The North Carolina Healthy Food Environments In Hospitals Project: An Analysis of the Implementation Process and the Role of Feedback

Background: Increases in adult obesity and employee health care costs have lead many organizations to adopt health promotion programs. But only a few hospitals in the U.S. have successfully implemented programs that target environmental and behavioral changes to improve the food culture. Such programs have been shown to work, but their implementation and maintenance are largely unsuccessful from insufficient managerial and resource support.

Program background: In 2008, NC Prevention Partners developed and disseminated Healthy Food Environments in Hospitals (HFEH), a project aimed at improving employee and visitors’ health in North Carolina hospitals. To reach full implementation (Red Apple status), hospitals had to complete multi-step, complex requirements like increasing availability and affordability of healthful foods and promoting healthy eating habits through marketing and health education. As of March 2011, 86 of 129 hospitals implemented the project and are in maintenance stage. To date, HFEH might be the largest national systems-wide approach to improving nutrition in hospitals.

Evaluation Methods and Results: This study analyzes the factors that made implementation successful, and the role feedback played during implementation and maintenance.

In-depth interviews with 53 project implementers at nine Red Apple hospitals throughout NC. All interviewees belonged to hospitals that successfully implemented HFEH. Implementers ranged in managerial level (e.g., CEO to cafeteria cook) and hospitals ranged in size (480 to 6,000 employees). Interviews lasted between 20-40 minutes and were conducted using a semi-structured guide. Interviews were audio- and video-recorded, with consent. Interview transcriptions were analyzed using a grounded theory approach and Atlas.ti software.

Four main factors were necessary for implementation success: employee feedback, and support from senior managers, fellow implementers, and NCPP staff. Feedback showed that employees adopted/accepted project-related changes; support from senior managers guaranteed financial resources and the project’s long-term survival; support from a team of interdepartmental, committed implementers provided necessary human resources and skills; and support from NCPP staff provided tools, guidance, and encouragement. These factors improved implementers’ attitudes toward HFEH and provided motivation and resources to complete the project. Three types of informal feedback influenced implementation and maintenance: direct and indirect comments from employees and visitors, observations of changes in eating habits, and changes in cafeteria sales of healthy items. Positive feedback helped implementers see the project as beneficial to employee health and the hospital’s culture of wellness, motivating them to complete HFEH and maintain it. Senior managers received less direct feedback and middle managers believed more strongly in NCPP’s contributions during implementation.

Conclusions: Internal and external hospital support helped the implementation succeed, and informal, short-term feedback impacted implementation and maintenance. Interviewees’ perceptions of the implementation factors and types/role of feedback hardly differed with managerial level.

Implications for research and/or practice: Practitioners interested in implementing food environment interventions in health care settings should ensure financial support, encourage cooperation between implementers, and provide easy-to-use tools, guidance, and a feedback tool to help implementers see short-term project-related changes. For maintenance, practitioners should keep implementers aware of positive feedback as proof that the intervention is having its intended impact.