an understanding of healthy eating and often practiced eating well from day to day. This contradicted some assumptions of our client, particularly in relation to a lack of knowledge about healthy eating. In order to deepen our understanding of struggles faced by nursing staff, we continued our synthesis.

Time: Nurses do not spend much time away from their units and rarely take longer than the amount of time it takes to speedily eat their snacks. They often eat whenever they get the chance, so there is never an opportunity to leave the floor to pick up food if they forget to pack.

There is a high level of anxiety for nurses who do not bring food to their units because they fear being unable to find food during their shift.

Distance: Because of the layout of HUP’s various buildings, the distance between many units and the cafeteria is great. The far distance and amount of time it takes to wait on an elevator/get to the cafeteria both hinder nurses’ ability to purchase foods from the cafeteria.

Cost: Nurses often noted the high cost of cafeteria food, particularly noting the cost per pound of salads that deters them from purchasing salads in the cafeteria. They pack their foods because many claimed to be economically conscious.

Health: Most all nursing groups claimed to understand what foods are healthy for them to eat. They often cited not wanting to eat fatty and fried foods because of how badly those foods made them feel while at work. Their struggle with health dealt with a lack of healthy options in the cafeteria and even at various food locations in the vicinity of the hospital. Both day and night shift nurses faced the problem of access to fresh, healthy foods.

Unit Culture: Nurses, especially new nurses, do not want to spend time away from their patients. They have a strong sense of responsibility for their patients, especially since they are the only position in the hospital in charge of 24/7 bedside care. Not only do they not wish to be away from their patients for long, but they also feel anxiety and guilt for leaving another nurse with double duty while they take a lunch break.

Their individual unit cultures often dictate these levels of anxiety and guilt.

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By externalizing data and categorizing themes, we also identified some significant differences between medical and surgical units. We chose to describe those differences to our colleagues, our client, and ourselves by building nurse profiles.

Profiles are a component of our design process that generalizes feedback from the many users we engaged in our focus groups and provides a contextual representation of the data. The following three profiles represent the general nursing characters we interviewed and the main struggles they face in terms of eating well while at work.

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“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.”

Nick Registered Nurse, Medical Unit Typical Shift: 7:00am-7:00pm | 3 days a week

Where he gets his food:

Where he eats his food: outside food 10% cafeteria

5%

other

3%

pack

85%

breakroom

5%

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Due to the nature of surgical units, Nick almost always packs his lunch. In fact, the days when he forgets to bring his lunch from home, he has a great deal of anxiety about how he is going to get food and when he will manage to eat it. The culture on the surgical unit is patient-centered and patient-devoted. He never leaves the unit because there is no time to leave. Each nurse is assigned up to four patients at a time depending on their level of need. When taking a break, Nick has to ask a co-worker to cover his patients as well, doubling their patient load, which causes him significant guilt.

He often eats his packed lunch quickly in the unit breakroom to be available for emergencies or any questions about his patients. He then returns to his patients right after he finishes his food, nowhere near the 30-minute break they are given. At times, he can spend as little as 5 minutes eating before returning to his 12-hour shift because duty calls and he must get back to tending to his patients.

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“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.”

Kate Registered Nurse, Surgical Unit Typical Shift: 7:00am-7:00pm | 3 days a week Where she eats her food:

Where she gets her food: outside food 2% cafeteria

3%

pack

95%

breakroom

100%

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Kate’s experience on a medical unit allows a little more flexibility when it comes to eating. The majority of the time she packs her lunch because she prefers her own food. She likes to eat healthy and is appalled by the lack of fresh, healthy foods in the hospital cafeteria. While she has the opportunity to leave the unit to pick up food and then return to eat in the breakroom, she prefers to have the time to sit and rest. She is on her feet working all day and any time that she forgets her lunch and has to walk to purchase food takes away from her time to relax. Medical units often implement a buddy system that encourages nurses to take their full 30-minute lunch break, but Kate stays on the unit most days to be available for questions and to continue being present for her patients. Plus it allows her more time off her feet.

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“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.”

Caroline Registered Nurse, Surgical Unit Typical Shift: 7:00pm-7:00am | 3 days a week

Where she gets her food:

Where she eats her food:

outside

25%

pack

75%

breakroom

100%

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Caroline works the night shift, from 7p.m. to 7a.m. She brings her own food most of the time, but especially on weekends, night shift nurses order food in from one of the many late night locations around the hospital, including pizza, wings, and Thai food. In fact, if she doesn’t bring her own food, her only option is to order in unless she wants to walk up the street to Wawa. Since CHOP closed their McDonald’s, Wawa is the only place that is open 24/7. Many nurses do walk to Wawa but only if they have a buddy to walk with them since it is late and several blocks up the street. Caroline claims that night nurses are the “forgotten shift.” Because of their shift times, she cannot even begin to think about food until around midnight, right when the cafeteria closes. Even if she is having an easier night, the cafeteria doesn’t have any freshly made foods after 7p.m. Her main struggle is not just a lack of fresh, healthy foods but a complete and total lack of access to any food.

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After our focus groups were completed, we reflected on our preparations and execution. We gathered invaluable data by using a face-to-face method of information gathering, but we also had to be flexible and easily adaptable to fit into the schedules of frontline staff. We often had to cut our sessions short or feverishly scribble notes while everyone carried on various pockets of conversations.

We learned that by providing various guiding questions and a little context for our project, employees were more than willing to be engaged and share their opinions with us. In fact, many noted how valued they felt because so many thought we were meeting with them to speak about patient food. When they learned that our focus was on their needs, they felt appreciated. Because we took the time to visit the nurses in their spaces and to accommodate to their schedules, they each took the time to seriously consider the answers to our questions and provide honest feedback on how best an initiative could be designed to fit their needs.

Building on the relationships we had established by reaching out to management and staff at HUP, we were able to replicate parts of this process with Support Staff in order to learn about another employee demographic at HUP.

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Design Challenge: Support Services Interviews

Using the tools developed for the nurse focus group interviews, we were able to interview another demographic, Support Staff. In our meeting with Mia Gonzales-Dean, the Director of Support Services, we shared our process of engagement with our nurse focus groups. We showed her our engagement materials and discussed the kinds of questions we were asking and our intentions for asking each question. She was intrigued by our ability to understand their culture by integrating ourselves into it as seamlessly as possible. She admired our quest to understand the struggles faced by the nurses and shared with us her desire to learn ways to increase the health of her employees. She shared her messages to her employees—imploring them to quit smoking because she wanted them to be around a very long time. She has created a family with her staff.

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Because of her desire to learn more about her employees, Mia gave us the go ahead to schedule sessions with a small representative selection of her 800 Support Staff employees. Mia wanted to learn more about her employees’ eating habits because she is so intimately involved in promoting health amongst her staff.

Support Staff eat lunch and take breaks “as operationally feasible.” They are allotted one-hour lunches, but they have staggered schedules because they need to be available throughout the day to help with hospital and patient needs. Support Staff is comprised of various professions and includes 118

• Transport Services is charged with moving patients from one place to another, including lifting them from their hospital beds to transport devices.

• Environmental Services provides the upkeep and janitorial services of all hospital facilities.

• Materials Management takes care of all linens for hospital rooms and materials for hospital units and rooms.

• Reception Team mans the information station at the front of the hospital and handles any general questions and directions for patients and their visitors.

• A udio and Video Services technically monitors the safety and security throughout the hospital.

All these needs are ongoing 24/7 so Support Staff schedules vary from day to day based on the hospitals schedule and needs.

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Meeting with Mia Gonzales, Director of Support Services

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We altered our approach but continued to place an emphasis on the value of face-to-face data gathering due to Support Staff schedules. The feedback we received from the nurse focus groups supported its benefits, namely a sense of ownership and contribution to a process that is meant to provide support to frontline employees. We set up 15-minute individual interview sessions for a total of 12 employees. Our interviews were located in the Support Services Conference Room in the basement of HUP. Our focus was to visit with them where they already are to eliminate any struggles they may have had with their work schedules. We valued their opinions and wanted to understand and acknowledge the perspective of Support Staff in our research.

Execution

These one-on-one interviews were based around their cafeteria usage but also evolved into a conversation about the current food state at the hospital. We designed the interviews to be fast paced and informative, to ensure we did not impose on their break time—especially since most support staff divisions require significant manual labor. The individuals interviewed supplied several insights into the working culture of Support Staff, particularly the on demand nature of their jobs. Often many of the tasks they are charged with have an immediate deadline, which makes it difficult to plan meals or enjoy much leisure time during breaks.

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Support Services Interviews, Transport Services

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Results In total, we spoke with 12 members of the Support Staff team. We spoke with 5 employees from Patient Transport Services, 6 employees from Materials Management, and 1 employee from Audio & Video Services.

We began to identify different conversational overtones between nursing groups and the Support Staff. We heard about their desire for healthier fresh foods in the cafetera and more extensive salad bars.

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In our Support Staff interviews, we heard comments like “Pizza is healthy because it has bread and bread is healthy” or “There is no way I’m going to pay $8 for a salad when I can spend $3.50 on a hot dog” or “The cafeteria doesn’t offer any foods that I can eat because of my health.” Often there appeared to be a lack of understanding of current health related information—especially in relation to the popularity of whole grains, meatless proteins, and vegetarian and vegan diets35. In both groups, we heard the theme of struggling with the cost of healthy foods. Support Staff themes fell into many of the same categories as did nursing staff obstacles.

Time: Support Staff are allotted an hour-long lunch “when operationally feasible” but often face inconvenient lines in the cafeteria. They often pack their own food because of its ease and their ability to spend more time off their feet during their breaks.

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Cost: Support Staff noted the high cost of cafeteria food and also the incredible cost of health food in general, even at grocery stores.

They often prefer to pack their own lunches to save money.

Health: Many Support Staff either did not have any real health concerns with what they ate or, on the other side, were faced with various illnesses and/or chronic diseases that prevented them from eating many of the foods in the cafeteria. One interviewee cited that they tend to eat at the food carts outside of HUP because the guy knows what she can and cannot eat.

Hospital Culture: Because of the nature of their jobs and the status of the hospital, all Support Staff employees must be “on call” at anytime—even during their breaks. While a significant amount of back office work goes into staggering their schedules, the needs of the hospital are unpredictable. As Mia said, Support Staff take their lunch and breaks “as operationally possible.” They suffer from similar constraints that are innately part of the hospital culture, especially in terms of demands on their time.

Most Support Staff have a similarly structured workday from day to day. The beginning and ends of their days are busy while their workload slows down around lunchtime. This is often when patients are in their hospital rooms having their own lunches.

Lunchtime typically falls between the hours of 12:00pm and 1:00pm, the cafeteria’s busiest time. While Support Staff do have a full hour for lunch, upwards of 20-30 minutes can be spent transiting to the cafeteria and waiting in lines for food and paying. Many of the employees we spoke with shared that they do not frequent the cafeteria. They noted several of the same obstacles to eating in the cafeteria that nursing staff outlined, including the high cost, poor health choices, and lack of time to go to the cafeteria. Often Support Staff, depending on their profession specialty, eat lunches that they have brought from home in the Support Services conference room or other similar areas on the bottom floor of HUP.

To further explain our data gathered from the Support Staff interviews, we created a two profiles to represent the voice and perspective of Support Staff employees. This enabled us to continue to describe various employee characters from the hospital environment who would be affected by a healthy cafeteria initiative.

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“When you work for HUP, you know it’s 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.”

Maureen Materials Management, Support Services Typical Shift: 7:00am-3:30pm | 5 days a week

Where she eats her food:

Where she gets her food: outside food 25% cafeteria

16%

pack

59%

cafeteria

24%

breakroom

76%

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Maureen works the day shift in HUP’s Material Management department. She deals with the cleaning and distribution of linens to the hospital. She works five days a week and has a structured work day of 7:00am-3:30pm. The beginning and ends of her shift are busy due to shift change but workload typically slows down around lunch time. Most days, lunch time falls between the hours of 12:00pm and 1:00pm but some days the rate of work does not allow this. She rarely goes to the the cafeteria, mainly because of its busyness during her lunch hour. Instead she usally packs her lunch or gets food from the surrounding food carts.

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“I try to pack my lunch because I prefer the foods that I prepare for myself. I am trying to look after my health because I can’t eat too much salt, and everything in the cafeteria is filled with it. Plus I don’t have much time during the day so I often eat alone at my desk so I can get my work done.”

Mark Administrator Typical Shift: 8:00am-5:00pm | 5 days a week Where he gets his food:

Where he eats his food: cafeteria

23%

cafeteria

23%

outside

19%

outside

21%

other

5%

other

8%

pack

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breakroom

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Mark works as an Administator at Pennsylvania Hospital. His day is mostly dictated by meetings and appointments that are scheduled for him. Due to the small size of his department, he must coordinate with coworkers to have time to eat. He usually eats whenever he can find time in his busy schedule. Mark always packs his lunch, this is due to his budget but he likes that it enables him to eat and snack at his workplace when he is available.

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Engaging Our Client: Understanding the User

Both our nursing focus groups and Support Staff interviews exemplify a process of gathering data in such a way that values the input from participants. The act of engaging face-to-face and listening intently produces a rich set of data that uncovers the needs of a group—in this case frontline employees who are often not included in the decision making process.

Our second major design intervention with our client included providing them with a better understanding of the user.

From both the nurse focus groups and individual support services interviews, we gained the knowledge of the hospital culture and how food fit into that. We learned about the biggest obstacles they face when it comes to being healthy at work, and we wanted to ensure that their voices would strongly resound with our client.

The strategy for this intervention was to allow the voices to speak for themselves. We designed obstacle and opportunity quote cards that we categorized into various themes, stacked them on the table, and asked our client to read over them. We also built employee profiles and printed copies for each of our clients to read over to better paint an accurate picture in their heads of what UPHS employees are like.

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Their response was encouraging. As they read through the quote cards and as we talked through the employee profiles we constructed, our client began to identify for themselves the major obstacles that employees face when it comes to healthy eating at work. They valued how our process as able to uncover the real struggles employees face on the front line, something they do not have the ability to do themselves.

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Lauren pointed out that listening to the voices of the employees helps Corporate “focus back on the patients and their care. Everything comes back to that--even the way that our employees are supported.” Rosemary asked us if we would like to continue our research and learn a little bit about employees from other UPHS entities, considering that any initiative would affect all 13,000 UPHS employees—not just employees at HUP.

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Design Challenge: Health Fair Table

We were offered the opportunity to have a table at the UPHS health fairs, events hosted at each UPHS entity that attract vendors to promote their services and educate employees on strategies for becoming healthy. Featured tables include vendors explaining their new insurance plans, discussing various medical procedures and their benefits, and offering free massages. UPHS HR Department was also present to explain the benefits plans for the upcoming fiscal year and the process of open enrollment for employees. Health fair tables occur every year in the beginning of April, the two weeks prior to open enrollment. Health fairs provide employees with the opportunity to learn about health related services while they are at work—so they can make educated decisions on their insurance plans and walk away with bags full of free swag.

There were 7 health fairs where we were offered a table, and we chose to focus our efforts on the three hospitals—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 serve as the focus in the development of a health cafeteria initiative.

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Preparation

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 and/or healthy eating initiative. We also wanted to provide our client with another tactic for gathering the employee perspective and showcase yet another method that can be used to craft more meaningful and more effective initiatives in the future.

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We began by designing tools that could provide us with quantitative data quickly and efficiently. Not only did we want to be able to report results quickly but also we had to design for the chaos of a health fair. Our client warned us that employees would drop by our table in search of a freebie to add to their collection of swag from the other 20 tables. Our goal was to engage individuals by making them feel that their voices were being heard and used to create a healthy workplace environment based on what they need the most. We had to design for quick interactions in a manner that could gather data efficiently.

We designed tools for gathering this information: 1. A “coin machine” was for individuals to use colored puzzle pieces to answer our quantitative data questions—the 3 questions we asked during our focus groups with nurses. The puzzle pieces were painted in 5 different colors, representing general job categories to help us identify any differences between main hospital employee groups. These included direct patient care, indirect patient care, administration, support staff, and other. We designed it for employees to choose their corresponding color puzzle piece and use a piece to answer each question and let us know where they get their food from, where they eat their food, and who they eat with. These questions were designed to gain insight into the current food culture at the hospital in the various groups of employees.

2. Prompt cards asking employees what obstacles they face in eating healthy at work and in being healthy at work. These cards were to help us identify common struggles that employees face while at work that could inform the next HR healthy initiative.

Our goal was to present our client with the seedlings for future plans rooted in the concerns and struggles of employees, again as a way to walk our client through our process and encourage them to seek research and hard data from employees before designing any future initiatives.

With these two tools, we planned to engage employees and hoped to excite a handful of them to further their discussion with us and to provide a voice of the employees in designing an effective healthy cafeteria initiative. By understanding the current food culture, we hoped to paint a picture of what employees need to be healthy at work. That way HR’s future initiatives could effectively address the barriers hindering their employees from being healthy.

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Health Fair Tables, Game Theory Data Collection

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Execution

During the 2 weeks of health fairs, from April 2 to April 13 before open enrollment for benefits plans, we traveled to the three hospital entities for their health fairs. While our project focused on HUP, we wanted to compare to see if there were similar circumstances at all three entities. Because we were working with Corporate HR, all initiatives out of their department had to be offered throughout the entire health system, so we wanted to begin to search for and to identify similarities and differences between the hospital environments that might dictate the methods HR will use in creating a healthy workplace for their various entities.

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Health fairs ran from 10am to 2pm. At HUP, we were located on the mezzanine. In the other two hospitals, their health fairs were hosted in the cafeteria spaces. We set up shop between various vendors who were encouraging individuals to have a colonoscopy done to protect their colon health, brush their teeth more effectively to take care of their heart, and have their blood pressure and BMI checked on the spot with RNs from Occupational Medicine. Each person who approached our table heard our spiel: “We are graduate students working with HR on a healthy cafeteria initiative. We are here today to learn more about the food culture at the hospital to inform where HR should focus its efforts in building a healthy workplace for its employees. We would love for you to participate and help us better understand what is happening now and what some of your greatest obstacles are to being healthy while at work.� We each must have repeated some variation of this speech hundreds of times.

People were drawn to our table because of the colorful puzzle pieces and were intrigued by the possibility of playing a game. Some went as far as thinking we were actually asking them to assemble a puzzle. We were often quoted as being “cute,” “fun,” and “creative,” but we also managed to engage several hundred employees from various occupations throughout the health system who took our mission and our questions seriously.

On a side note, between the various health fairs, we made slight adjustments to our data gathering tools. For example, we never used the physical timeline because it was the most confusing to employees, added to the time we asked employees to stand at our table, and honestly, there was not enough room on the table for everything. Also, we created a fourth “coin machine” box to provide easy prompts for employees to share their biggest obstacle to eating healthy while at work. Originally we asked this question with the prompt cards, but many individuals did not take the time to fill it out or left after the puzzle piece activity. Lastly, we encouraged participation at both Pennsylvania Hospital and Penn Presbyterian Medical Center by raffling off a Starbucks gift card. The possibility of winning did excite many employee participants although it may not have increased participation.

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Results In general, most all employees claimed they had the same struggles with eating healthy at work as many of the nurse focus groups and support staff at HUP. They shared that each cafeteria could improve the quality and quantity of healthy foods they offer.

A majority of employees choose to pack their lunches—to save money, time, and to be more nutritionally mindful. They often cited that time was one of the biggest obstacles to eating healthy at work.

Not only did this include lack of access to fresh, healthy foods but also expanded to mean an appropriate amount of time and/or a designated space to eat their food.

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Time: Many employees stated their inability to take much time to eat their lunches. While the distance to the cafeterias in PAH and Presby is much closer than at HUP, employees still did not often take leisurely lunches during the day. Time was always cited as a factor inhibiting or even discouraging their individual abilities of being healthy while at work.

Cost: Cost has been a theme throughout our interviews because the price of eating out everyday of the week becomes too steep. Often employees cited bringing their lunches as an economical solution to the higher prices of the cafeteria and even of many outside vendors.

Health: At the various hospital entities, we heard more from employees about various health concerns that they are plagued with. Many employees talked about their struggles with eating at the cafeteria because of diabetes, high blood pressure, Crones Disease, and a general desire to stay healthy and avoid becoming ill.

In general, most of the foods offered at all three cafeterias are fried or huge portions—making it difficult to watch what you eat.

Culture: The hospital cultures at the Hospital of the University of Pennsylvania, Pennsylvania Hospital, and Penn Presbyterian Medical Center are high energy and high demand. Most employees shared that they often quickly ate lunch in their offices or workspaces before getting back to their workdays.

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Engaging Our Client: Designing Change

In order to showcase all that we had done for our client at our final presentation, we wanted to put together a resource that documented our entire process and that could be used even after the close of our project. We wanted to do our best to ensure that we were designing change that could be implemented even without us there.

Our final client intervention was a final presentation and discussion that included additional UPHS employees at the table.

Attendees included Rosemary Ossman-Koss and Jennifer Brady along with Michele Fletcher, Assistant Vice President of Decision Support, and Mia Gonzales Dean, Director of Support Services at HUP. Our intention for this final intervention was to wrap up the project by setting the next steps for implementing actions.

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Our presentation was well received and sparked honest conversation about their current food practices throughout the hospital system and the behaviors that are being enabled by them.

Our client began to see that their past efforts were not addressing the complexity of the issue of being healthy at work. They were realizing that past initiatives could not alter behaviors over time because they were based solely in incentives, which eventually ran dry because they could not be sustained. Additionally, they recognized the irony in what is being served in the cafeterias and their mission statement as a health system. Michele Fletcher exclaimed “We are enablers!” other quotes? once she realized the difficulties in trying to educate employees on healthy eating while simultaneously providing fattening foods in the hospital cafeterias.

They began to propose the need for conversations throughout the health system as a way of addressing this irony and need for change.

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To help our client articulate our process, we created a final booklet for them. It outlined our entire project from our understanding of the problem to our research and synthesis to our recommendations for moving forward with a healthy cafeteria initiative and future health related initiatives. We designed the document to be an easy reference to what we did over the course of the semester that could carry on our ideas and research. The document consisted of three sections: Project Overview, Process and Summary and Recommendations. The Project Overview acted as a brief introduction to our team, the HCD process, and the project’s goal and approach. The Process section described our process of UPHS employee engagement. We ran through the various methods we used to gather and record information from employees. The Summary and Recommendation section provided an overall summary of the results, as well as recommendations as to how to move forward. We broke up the recommendations into three main categories: Step, Jump, and Leap. The next few pages explain and breakdown what these mean.

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FInal Presentation and Discussion with Jen, Rosemary, Michele, and MIa

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Recommendations

We proposed three types of strategies for moving forward to develop a healthy cafeteria initiative and for creating and implementing future HR Benefits health initiatives. We adopted the Step Jump Leap strategy to explaining next steps for implementing health initiatives for employees throughout the health system, all of which were informed by both of our thesis problems. Some ideas directly address the needs of the users at HUP that enable them to eat well while at work. Others focus on our client’s decision-making process and offers alternate strategies for creating successful initiatives in the future. Many ideas directly related to employee health were designed to address the various obstacles currently faced by employees when it comes to their health at work.

Throughout the semester, we offered various intervention ideas and proposed several strategies. We recognize that there are operational challenges we are not aware of that could hinder the implementation of many of our recommendations, but they are potential solutions that are rooted in what we learned from engaging various stakeholders and what we read in our behavior change literature.

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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 cafeteria—by making it easier to eat healthy foods while at work.

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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, then 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.

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Food Labeling: Stickers

Well focu

sed

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 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.

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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 Google’s.

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Information Station The current location of the information station is not 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.

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Food Labeling: Visualizations Bringing a tangible reality to what people put into their body can create awareness. Visualizations such as the one to the right provide individuals with a graphic representation of the amount of an ingredient in a single item. These graphics are intended to dissuade employees from adding useless calories to their daily diets. Paired with the right information, the visual will demonstrate exactly all that goes into our body when we ingest certain items.

Wing Friday Wing Friday is a huge seller at HUP’s cafeteria. Through our research, we heard employees say 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. As Brian Wansink argues in his book Mindless Eating, these small changes can add up to huge results.

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Improved Salad Bar This was a request from every group of nurses we spoke with and demonstrates that many individuals 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.

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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 from the specific location of the cafeteria to other issues that became prevalent in our research.

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Food Cart A major issue that is faced by 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.

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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 site 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 could more easily translate into actionable steps that can change into more permanent behaviors.

Employee Meal Card

Well

focused

UPHS Employee 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.

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Mobile Application

Well

focused

Our idea for a mobile application would provide a level of education that could synchronize with the cafeteria’s menu. In essence, employees could use this application to learn about what foods they 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. 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.

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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 for creating change.

Altered Hours A major struggle faced by nurses is that the cafeteria hours are not conductive 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 are 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.

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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.

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Workshops In the process of conducting our research, we met with groups of administrators eager to engage in helping us find solutions to the cafeteria problem. It became clear to us that UPHS could benefit from establishing a routine of workshops. 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 UPHS.

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 to make employees feel that they are part of something meaningful. As an example, we offer our health fair table design. By borrowing principles from play 167 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.

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 on how that information is communicated back to employees in terms of the actions the information informed. The value of participating has not been made evident to employees but it must be if they continue to learn about the most important areas of concern and opportunities for change.

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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 system’s mission is high consumption of bacon. We learned that bacon is a best selling 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.

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 meaningful changes—the changes more urgently needed 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 across the health system, and will continue to improve upon the incredible work done by all UPHS and Penn Medicine employees.

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TRANSITION TO OUTCOMES

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Conclusion

The constraints of a semester timeline placed a limit on designing and prototyping change, not to mention implementing and measuring its impact. The majority of our thesis project development, conducted from December 2011 to May 2012, was spent building relationships with our client and prototyping non-online survey-based scenarios for data collection. At various times during our project, we were slowed by UPHS protocol and a general unfamiliarity with our iterative process. In an outcomesdriven environment, a qualitative, user-centered process can be intimidating or more importantly, just not how things are typically done. Our work successfully offered an alternative approach to designing health initiatives for employees by demonstrating a new way of thinking about the initiatives and about UPHS employees.

The success of our process can be demonstrated in three parts: • Our stakeholder engagement techniques and humancentered design process led to the discovery and deep understanding of UPHS’ culture and current behaviors throughout the organization, proving the value of a usercentered research process.

• Our recommendations are based on research we conducted both with various stakeholder groups and their needs and are rooted in research on behavior change.

• Many of our recommendations have been integrated into future UPHS initiatives for the upcoming year.

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We see incredible value and even a small success in our process and our efforts over the semester. A humancentered design process can be used to change corporate culture by allowing the culture to analyze current practices.

This enables a conversation about the real struggles and problems plaguing the organization so that efforts can be spent wisely in making successful changes. Organizations, like UPHS, can then restructure their practices to align with the overall mission of the organization. In our project, we were able to steer our client away from focusing the blame solely on UPHS employees. Instead, we were able to move them beyond a narrow focus on the cafeteria to understand that these discussions need to involve more stakeholders to truly build a sustainable environment that supports healthy behaviors for both employees and for patients.

Our project was about bringing design into a culture that does not have design, and we were able to establish value in the design process. While our direct client sees this value, they are not at the point to implement this process without designers. We believe that more work needs to be done or would need to be done in the future to facilitate a permanent use of our process. Our work introduced how valuable the process can be by focusing on designing a healthy cafeteria initiative for employees—using their current struggle with health care costs as the vehicle for demonstrating the need for a process like ours.

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Our recommendations often came straight from the mouths of the employees faced with trying to be healthy while at work in a busy hospital environment. Additional recommendations were more generally about using our semester’s work as a model for designing and researching to identify the focus of future initiatives. Our research on behavior change helped shape many recommendations, including ones originally proposed by our client. By beginning to think beyond a carrot/stick model of behavior change and by learning about how other organizations are improving the health of their employees, UPHS can begin to implement initiatives that will significantly impact employee health and their bottom line.

Our client, in the end, did seriously consider many of the ideas we proposed. Rosemary shared that many of our ideas have been included in plans for future Well Focused initiatives. If our project timeline had been longer, we believe we could have been integral in facilitating conversations across the various entities about employee health and their needs. We do, however, also believe that our direct clients could become advocates for our engagement process as they move forward and make changes before the 2018 excise tax.

In concluding the project and reaching out to additional stakeholders to report out our results, we learned that we must more thoroughly design ways to enable our client to effectively communicate the value of our research and deep understanding of certain user populations to their peers within the health system.

This is necessary for ensuring that our work will be used to make impactful changes for employees. By engaging our client in our process throughout the semester, they were able to see the value

unfold, and we were able to see a huge transition from their initial hesitations with allowing us to engage with employees to their praises of how meaningful the research will be for them in their future work. As positive as that sounds, they unfortunately still exist within an organizational hierarchy that supports results-driven initiatives that are not necessarily based in the needs of the users whose behaviors need to change. We learned that there is no such thing as a two-year return on investment in UPHS language.

Ultimately, there needs to be a culture shift across the entire health system that values a process geared to understanding systemic problems and addressing them in order to create change.

Our design process enables real change to happen because it invests significant effort in understanding the culture upfront in order to design meaningful methods of change. In the course of our project, we believe we helped UPHS gain the understanding of a different way to start imagining those changes and a new kind of language to make actions possible.

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APPENDIX

Appendix A: Glossary “Cadillac Tax�: an excise tax included in the new health care reform law that imposes a 40 percent tax on employer health plan costs exceeding $10,200 for single coverage or $27,500 for family coverage in 201836.

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Culture of Health: this is what must be created in order to have a healthy workplace. It includes having company leaders actively engaged in the effort, collaborating with healthcare providers and vendors whose goals are aligned with the company’s goals, establishing the right kind of incentives for employees and motivating all to improve their health. It involves a process of constantly tweaking the programs to fit the needs of all company employees37.

Deliverable: a thing to be provided, especially as a product of a development process38.

Disease Management: aims to manage a disease by keeping conditions from worsening39. Most health care has been operating on the level of disease management, treating a disease once it has already affected the body.

Disease prevention: growing in popularity, disease prevention seeks to achieve and to maintain a level of health so that there is never an onset of disease40. Such employer sponsored programs

and initiatives encourage employees to take ownership over their health and make choices that will keep them healthy. Often these programs use incentives to encourage employee participation, including discounts on gym memberships and/or off health insurance premiums41.

Employer-Based Wellness Program: a program that provides employees with some kind of rebate, discount, or reward up to 20 percent of the cost of coverage. There are federal grants from the Department of Health and Human Services available to businesses in order to establish wellness programs. Participation in the program cannot be based on individual employees meeting a certain health status42. Effective programs can reduce the number of absences, increase productivity and lower health care costs43.

Health-Insurance System: intended to protect individuals and households from excessive financial loss due to medical bills, and also to help patients procure health care at negotiated prices44.

Human-centered design: a process in which the needs, wants, and limitations of end users of a product are given extensive attention at each phase of the design process45.

Iteration: the action or a process of iterating or repeating as a procedure in which repetition of a sequence of operations yields results successfully closer to a desired results46.

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Premium: agreed upon fees paid for coverage of medical benefits for a defined period. Premiums can be paid by employers, unions, employees, or shared by both the insured individual and the plan sponsor47.

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Wellness Incentive-Based Programs: a program that is implemented in a work place that encourages employees to take care of their health with some sort of incentive. By doing some, the employee is rewarded and the employer decreases their health care costs and has healthier, more productive employees. Often, many of the interventions directly relate to increasing exercise and fitness, which have been shown to significantly lower health costs in the long term. These programs are designed to change behaviors and improve the health of participants48.

Prototype: a first full-scale and usually functional form of a new type or design of a construction49.

Stakeholder: one who is involved in or affected by a course of action50.

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Appendix B: What Experts Are Saying

Many argue that the entire health care system is broken and that significant changes must be made in order to impact our current poor health trajectory and continued decline. In his book A Return to Healing: Radical Health Care Reform and the Future of Medicine, Dr. Len Saputo argues that the current “disease care system” is driven by “a model that reduces each person to his body, his body to a machine, and his health needs to a set of symptoms to be treated mainly by drugs—too often ignoring the patient’s mind, emotions, spirit, environment, and lifestyle51.” Instead, he proposes a model called integrated health care, which aims to take care of the entire being, to achieve health by treating with medications last and instead focus “treatments” on lifestyle improvements. He believes that the current system emphasizes the cure-all power of prescriptions and ignores the ability of the body to repair itself when the body is given the right conditions, such as correct amounts of vitamins and nutrients.

Similarly, Dee W. Edington, a prominent health management research scientist, states that “We have to create a culture of health.

We have to get to the point where people start valuing the energy and vitality health brings, instead of only thinking they are healthy because they don’t have diabetes yet52.” He continues to argue that “Treating wellness is much cheaper than treating sickness,” and the best interventions are cultural and environmental. Instead of emphasizing individual behavior change, Edington believes that the greatest results come from interventions that change the way the environment dictates actions. He supports the notion that companies can make these changes for their employees.

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Dr. Andrew Weil, in his book Why Our Health Matters, takes a similar stance to both Saputo and Edington by arguing that the current health care system as a whole is an industry fixated on making money and quick fixes and that we must return to care rooted in the body’s ability to heal itself and care that encourages a healthy lifestyle. In particular, he makes the case for the irony present at many hospitals. He states that hospital cafeterias serve the best of the worst when it comes to American cuisine. He says “Fast food has no place in these settings. The food in health-care facilities should taste good as well as exemplify good nutritional principles. It should inspire patients, families, visitors, and staff to make better food choices53.” Weil argues that hospital cafeterias are only part of the much larger problem our health care system is currently facing. All three experts argue for a shift from disease management to prevention in whatever ways possible to save our ailing population.

While not fully embraced by the entire community54, there are studies being done and evidence being complied that state investments in keeping employees healthy will have ample returns in reduced treatment costs later55. By focusing on prevention, not only do we keep ourselves healthy but we also save ourselves a lot of money. For example, a study by the Trust for America’s Health “found that the U.S. could save $29 billion in health care savings in five years if we could all lower the obesity rate by just five percent56.” According to experts at the New York Academy of Medicine, programs that are aimed at diet, exercise, and smoking prevention—the trio often associated with disease prevention efforts—could drive down health care costs tremendously. They

claim that “Spending $10 a year per person would save the United States more than $16 billion annually within five years for a return of $5.60 on every $1 invested57.� While money speaks specifically to a return on investment, prevention also improves much more than our wallet size. Health and wellness programs improve energy, productivity, quality of life, and feeling of well being. These do not equate directly to hard dollars and so are often controversial in discussing the value of employee health programs and initiatives.

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Appendix C: Why Food

In many health and wellness programs and initiatives, the focus remains primarily on nutrition, smoking cessation, and fitness.

Our current health crisis is comprised of many variables, but the food we eat is one of the most important factors and deserves our attention. For a number of years, there has been a focus on eating fresh and healthy foods instead of overly processed junk foods, but there is unfortunately still a rising percentage of obesity and health related problems in both children and adults58. According to the Centers for Disease Control and Prevention data from 2010, one-third of the adult population in America and over 17% of children are obese59. Additional areas of concern are with the increase in cases of diabetes, heart conditions, and food allergies.

The consequences of eating bad food, and too much of it, will affect much more than the healthcare industry. The impact of food reaches to areas of the economy, trade, water and land quality, the atmosphere, and much more60. While these topics are not addressed in our thesis, they briefly demonstrate the scope of the problems related to our current reliance on processed foods.

There is very little emphasis that is placed on nutritional science or true recognition that what we put in our body affects us greatly. It is not just that food provides calories to keep our bodies going. On the contrary, food provides us with the nutrients necessary for daily functioning at the cellular level . The food pyramid was drawn, re-drawn and most recently turned into a visual of a plate describing food portions, but it along with a whole host of other educational information drafted by the government or other agencies, these tools have not seemed to have actively translated to great changes in the majority of us. Examples of diagrams, such as the food plate, do not provide actionable steps or changes to the environment that are necessary for creating necessary changes in our health.

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Appendix D: Literature Review

Our literature review is specifically tied to exploring various ways of addressing our first thesis problem—changing behaviors to improve health through a healthy cafeteria initiative. Our research focused on understanding the problem, the ways of creating change, and various methods for tackling issues of eating that can redefine our current and often problematic relationship with food.

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Literature on Understanding the Problem

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In a book related to our health or lack there of, The World is 62 Fat by Barry Popkin examines our relationship to food and how it has changed over the last 50 years. Popkin argues that over the last few decades we have managed to cause the terrible obesity epidemic that we are now facing. He includes studies that he has done with individual families across the world, watching their habits over the last decades. He argues that a combination of technological advances, lack of movement and lack of attention paid to what we fuel our body with has placed us in the middle of this epidemic that only appears to be getting much worse. He includes a history of beverage production and how an extreme increase of intake of these calorie-filled beverages with no reduction in food intake and increase in portion size has led to too many calories in our day.

Increased calories along with advances such as the dishwasher and washing machine that have replaced our individual needs to move and perform activities have led to our sedentary bodies. He compares looking at his life in 1950 to the lives of children growing up now and the choices that families make in what food they consume and what they spend their free time doing. In addition, the food industry has done much in promoting the kinds of behaviors that are causing our diseases and our premature deaths.

Popkin continues to ask readers to take a stance to make changes, not only for the health of their families but also for the health of our nation and our world. This includes things like a) designing cities in such a way to allow for children to walk to school, b) making grocery stores with fresh produce accessible to everyone, c) looking closely at the industries that are being subsidized and driving down costs but at what expense to us (specifically livestock,

corn and soybeans that ultimately are not good for our health), and d) controlling the number of calories that we eat in each day and encouraging others to eat better.

In Why Our Health Matters63, Dr. Andrew Weil provides a broad understanding of the current state of our health care system, particularly that it is broken and places far too much emphasis on technology and pharmaceutical treatments rather than on prevention of diseases to begin with. He proposes various ways of tackling the entire system and starting fresh with an effective, preventative system. In particular, we paid close attention to his arguments for changes that will affect rates of obesity. His emphasis is on education, not necessarily education of individuals who must change their behaviors but of the entire system of health experts.

There is little attention paid to nutrition. He argues that is takes more than cutting calories and exercising more to produce good health. What matters more than anything else is what we use to fuel our body. His focus is not only on educating everyone on the right types of food for our bodies but also on making a positive impact on the ways in which our food is produced. He goes as far as to mention the Farm Bill and its devastating impact on our current behaviors.

According to Weil, the entire environment and methods used for food production and current uses of government subsidies must be revisited and altered to produce the results we are seeking, namely health without complete reliance on drugs and invasive treatments.

He advocates for a change in the entire system and focus on what might be considered “old school� methods of exercise and an understanding of nutrition to prevent illness from happening in the first place.

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Literature on Behavior Change

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In the book Nudge64, authors Richard H. Thaler and Cass R. Sunstein make the argument that environments affect how people behave and that we can use this knowledge to design spaces, systems, etc. to positively affect people’s lives. Thaler and Sunstein state that we have two systems: an automatic and a reflexive; or a Homer and a Mr. Spock. They argue that our automatic system is what drive our impulse decisions while our reflexive system requires actions that are thoughtful and is much slower at decision-making.

Keeping this in mind, the authors note that one of the main goals of their writing is to teach the reader that the environment can be designed in such a way as to allow our automatic systems to lead us to better, healthier and longer lives.

They define this as “libertarian paternalism,” an approach to designing how humans make decisions. Thaler and Sunstein argue that by understanding how this “choice architecture” can be designed, we can learn how to nudge individuals in ways that will benefit their health, wealth, and happiness. For example, the authors include the arrangement of a hospital cafeteria in their examples of choice architecture in action. Their understanding is that people do not often choose what is best for themselves, but that experts within each field can use their expertise to make our lives better. Libertarian paternalism allows the freedom and flexibility of choice but makes it easier on the Homer Simpson in each of us to make better decisions without encroaching on our ability to choose for ourselves. Choice architects can nudge individuals in directions that will benefit us rather than harm us. This is a very hands-off way of creating change, altering the environment in such a way to make good decisions more accessible.

Our worry about this approach is that it highlights exactly how easily people can be manipulated even though these changes would be made to produce the best results for our health. It is wellintentioned sneakiness that greatly de-values our individual abilities to choose for ourselves. There is no element of education involved in this process so individuals cannot learn better behaviors to use outside of the hospital cafeteria, so the time spent outside of the hospital can still significantly encourage poor eating behaviors. We had to expand our focus to research additional methods of creating behavior change.

In the book Switch: How to Change Things When Change is 65 Hard , brothers Chip and Dan Heath provide an alternative set of steps for creating change behaviors in both individuals and large organizations. They argue that creating change is much more about engaging the individual in why he or she needs to change while also shaping the environment to make change possible. They provide the analogy of an elephant and a rider to represent the two very different and very powerful sides to our one mind; the emotional and the rational sides. In order to create change, the Heath brothers state that there are very different tactics for appealing to both the elephant and the rider. Change cannot occur unless both elephant and rider are willing to head down the same path, a path that is shaped to support that change.

Unlike Thaler and Sunstein with their focus on shaping the environment through nudges that change behavior, the Heath brothers emphasize a 3-part approach to addressing the problem of unwillingness to change, a metaphor created by Jonathan Haidt.

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The change creator must engage the emotional nature of the elephant by creating motivation, appeal to the logic of the rider by providing clear direction, and create a path that encourages and supports the new change. They provide a variety of tactics in order to create change, including strategies to find examples of what is working instead of focusing on what isn’t working, advice to shrink the change and provide actionable steps to those that need to change, and focus on engaging the group because behavior is contagious.

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The Switch approach is a likely candidate for our work with UPHS because it engages individuals on a variety of levels. Not only does it propose to make environmental changes like Kaiser Permanente, Pitney Bowes, and Cleveland Clinic did but also motivates employees by getting them excited about taking care of themselves and makes it simple by giving them actionable steps. In fact, Kaiser Permanente, Pitney Bowes, and Cleveland Clinic probably all have applied a Switch-like method for creating change at their organizations.

This method also encourages organizations to take the time to research exactly where the greatest impact can be made by understanding the culture and employees needs—a very human centered design approach!

In the Book The Tipping Point: How Little Things Can Make a Big Difference66, author Malcolm Gladwell breaks down the characteristics and possible origins of great change and sweeping epidemics. He argues that in all his examples, little changes added up to make a big difference and that once a certain threshold was reached (what he calls the “tipping point”) things changed all at once. There are behaviors that are so contagious that they can affect entire populations, sometimes for the better and sometimes for the worse.

In order to create large scale, sweeping change, Gladwell argues that it is important to understand the three factors that were present in other examples. He defines these as the three rules of the Tipping Point—the Law of the Few, the Stickiness Factor, and the Power of Context. In the Law of the Few, he argues that it is always a few who are responsible for driving the epidemic, and it is the nature of the messenger that determines the success of the message. In the Stickiness Factor, he states that packaging information can be done to make it irresistible and make the message stick. Lastly, Gladwell argues that we often do not value the Power of Context as much as it should be. He defines context as a powerful agent in dictating behavior. It is a feature in the environment that is the impetus for change, not necessarily a certain kind of person.

Gladwell’s emphasis in his book is that by understanding the nature of the Tipping Point that we can begin to redefine the way in which we look at the world. We have the power to test our intuitions and assumptions to create our own tipping points. Gladwell concludes that “…Tipping Points are the reaffirmation of the potential for change and the power of intelligent action,” (259). It is possible to create change in people and in places that appear to be stagnant and immovable, and the three rules of the Tipping Point allow each of us to begin crafting that change. While not as instructive as the books

by Thaler and Sunstein and the Heath brothers, Gladwell narrates a story of hope—about the qualities we each have to make change happen. By understanding our own unique skills and by knowing the characteristics of epidemics that have created vast movement, we can take charge to make things happen, for better or for worse.

In The Power of Habit: Why We Do What We Do in Life and Business67, Charles Duhigg characterizes our habits and the influence APPENDIX

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they have on our lives. He explains that our habits are an automatic three-step process. They are loops constructed of a cue, a routine, and then a reward. They are patterns that allow our brains to conserve energy and enable us to “multi-task.” For example, reversing our cars out of the driveway is actually a complicated task involving a series of actions, yet many of us accomplish it without thinking every morning on the way to work. Instead, we are preoccupied with other more important details of the day. These habits form, for good or for ill, without much thought on our part. In fact, that is Duhigg argument. If we can understand how habits form, then we can use that information to construct new and better habits. He states “So unless you deliberately fight a habit—unless you find new routines—the pattern will unfold automatically,” (20). It is in this fighting action that we alter the middle of the habit, the routine, and can switch from sitting on the couch watching a television show with a beer in hand to throwing on our running shoes and becoming more active.

Duhigg’s book provides examples from individual struggles with addiction to NFL football teams striving for a Super Bowl win to large organizations facing financial crisis. His argument is that by recognizing the triggers that initiate our habits, we can make significant strides in improving our lives. Our lives are filled with habits, as small as when and how we brush our teeth in the morning. We operate mostly on a default setting. Having the belief that we can create change is the most important tool in creating meaningful change in our lives and the life of our organizations and communities. “This is the real power of habit: the insight that your habits are what you choose them to be,” (273). Duhigg emphasizes that in any situation it was the individual that made a plan of how to maintain a change during the hard times, during periods of great stress and pain, that were the mot successful in creating new habits.

Literature on Eating

In the book Mindless Eating68, author Brian Wansink argues that there is a range of calories, that if we can control, can add up to huge health benefits over time. He coins it the “mindless margin,” a handful of a few hundred calories that we can easily overeat and that easily adds up to weight gains of 10-20 pounds over the year.

He does propose that it is just as easy to adapt our environment to keep these calories in check. As the Director of the Food and Brand Lab, Wansink conducts studies to analyze factors like plate size, location of food, and food naming to learn about how our eating habits are dictated by our environment. He firmly believes that small changes in the environment will benefit our health. Instead of committing to a diet or making radical changes to behavior, it is possible to make a significant impact that does not deprive or cause any unnecessary mental anguish.

He offers examples of how to best reengineer our food habits in a way that is natural and not disruptive to our daily lives.

For example, he offers the simple idea of a checklist. This list would feature three 100-calorie changes that could mindlessly turn into positive eating habits. This could include daily tasks, such as “make half my plate vegetables” and “ drink only one sugared beverage,” that can be checked off each day. Wansink reminds the reader it is fine to not be perfect every day, but these small changes can add up to a couple lost pounds over the course of the month. Another example includes the simple act of eating off smaller plates.

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behavior of UPHS employees. His language is encouraging and could help motivate individuals to understand that small goals and even smaller steps can add up to huge results. His set of tools allows all of us to take back control over the food we eat in a way that is not overwhelming. These tactics can easily translate to actions for UPHS employees struggling with their relationship to food.

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In the book Savor: Mindful Eating, Mindful Life69, Thich Nhat Hanh and Dr. Lilian Cheung outline a different approach to eating.

They argue that life as we know it is chaotic and speeding forward even faster than before, an acknowledgement made across the spectrum of occupations. We are getting lost and are suffering because of it. Many of us turn to food for comfort and then regret what we see in the mirror. Hanh and Cheung state that “We do not pay attention to how much food is served or how much we have eaten, how tasty the food is or whether we’re hungry at all,” (25). We are falling victim to our unwillingness to step back and recognize what we are doing to ourselves by not giving ourselves and what we eat much attention. We are simply being driven by external cues that dictate the ways in which we live.

As a solution, they offer a Buddhist approach to eating and enjoying food that redefines our relationship with it. They emphasize eating mindfully, a practice of being present in the moment and cognizant of what we are filling our bodies with—the texture, the smell, the experience of the food. They emphasize the need for little steps of attempting mindfulness that provide a taste a success, a starting point for the road to recovery and ownership of our lives and bodies. This is not a race or an easy feat to accomplish,

but it begins to add to our arsenal of tactics for overcoming our tormented relationship to food or to conquer the excess weight we have carried around far too long. They argue that by being mindful of ourselves we are able to gain insights as to how our current relationship with food has been established and allows us to work on bettering ourselves in more than just a physical way. They share that we each already have the tools we need to make these changes.

Mindfulness allows us to access them.

While we might not be able to convince everyone to adopt a Buddhist philosophy to every meal, there are organizations that have begun to implement these tactics as a monthly practice. At Google’s headquarters, eating mindfully is practiced in the cafeteria once a month to broaden the scope of the staff’s learning and promote health and well being in various ways. It is an interesting way to remind individuals that there are many ways to make changes, especially to one’s body, that does not involve crash dieting and intense exercise.

All of these books provided a foundational understanding of way in which to begin designing solutions that would affect the current mis-behaviors of UPHS employees in the cafeteria. To truly understand how to change behavior, we obviously needed to know and to understand the behaviors we were trying to change. That was our next step, knowing the user.

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Appendix E: References 1. “ The Point of the Cadillac Tax” Accessed January 10, 2012 <http:// theincidentaleconomist.com/wordpress/the-point-of-thecadillac-tax/> 2. Interview

with Rosemary Ossman-Koss, February 3, 2012.

3. “Preventative Medicine Merges as A Health Care Growth Driver” Accessed February 5, 2012 <http://www.pharmaphile. co.uk/2011/04/preventive-medicine-emerges-as-a-health-caregrowth-driver/> 4. “How Not to Get Sick: A User’s Guide to Good Health at Every Age” Accessed July 20, 2012 <http://www.time.com/time/specials/ packages/0,28757,1903873,00.html> 5. “Chart shows staggering rise in health insurance cost” Accessed July 20, 2012 <http://www.reliableplant.com/Read/27915/Chartrise-health-care-costs> 6. Weil, Andrew. Why Our Health Matters. New York: Hudson Street Press, 2009.

7. “U.S. Health Care Cost” Accessed January 23, 2012 <http://www. kaiseredu.org/issue-modules/us-health-care-costs/backgroundbrief.aspx> 8. “ Time Magazine Cover” Accessed January 23, 2012 <http://www. time.com/time/covers/0,16641,20090622,00.html> 9. “Disease Management Position Paper” Accessed February 3, 2012 <http://www.aafp.org/online/en/homepolicypolicies/d/ diseasestatemgt.html>

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10. “The Best Disease Prevention Strategies are Free but Rarely Publicized” Accessed February 3, 2012 < http://www.naturalnews. com/007452.html> 11. “Redesigning Employee Health Incentives-A Lesson from Behavioral Economics” Accessed February 20, 2012 < http://www. nejm.org/doi/full/10.1056/NEJMp1105966> 12. “How Not to Get Sick” Accessed July 20, 2012 <http://www.time. com/time/magazine/article/0,9171,1904143,00.html> 204

13. “Definition of Wellness” Accessed March 4, 2012 <http://www. definitionofwellness.com/> 14. S aputo, Len. A Return to Healing: Radical Health Care Reform and the Future of Medicine. San Rafael, California: Origin Press, 2009.

15. “Chronic Diseases” Accessed March 3, 2012 <Healthypeople.gov> 16. “Americans are Fat and Getting Much Fatter” Accessed March 3, 2012 <http://www.wellness.com/forum/forum_posts. asp?TID=8048&PN=1> 17. “State of Working America” Accessed July 23, 2012 <http://www. reliableplant.com/Read/27915/Chart-rise-health-care-costs> 18. “A Culture of Health” Accessed March 3, 2012 <http://www. hreonline.com/HRE/story.jsp?storyId=533337130> and American Heart Association at <http://www.heart.org/HEARTORG/> 19. Weil, Andrew. Why Our Health Matters. New York: Hudson Street Press, 2009.

20. “About Wellness Insitute: Who We Are and What We Do” Accessed March 20, 2012 <http://my.clevelandclinic.org/wellness/aboutus. aspx>

21. “ The Success of Pitney Bowes” Accessed March 21, 2012 <http:// www.workforce.com/article/20070213/NEWS02/302139995> 22. “ Total Health: More Than a Health Care Organization” Accessed March 21, 2012 <http://www.kaiserpermanentejobs.org/totalhealth.aspx> 23. “The promise and peril of wellness” Accessed March 20, 2012 <http://www.washingtonpost.com/blogs/ezra-klein/post/thepromise-and-peril-of-wellness/2011/08/25/gIQAGzPfkL_blog.html> 24. Report: Cleveland Clinic “Message from the CEO”

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25. Pitney Bowes “Employer Health Strategy,” page 10. Accessed March 20, 2012 < http://www.oppapers.com/essays/Pitney-BowesEmployer-Health-Strategy/881188> 26. Pitney Bowes “Employer Health Strategy,” page 12. Accessed March 20, 2012 < http://www.oppapers.com/essays/Pitney-BowesEmployer-Health-Strategy/881188> 27 “ The Success of Pitney Bowes” Accessed March 21, 2012 <http:// www.workforce.com/article/20070213/NEWS02/302139995> 28. “Yes, You can reduce your health care bill” Accessed May 13, 2012 <http://www.forbes.com/2009/06/10/preventative-health-careentrepreneurs-human-resources-marks.html> 29. “Initiatives help Cleveland Clinic employees get healthier, lower insurance costs” Accessed March 3, 2012 <http://www.cleveland. com/healthfit/index.ssf/2011/10/clinic_employees_get_healthier. html>

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30. Thaler, Richard H. and Cass R. Sunstein. Nudge: Improving Decisions About Health, Wealth, and Happiness. New York: Penguin Group, 2008.

31. “In the Cafeteria, Google Gets Healthy” Accessed Apirl 15, 2012 <http://www.fastcompany.com/magazine/164/google-employeehealth> 32. Heath, Chip and Dan Heath. Switch: How To Change Things When Change Is Hard. New York: Broadway Books, 2010.

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33. Wansink, Brian. Mindless Eating: Why We Eat More Than We Think.

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34. “Isn’t It Time to Reconsider the Carrot and Stick Method of Employee Motivation?” Accessed July 14, 2012 <http://www.tlnt. com/2012/02/15/isnt-it-time-to-reconsider-the-carrot-and-stickmethod-of-employee-motivation/> 35. “Vegetarian Diet-What You Need to Know” Accessed July 20, 2012 <http://health.usnews.com/best-diet/vegetarian-diet> 36. “Definition of Cadillac Tax” Accessed March 3, 2012 <http://www. benefitspro.com/2010/05/19/most-large-employers-face-cadillactax-study-shows> 37. “A Culture of Health” Accessed March 3, 2012 <http://www. hreonline.com/HRE/story.jsp?storyId=533337130> 38. “Definition of Deliverable” Merriam-Webster Online. Accessed July 26, 2012 <http://www.merriam-webster.com/dictionary/ deliverable> 39. “Disease Management Position Paper” Accessed February 5,

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