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Measuring Progress Towards a “Culture of Health”: A Primer

Do you know whether heartburn pills are safe for long-term use?

Conventional “pry, poke and prod” wellness died last month, when Ron Goetzel, in an unexpected and unprecedented display of candor, announced that only “about 100 programs” have succeeded, but “thousands” fail.  That failure rate validates what we’ve been saying all along: wellness isn’t an industry–it’s a lottery. It was worth all the abuse I’ve taken for the satisfaction of seeing Ron — and most of his cronies — finally succumbing to proof.

new yorker wellness

Now that I’m done gloating (for today), it’s time for everyone to take Dee Edington’s advice instead — most recently in his new book coauthored with Jennifer Pitts — and move towards the attainment of a culture of health.  (Dee is joined in this pursuit by Jon Robison and others — all have advocated this for a long time.)

Ironically, that means cutting way back on your screenings, to a level that adheres to US Preventive Services Task Force guidelines, and investing the savings in your culture of health.

[Cue 10-second shameless plug…]

Obviously, Quizzify would be one such investment — our mantra is: “To create a culture of health, one must create a culture of health literacy.”

But this post isn’t about how to create such a culture, an undertaking whose complexity and direction will vary by organization. This post is about how to measure it.  It’s a clip-and-save (or download-and-file) set of metrics that might be expanded or otherwise modified over time, with reader input.

Holdover metrics

Most conventional measurements are about preventing diabetes and heart attacks, but your avoidable cost lies elsewhere — the top 25 DRGs have almost nothing to do with wellness.  Further, some metrics, like BMI, are demonstrably invalid as a population health measure. Considering all the conventional metrics together, even award-winning programs don’t generate noticeable improvements despite measuring only self-selecting active repeat participants. (Not to mention that Vitality, itself in the wellness business, couldn’t improve its own employees’ key metrics.)

Having said that, I would continue to measure one health outcome metric: “wellness-sensitive medical events (WSMEs),” as recommended in Why Nobody Believes the Numbers and now (albeit reluctantly) recommended by HERO.  Most importantly, that metric is a mainstay of Intel’s esteemed Validation Institute. The V-I has bestowed recognition on a select handful of health plans — Blue Cross of Louisiana, Blue Cross of South Carolina, Harvard Pilgrim, Novacare, Presbyterian, Providence.  You can see from the links how they use these measures to track (and reduce!) WSMEs (or just disease management events, depending on the plan). That measure is objective.  WSME rates respond to both disease management and wellness.  There is no selection bias, no regression to the mean. It is the single best indicator of control and avoidance of chronic disease.

New Proposed Metrics

A “culture of health” can’t be measured with facile blood values or weight. You need to measure culture, not lipids. And you need to do it without lining up employees to be weighed or otherwise inconvenienced or even humiliated. Weigh-ins disrupt your organization both literally and figuratively…and not in a good way.

Quite the opposite, my experience running a NASDAQ company steers me to measures that don’t disrupt operations to collect data. Those would be easily collectible, objective, and population-wide measures. Remember, you need the support of line managers, and an excellent way to get that support is bringing them insights, not taking their staff off the job.

Let’s start with absenteeism.  All-cause absenteeism is a great metric because absenteeism rates reflect not only illness, but stress, depression, and general job dissatisfaction – all indicators of a healthy culture.

It’s not that easy.  For starters, organizations must first distinguish scheduled from unscheduled paid time off. Once you’ve done that, here are several things to consider.

  1. Focus on changes in absenteeism, not absolute levels. We don’t have a benchmark. Benchmarks will vary by industry anyway.
  2. Measure everyone, not just “high-risk” employees who were in an “absence management program.” That is pure regression to the mean. The 20% who were most often absent last year will mostly not be the 20% who are most often absent this year.  So your program will always show success but your overall lost work days likely won’t decline.
  3. And don’t use self-reported changes, with questionnaires and HRAs asking: “How much work did you miss last year because of such-and-such?”

Next, recruitment/retention. What are your rates?  Why do people say they want to work at your company? What do they say on exit interviews? Do you force-rank employees or track the ones you most want to keep?  Compare your retention rates for them to other employees, who may stick around only because they don’t have other attractive options for employment.

Finally, some process-oriented organizations (like manufacturers) have easily measurable productivity standards.  Rework/defect rates might be one measure, though that could have a high signal-to-noise ratio.  If specifically health is being measured, rework/defect/incident and other productivity measures towards the ends of shifts could be contrasted with rates earlier in the day.  If a healthy workforce in a healthy culture does anything, it should be avoiding fatigue…and mistakes due to fatigue should correlate with continuous hours worked.

Each of those is a top-line measure, that would then lead to root-cause examination…and at this point we can’t offer a one-size-fits-all solution (though my colleague and co-owner of this blog, Vik Khanna, consults on this topic). But that’s what measurement is all about—measure, manage, and then re-measure.  This difference is that for culture of health measurement, let’s start with valid measurements instead of repeating the mistakes of the past.

This is just a starting point.  We look forward to your comments, here and on linkedin, to refine these measures and take them to the next level.  Perhaps we will post an updated version including those new ideas.


  1. Mitch Collins says:

    I am always amazed when wellness apologists say “Well designed programs……” work, save money or whatever. But almost no one is able to do so. Hmmmmmm….


  2. Rosie Ward says:

    I would add that a “Culture of Health” is a step in a better direction but still very flawed. What the industry calls “culture” is really Climate – programs, policies and interventions that support healthy lifestyles. That’s nice, but who cares if your organization has a “culture of health” when the actual underlying culture is dysfunctional? Climate (aka “culture of health”) is merely a manifestation of the underlying culture…which is fundamentally guided by the quality (or lack thereof) of leaders and the quality of the employee experience they create. We can measure culture – and the FUSION (i.e., interconnectedness) of organizational wellbeing measures (e.g., quality of leadership, feeling connected to the company vision, having purpose in their work, etc.) and employee wellbeing measures (no blood tests here):


    • whynobodybelievesthenumbers says:

      I see your point. I feel like Quizzify doesn’t have a “culture of health,” but it does have a healthy culture. And there is a difference. Still, as you say, culture of health trumps pry, poke and prod even if it’s not the final step.


      • drrosieward says:

        Well, for what it’s worth (and I can only go off experiential data over years, not empirical data), Building healthcare consumerism skills is the ONE exception I’ve found when it comes to offering programs to employees…meaning organizations can have even a toxic culture but if done well and positioned and communicated well, employees actually appreciate learning how to better navigate this complex, messed up system. The worst I’ve ever heard (and these employees were mandated to attend) is, “thanks…that wasn’t as bad as I’d thought it would be”. Adding value in helping employees in this space versus trying to control their lifestyle behaviors can be a decent first step in overcoming “wellness or else” programs and helping to mend fences where employees might start to feel a little valued. But even that will only go so far if the organization doesn’t work on it’s underlying culture issues. 🙂


      • whynobodybelievesthenumbers says:

        We get similar reports about Quizzify. Literally someone wrote “this is nowhere near as bad as the wellness program.” It left us blushing…


  3. Sam Lippe says:

    great measurement ideas! I wish I could come up with more. What’s lacking is a way to measure culture of health or healthy culture in businesses that don’t produce widgets.


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