Emergence: Workplace Health Management: Complexity – Part 8

Long-Term Strategies for Workplace Health Management

We have been remarkably successful over the last half-century helping spread workplace wellness, by any other name, into a world-wide movement as an antidote to individuals and organizations living life at a sub-optimal level due to less than healthy lifestyles, environments, cultures, and climates at the workplace, in families, and within communities. In the best case we have seen organizations and individuals grow into an accepted and valued part of the way of life in organizations, families, and communities.

The original objective of this eight-part series of posts was to come to the realization that what we have accomplished in the past will not be adequate in the next half-century or even the next decade. We can bring our science and outcomes to a higher level by asking better questions, discovering better metrics and measures, and creating better solutions to meet the needs of individuals and organizations.

Asking better questions.

Throughout seven and now eight posts, I made many suggestions related to the past and the future infrastructure of workplace positive health management. One of the reoccurring suggestions is to:

  • asking better questions,
  • discovering better metrics and measures, and
  • creating better solutions.

Our experience at the University of Michigan Health Management Research Center demonstrated that a specific, single-focused intervention did not impact the main-effect the way we expected; but, it impacted one or more of the other main-effects. These analyses showed us that either the stimulus-impact system is very complicated or complex, or our original thinking was faulty. We published these finding because of the surprise effect; we found that when medical costs went up or went down, nearly all the risks and behavioral factors, including the specific target of the intervention, had moved in the same direction. This finding introduced us to the stimulus-impact systems effect and greatly changed the way we analyzed the effects of interventions.

Learnings. Our learning from this experience was to refine our questions and to continue measuring all possible impacts. Earlier we had published a paper describing that risks and behaviors traveled in clusters, seldom a single stimulus. These two studies led us to the realization to develop a complicated pattern of key results, which led to inventing the Trend Management System, which was 84% accurate in predicting high costs for up to three years. Few, if any prediction, is accurate after three years because the predicting elements change as does health care costs.

The learning from the combined experiences is to not get so convinced of your expected outcome that you miss the unexpected consequence of a major outcome.  Keep track of your results and with collaboration you may, in fact, come upon a major discovery or product that could move your work dramatically forward or change the total field.

Creating better questions and research collaboration between researchers and private companies providing critical data could, as Bill Gates said, lead to the following:

“The private sector knows how to take great research,
turn it into a high-quality product, and
ultimately create a great company to
bring a transformative technology to market.”

Constraints of our own making. We may be a long way from comparing us to research and collaboration in industry. As a workplace health management field, we typically have not asked questions outside our own research capability, capacity, or self-interest. We have done very little collaboration and flow of great products resulting in transformative technology. In fact, we have done nearly the opposite as some researchers “circled the wagons” to defend our questionable results. We typically have been operating as single independent individuals or organizations operating without outside collaboration to develop exclusive intellectual property. This mode of operation limits the depth of our questions and excludes the benefits of cooperation and collaboration for the good of the field.

Discovering better metrics and measures.

The concepts of collaboration, cooperation, and flow are highly interesting to me, but we have so few dedicated researchers in our field that this is not a realistic strategy for us in the short term. However, since this final post is related to a long-term vision and strategies, it is appropriate to explore different strategies.

Recent new interventions.  As a field, we have found interesting and applicable applications and currently use interventions from allied fields such as psychology, sociology, business, medicine, public health, and others. We have adopted many of these interventions such as happiness, mindfulness, resilience, kindness, gratitude, generosity, compassion, empathy, purpose, and others. Although these interventions may be related to specific populations, we have adopted the interventions without proper evidence and knowledge of the content, applicability, history, appropriate populations, measurement analytics, feedback, coaching, and especially the pathways these tools evoke to get to the early, intermediary, and main-effects.

I suggest that before adoption of these allied interventions we customize the tools to our populations by asking the providers or consultants to show us the origin of the intervention tools, the target population of their validation, and the reliability of their testing. In addition, we should examine their suggested intervention tools, metrics, and measurement protocols. If we are convinced of their evidence, we then need to find ways to ensure our population is compatible with the population they used. This is true any time we move from one population to another, which has been an ongoing weakness or our research and applications.

In the immediate and short-term, we need to find ways to train our staffs and researchers, so we can take advantage of the new interventions. Even with appropriate training, the new interventions likely will not be focused enough on the foundational and basic needs of positive workplace health management. We may need to find alternative metrics and measurement tools that fit our own examples. Overall, we need to be very careful about adopting findings from other fields and international data, both representing varying cultural issues. In addition, we need to insure our staff is in an advantageous position to learn, explain, and deliver these innovative and they will remain relatively new and untested programs until tested in our populations.

Better questions require better metrics. Given the level of questions we now ask, it is obvious that better metrics and measures are needed. However, when we begin to ask even better questions, the demand for better metrics and measures will again be a priority.  Better questions and metrics are an unending necessity.

Our field is so based upon economic return for the organization that there is little energy for improving the current metrics, and measurements.  At the UM-HMRC, being a University non-profit, I had over 35 years of freedom to weave basic and foundational research into our applications with hundreds of companies. Most of the companies that funded our work also wanted answers to the same economic questions as other companies.  Our Corporate Consortium (20-30 companies) allowed a platform for appropriate inquiry, challenges, shared data, and a story-telling environment in annual sharing sessions. Not perfect but an environment driven to find Next Practices (innovated practices).  This commitment to creative and applied work combined well with our commitment to basic work, so we easily could include both sets of questions within the existing funding levels.

Better metrics require better questions. We created a data base of several million individuals in our “big data” set which allowed us to answer advanced questions and create valid algorithms to use in prospective analyses.  Several of our algorithms were licensed by non-profit and for-profit companies to improve their own research and evaluation capabilities. Our field has the applied and basic research capacities to do the same, although most companies are for-profit. The financial resources we (UM-HMRC) used for basic research is now the money the for-profits use for their own profit or expansion of their core business models. I do not see this situation changing in the immediate future, so the need for basic research, unencumbered by corporate profit, is a hoped-for long-term strategy.

The following are stretch objectives within our current capacity, thus short- or long-term strategies

  • Health and performance management needs to be subjected to more serious field research and better collaboration and sharing between researchers, practitioners, and participants.
  • More collaboration is needed between advanced researchers to focus on health risk factors and physical and psychological behaviors as the basis of products for our holistic dimensions of health. In addition, design tools, products, methods, and interventions that reflect the best and publishable research are urgently needed if we intend to rise above being solely a provider of services to companies.
  • We need information about the generation of biological pathways from applying external interventions to early and intermediate indicators, to impact main-effects and anything in-between.
  • We need better collaboration among academic researchers, private sector companies providing unbiased researchers, and the practitioners at the workplaces to bring in unique objectives and viewpoints. Currently, many workplace health management initiatives hire consulting companies to advise on the wellness initiatives including selection of interventions and incentives, implementation processes, and selection of metrics and measurement strategies. Unfortunately, many consultants demonstrate very little understanding of the company and even worse have little understanding how interventions work, leading to fundamental mistakes.

What can we do now and in the short term? A key message is, “An expansion of the research or analyses we currently do will not meet the level of research needed to keep us in tune with others who are addressing more basic and fundamental levels of knowledge.”  A commitment to new knowledge will take a commitment from advisers, consultants, and companies sponsoring the workplace positive health management initiatives. In keeping within the strategy suggested above, the following are some of the minimal issues or questions I feel we can answer at our current or short-term level of knowledge and interest.

  1. What’s the nature of the problem we want to explore?
  2. Why will an intervention be needed?
  3. Why this population?
  4. How will the intervention be made available to the participants?
  5. What are the key metrics?
  6. How are the early and intermediary metrics measured?
  7. What are the targeted main-effects for each intervention?
  8. What could be some of the unintended consequences? How would we react to the unintended consequences?
  9. Do we have multiple hypotheses?
  10. Do we have a theory about the measurements for the early impacts, the key metrics for the intermediary impacts, and the metrics and measures for the main-effects?

Creating better solutions.

There are at least, five fundamental early or intermediary key process success factors that determine the successful delivery of the intervention stimulation to impacting the main-effect. These five are first or second level indicators of success or failure of the intervention. If the indicators are positive the initiative is going in the intended direction. If negative the team should pause the intervention and re-evaluate alternative strategies.

  1. Participation
  2. Engagement
  3. Motivation
  4. Early stage metrics
  5. Early stage measurements

The following bullets apply equally to management and non-management employees but demand appropriate approaches if the intervention is to have a chance to succeed.

  • Participation. Calculating participation rates have been confusing. Some organizations count participation as the number of employees who register for the intervention. Other organizations count participation as those who show up for some percent of the number of intervention sessions. If we are to compare and move the science forward, we need to separate these two group via a clear definition. I clearly prefer the latter definition of participation.
  • Morale. Low employee morale, frustration and poor communications could easily lead to poor participation in workplace health management initiatives and mediocre performance by individuals and the organization. In each of these situations individual and organizational health and performance are negatively impacted. Fortunately, the health management staff interacts daily with the employees and should have a current reading of their morale. If the morale is high but participation is low, this may indicate something is wrong and the staff needs to do some one-on-one interviews to assess the situation and make program changes accordingly. Typically, approximately 60% of the employees report they did not know about the opportunity to participate thus the communications were not successful
  • Engaging in the initiative. Employees have choices to leave or stay depending on working conditions, organizational culture, or climate around their daily work schedule. The offerings or demands related to the health management initiative could also impact their feelings about the organization and actual engagement with the goals and intention of the organization. If the overall feelings are negative this could be an opportunity time for the Director or staff to try a different approach to the groups attitude or consult with human resources to get appropriate help within the company.
  • Motivation. Positive personal motivation is another one of the early markers contributing to the success of the health management initiative. This issue is about all employees, including those in management positions, feeling recognized and appreciated and having their needs met at the workplace. Sometime management and other employees are coming at issues from different angles. This presents the health initiative with an opportunity to make sure all employees find a common path to an agreement about personal attitudes. The staff is at an advantage since they are around the employees each day and understand the motivational climate and practical solutions.
  • Early stage metrics. Typically, we view metrics and measurement at the end of the year or at the end of a program. It is not unusual to get two different answers depending on when the values of the metrics are determined. Metrics and measurements mean more to the employee when taken closer to the activity and are better at driving motivation for future activity. It is like taking a test while in school and having to wait until the end of the year to find out how you did on the test or in the course. Participation metrics are early process indicators of success (after separating those who participated from those who only enrolled in the program.) Many programs lose valuable data for failure to collect the appropriate data at the appropriate time. Also, be sure the employees do not interpret these metrics as measures of their personal success. The objective of these early measures is evaluating the early successes of the intervention in maintaining the expected path leading to impacting the main-effects.
  • Early stage metrics and measurement. Measurement and communication need to be tied together. Measurement without communication leads to confusion and lack of motivation, and communication without measurement leads to a lack of trust among employees and management. Communications need to be transparent to employees and management. When communications lead to a problem with employees or management it needs to be discussed jointly and immediately.
  • Measurements and Statistics. The exclusive use of quantitative statistics often leaves everyone with nothing to discuss, since the results are either statistical non-significant, a very small but significant difference, or a chance of showing a significance in one or more of the main-effects. Many reasons can be created for lack of clear results. Positive statistical results are typically satisfactory to employees and to management. Regardless of the statistical outcome, in most cases quantitative statistics are not the right approach given the necessary assumptions about the distribution of the data and the continuous or non-continuous nature of metrics. Also, the individual’s results are hidden or buried in the group data. The measurement missed the fact that some individuals improved while other had no change or perhaps even got worse. Fortunately, most individuals know their own data and find their own level of satisfaction. Unfortunately, outsiders or management sees only the group results and loses sight of the individual results and inadvertently assumes that everyone moves in the direction of the results.
  • Qualitative analysis. There are many ways to give everyone a better and more realistic view of the data such as qualitative statistics which have fewer necessary assumptions, easier to understand, and individuals can see their true results. Also, individual counseling (by the staff or an experienced coach) is an effective approach and brings the individual closer to the true intention of the intervention and the total initiative.

Future work necessary for maturity:  How do we get to know what do not know now?

After our focus on the past, present, and short-term strategies for development of workplace positive health management, let’s now turn to what could be long-term strategies for the following two categories:

  • four levels of opportunity consisting of: practitioners, providers or consultants, academic researchers, and advanced researchers, and
  • the total field of workplace health management.

The strategies below are about my conclusions and recommendations of what we can consider a collaborative path to solve the simplistic issues, some of the complicated issues, and unbundle more of the complexity of health. As a result, we will bring increasing order to our work to further understand how positive health can move our organizations, employees, clients, families and communities further towards the full potential of being human.

The following are challenges by categories of contribution to workplace health management.

Challenges to practitioners, providers, and academic researchers

  • What constitutes a meaningful and practical health management initiative?
  • What is a reasonable participation rate for the respective employee categories?
  • What constitutes meaningful successes and outcomes in early-term, medium-term, and long-term main-effects?
  • Is there a check-list of key process success factors to accomplish along the way?
  • Other

Answers to these questions would move the field towards an orderly discovery of a solid foundation as we build into the future. Clearly, we need new understandings about simplistic, complication, and complexity of health. These new understanding will allow our continual growth into the future and bring the field closer to maturity as a serious scientific advancement towards the human potential.

Challenges to providers or consultants:

  • How does one intervention interact with another intervention and how do the outcomes compare?
  • When do the number or types of interventions begin to show decreasing value of the outcomes?
  • What is the timeline for each of the interventions to show a meaningful early and intermediately status and impact on the main-effects?
  • Other

These are important questions for providers and consultants to be able to give credible responses when organizations and practitioners ask about the efficacy and effectiveness of their suggestions.  Why offer the suggested interventions?  What are the expected and independent outcome compared to other interventions? How do the suggested interventions impact individuals and the organization? How do the metrics and measures appropriate for the interventions get measured and communicated?

Challenges to researchers employed by providers and consultants:

  • Is there a core set of interventions that account for 80% to 90% or more of the total value of the outcomes?
  • Is it possible to isolate the independent impact of one intervention?
  • Is it possible to incorporate the strength of the interaction of the interventions when measuring the impact on the main-effect?
  • Other

Researchers employed by providers need to be able to demonstrate how their recommended interventions perform when introduced to an employee group. Also, which employees are typically attracted to each of the interventions and what is the recommended sequence of introduction?  Providers and organizations themselves should be held accountable for the knowledge about how their products work, the recommended sequence of use, and the expected quantitative and qualitative outcomes.

Challenges to advanced researchers:

  • Is it possible to develop qualitative or quantitative methods and metrics to create a path-analysis of the impact from the intervention to the impact on the main-effect?
  • Is it possible to discover how to reverse the step by step pathway by starting with an outcome and working back to the intervention?
  • How do clusters of interventions impact outcomes more than the sum of the impacts of the individual single-focused interventions?
  • Discover new pathways of an intervention (or new interventions) to impact an existing or new main-effect and thus to encourage continual unraveling of the complexity of health.
  • Other

We have very few advanced researchers in our field. Most of those who do research are employed by provider organizations which puts them in a biased position to start with.  When advanced researchers are employed in Universities or in special non-profits entities we expect them to answer more in-depth questions. Answers to the above questions or statements are ones which would broaden the scientific base to allow us to rapidly increase our effectiveness in improving wellness, health and performance towards our human and organizational potential.

Challenges to the total field.

Many of the following statements are redundant to the above and even redundant to some of the statements in Post 1 through 7. My objective now is that I would like all individuals and organizations to be aware of the overall urgency of the addressing these questions.

Below are some of what I feel we do not know now but we need to know to lead this field to another level of maturity.

  • Evaluate the total impact of interventions by studying the impact on the early and intermediate stages and main-effects outcomes.
  • Evaluate the longer-term impact on main-effects and on the lasting impacts on the unintended consequences.
  • Evaluate double or triple counting of benefits from the various interventions
  • Clarify the biological and psychological paths taken by different interventions to get to the same main-effects or to several main-effects.
  • Unravel more of the complexity of health and poor health.
  • The discussion or answers to the above four issues (plus others) will help put our field into a recognized and defensible space and make credible advances and contributions to wellness, health, and performance of individuals and organizations.
  • Other

There have been hundreds of studies demonstrating an association of single-focused interventions with positive results for a variety of single outcomes (main-effect analyses). The authors of these studies should be congratulated but they may have inadvertently contributed to the confusion in the field and contributed to a threat to our effectiveness.  As we all know, more is not always better, and, in fact, some interventions take away a considerable amount of the effectiveness of other interventions and the initiative.

Another one of the learnings we had during my years of studying lifestyle, risks, clusters and behavioral research at the UM-HMRC was that many of these factors travel with other risk factors and even behaviors. I have a strong belief that interventions also travel in clusters, since so many of the interventions have similar impacts on the main-effects. We need to sort-out these positive and negative impacts on the main-effects.

We know lifestyle factors such as behaviors, biometrics, psychological, environmental, cultural, etc. as well as workplace environments, family, and community all have an impact on the health of an individual.  We now approach health as a complex challenge, which means that:

trying to understand results by looking for simplistic changes
in the main effect is, at best an association, and
unlikely to explain the true causal impact.

It is likely premature for me to expect widespread support or agreement that we are into complexity and certainly too early to have an organized discussion about addressing the issues.  However, we need to “lower the cannons” and look for commonalities rather than who or what solely represents the best or worst of the workplace positive health management initiatives.  We need to look for common ways each of us can help improve the health and performance of employees and of organizations.

Health of employees has been and currently is typically modelled after the holistic individual models of Maslow, WHO, Hettler, and the Positive Individual Health of Edington and Pitts.  Organizational health is typically measured by a collection of data elements including healthcare data, workplace culture, climate, environment, job and life satisfaction, engaging in healthy activities and risk factor reduction, and Positive Organizational Health of Edington and Pitts, and many others perhaps as important as those listed.

Final Words

Each of us needs to consider “what can I do?” This series of eight Posts has been especially important to me as I continue to transition from the Director of the University of Michigan Health Management Research Center (with terrific colleagues over the years) to an Adviser and Consultant role.

  • We all know that throughout history there have been situations where the threats or dysfunctional initiatives in organizations go unnoticed or ignored. I would like to open the conversation to full inclusion and transparency. I have watched storm clouds developing for some time now and I believe it is time to bring the issues into the light for a full discussion, thus my initial thoughts throughout this 8-blog series.
  • My strategy or intention is to have additional discussions with individuals in small companies working with other small companies or working with organizations who are focused at the grass roots level in health and wellness. You could also be working with large corporations with a focus on smaller-sized work groups.

My concern for Workplace positive health management are ever increasing when I think of all the conflicting tactical and generic advice that many intervention and communication “experts” are inadvertently convincing organizations to adopt.

My concern is we have inadvertently skipped a critical step during the initial process of introducing a workplace health management initiative into an organization. That missing step is: to awaken individuals and organizations of their best chance to achieve their potential by knowing the why, what, and how to acquire the attributes specific to their own needs and possibly the wants and needs of their family and community—this is the point of the stories and the eight posts—.

  • Everything that happens in our life impacts our health and the health of others, even a smile.
  • Employers win when the employees win, and the employees win when the employer wins
  • We can help the healthy people and the healthy organization stay healthy, at least to our current level of understanding of health.
  • Most questions begin with naïve simplicity but soon address the complications of health and poor health and finally attempt to unravel some of the complexity of health and poor health.
  • To get to a higher level of human potential we need to find the right “disruptive innovation” to discover the core of our individual and organization’s system.

Many of my suggestions are within the current scope and understanding of most of us in the workplace positive health management field. On the other hand, perhaps my vision for this field is beyond the dreams of others.  If so, we will need to integrate the more basic information and findings of others with the needs and context of practitioners and actual participants. Unfortunately, this would mean we will continue to follow the research findings of others in the different disciplines or between the disciplines who would be doing the systems thinking for us.

I feel it the responsibility of everyone in this field to:

  • become aware of and to teach others of the awareness, the knowledge, and the practice of positive health management;
  • feel it is the responsibility of every team, group, and professional organization to support one or several hours/sessions to this advanced thinking (call it “what if” time);
  • experience “what if” time to explore “what is it we do not know” to improve our innovative and creative minds; and
  • teach everyone to use their innovative and creative minds to create “Next Practice” designs to solve simple or complicated problems
  • We know more about poor health and treatment than about good health.
  • Is good health the absence of disease or is disease the absence of good health?
  • We know it is more expensive in terms of time and dollars to fix poor health than it is to help people stay in good health?

We need creative and committed people
if we are to be in a position
to turn this field over to the next generation of<
creative and committed people