integrating tobacco control into health care delivery charles j. bentz, md, facp medical director:...
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Integrating Tobacco Control into Health Care Delivery
Charles J. Bentz, MD, FACP
Medical Director: Tobacco Cessation and Prevention
Providence Health System: Oregon
Quitting saves lives… •34,439 male British doctors•Smokers die 10 years younger•Cessation improves life expectancy
Doll R. et al. Mortality in relation to smoking: 50 years‘ observations on male British doctors BMJ, doi:10.1136/bmj.38142.554479.AE (June 2004)
Age quit Years gained
30 10
40 9
50 6
60 2
What is Success?• Spontaneous Quit Rates 2-3% quit @ 1 year • Office-based (dose-response)
– Minimal Counseling: 4%– Brief Counseling: 5%– Counseling: 8-10%
• Interactive internet 5-10%• Interactive telephone 10-25%• Group classes 15-25%• Classes with medication 25-35%• Residential treatment 45-50%
Public Health Service Guideline 2000Hughes et al, CA cancer journal clinic, 2000 50:143Providence Tobacco Cessation & Prevention Program
Costs of Smoking
• Business Costs of employees who smoke:– Greater absenteeism– Time spent on smoking rituals– Higher health care costs– Higher life insurance premiums– Higher risk of industrial/occupational injury– Higher disability costs– Higher number of disciplinary actions
Indirect Employer Costs:
• On average– Male smokers miss 3.9 more days/yr– Female smokers miss 2.1 more days/yr
• In Oregon– Annually 1,000,000 lost days: $100,000,000– Annual costs of lost productivity due to
premature deaths: $600,000,000
Warner KE, Journal of Occupational & Environmental Medicine, 1996Oregon Tobacco Facts: Department of Human Services, October 2001
Direct Medical Costs in Oregon
• Smokers use the health care system 50% more than non-smokers
• Annual direct medical expenditures:– Private individuals / business: $450,000,000– Public funds: $350,000,000
• Annual cost per tobacco user: $3000
• Annual cost per Oregonian: $750Oregon Tobacco Facts: Department of Human Services, October 2001Clearing the Air at Work: Orange County Health Care Agency, 1994
Cost of workplace tobacco dependence
$ 1,000,000
$ 2,000,000
$ 3,000,000
$ 4,000,000
$ 5,000,000
$ 6,000,000
$ 7,000,000
1,000 2,000 3,000 4,000 5,000 6,000
Blue colla
r (36%)
White collar (15%)Mixed workforce (26%)
Source: Mercer Human Resources Consulting, New York, NY
Number of employees
Cost-Effectiveness
Quist-Paulsen P, et al. Eur J Cardiovasc Prev Rehabil, 2006, 13(2):274-280
Treating tobacco dependencereduces costs
• Comprehensive tobacco dependence treatment achieves quit rates of 10%to 35% per year
• No other disease prevention measures are as well tested or successful
• Employers can realize positive first-year returns on this investment and future returns exceeding 300%
US Department of Health and Human Resources, Rockville, MD Mercer Human Resources Consulting, New York, NY
How do we do a better job….
…treating tobacco use and dependence?
Treating Tobacco Dependence: 1993
SMOKER(who wants to quit)
Cessation•Group Classes•Pay Full Price•2 dozen / yr
Providence Health System Task Force on Tobacco Cessation and Prevention
• Physician Leader• Program Manager• Respiratory Care• Pharmacy• Human Resources• Behavioral Health• Employer Health• Prov-RN
• Health Education• Research Analyst• Oregon Lung
Association • Quality Management• Women & Children’s
Program• Thoracic Oncology• E-Health Representative
Prevention Planning Process: 1994
ProvidersWe need to have a dedicated Physician Champion who can lead this effort. We also need provider education and incentive
InterventionsWe need to put in place the benefits for evidence-based interventions to help current smokers quit
ClinicsWe need to develop and implement changes in infrastructure needed to address tobacco systematically in clinics
Health SystemWe need to have a regional focus on every thing we do. The health system needs to win.
Target GroupsIn addition to population based efforts, we also need to target those at highest risk, employees, and special populations
CommunityFrom the start we need to strategically partner to allow for a prevention focus (vs. treatment)
SMOKER(who wants to quit)
EvaluationWe need to make measuring qualitative and quantitative outcomes a priority
HospitalsAcute care is the key strength of our health system
Treating Tobacco Dependence : 1994
Providers•Physician Leadership
SMOKER(who wants to quit)
Cessation•Group Classes•Pay Full Price
Treating Tobacco Dependence : 1995
Providers•Physician Leadership
Cessation•Group Classes
•$5 copay•Self-Help Materials
Clinics•EMR Resources
Health System•Prevention Planning
Target Groups•PHS employees
Community•TOFCO
SMOKER(who wants to quit)
Treating Tobacco Dependence : 1996
Providers•Physician Leadership•5 A’s Training/Education
Cessation•Group Classes•Self-Help Materials•NRT Benefit•Telephone Support
Clinics•EMR Resources•5 A’s Training
Health System•Population Health Improvement
Community•TOFCO•Legislation
Hospital-Based•Inpatient Program
•Proposal
Evaluation•C.O.R.E.•Utilization
SMOKER(who wants to quit)
Target Groups•PHS employees
Treating Tobacco Dependence : 1997
Providers•Physician Leadership•5 A’s Training/Education•Reimbursement
Cessation•Group Classes•Self-Help Materials•NRT benefit•Telephone Support
Clinics•5 A’s Training•EMR Resources
Health System•PHI funding•Statewide Guideline
Target Groups•PHS employees •Clinical Programs
Community•TOFCO•Legislation•Guideline
Hospital-Based•Inpatient Program
•2nd proposal
Evaluation•C.O.R.E.•Utilization•CQI
SMOKER(who wants to quit)
Treating Tobacco Dependence : 1998
Providers•5 A’s Training/Education•Reimbursement •Physician Leadership
Cessation•Group Classes•Medication benefit•Telephone Support•Self-Help Materials
Clinics•5 A’s Training•EMR Resources•Resources: Primary Care, Specialties, Pediatrics, OB/GYN
Health System•Funded Research
•$180,000
Target Groups•Disease Management•PHS employees• OMAP Project Prevention
Community•TOFCO•Legislation•Oregon Quit Line
Hospital-Based•Inpatient Program•Behavioral Health/CD
Evaluation•C.O.R.E.•Programs•CQI
SMOKER(who wants to quit)
Treating Tobacco Dependence : 1999
Providers•5 A’s Training/Education•Reimbursement •Physician Leadership
Cessation•Group Classes•Medication benefit•Telephone Support•Self-Help Materials
Clinics•5 A’s Training•EMR Resources•Paper-Based Resources•Resources: Primary Care, Specialties, Pediatrics, OB/GYN
Health System•Funded Research
•$230,000
Target Groups•Disease Management•PHS employees•Primary Care
Community•TOFCO•Legislation•Oregon Quit Line
Hospital-Based•Inpatient Program•Behavioral Health/CD
Evaluation•C.O.R.E.•Programs•Research
SMOKER(who wants to quit)
Treating Tobacco Dependence : 2000
Providers•5 A’s Training/Education•Reimbursement •Physician Leadership
Cessation•Group Classes•Medication benefit•Telephone Support•Self-Help Materials
Clinics•5 A’s Training•EMR Resources•Resources: Primary Care, Specialties, Pediatrics, OB/GYN
Health System•Funded Research
•$260,000•NCQA Accreditation•1st AAHP Award
Target Groups•Disease Management•PHS employees• Women & Children
Community•TOFCO•Legislation•Oregon Quit Line
Hospital-Based•Inpatient Program•Behavioral Health/CD
Evaluation•C.O.R.E.•Research•Publications
SMOKER(who wants to quit)
Treating Tobacco Dependence : 2001
Providers•5 A’s Training/Education•Reimbursement •Physician Leadership
Cessation•Group Classes•Medication benefit•Telephone Support•Self-Help Materials
Clinics•5 A’s Training•EMR Resources•Provider feedback•Resources: Primary Care, Specialties, Pediatrics, OB/GYN
Health System•Funded Research
•$810,000•2nd AAHP Award
Target Groups•Disease Management•PHS employees• Women & Children
Community•TOFCO•Legislation•Oregon Quit Line
Hospital-Based•Inpatient Program•Behavioral Health/CD
Evaluation•C.O.R.E.•Research•Publications
SMOKER(who wants to quit)
Treating Tobacco Dependence : 2002
Providers•5 A’s Training/Education•Reimbursement •Physician Leadership
Cessation•Group Classes•Free Medications•Telephone Support•Self-Help Materials•Prov-RN
Clinics•5 A’s Training•EMR Resources•Resources: Primary Care, Specialties, Pediatrics, OB/GYN
Health System•Research > $800K•OR DHS Award•3rd AAHP Award
Target Groups•Disease Management•PHS employees•Women & Children•Web-Based
Community•TOFCO•Legislation•Oregon Quit Line
Hospital-Based•Inpatient Program•Behavioral Health/CD
Evaluation•C.O.R.E.•Research•Publications
SMOKER(who wants to quit)
Treating Tobacco Dependence : 2003
Providers•5 A’s Training/Education•Reimbursement •Physician Leadership
Cessation•Group Classes•Free Medications•Telephone Support•Self-Help Materials•Prov-RN
Clinics•5 A’s Training•EMR Resources•Resources: Primary Care, Specialties, Pediatrics, OB/GYN
Health System•Research > $800K•Leadership: ATMCRWJF, CDC, AAHP•H.S.I. Program
Target Groups•Disease Management•PHS employees•Web-Based•Women & Children•Clinical Programs
Community•TOFCO•Oregon Quit Line•Business Case
Hospital-Based•Inpatient Program•Behavioral Health/CD
Evaluation•C.O.R.E.•Utilization•CQI
SMOKER(who wants to quit)
Treating Tobacco Dependence : 2004
Providers•5 A’s Training/Education•Reimbursement •Physician Leadership
Cessation•Group Classes•Free Medications•Telephone Support•Self-Help Materials•Prov-RN
Clinics•5 A’s Training•EMR Resources•Resources: Primary Care, Specialties, Pediatrics, OB/GYN•TAR SOFTWARE outreach
Health System•Research > $800K•H.S.I. Program•Leadership: ATMCAAHP-HIAA
Target Groups•Disease Management•PHS employees/policy•Web-Based•Women & Children•Clinical Programs
Community•Oregon Quit Line•Make it Your Business•Statewide Conference
Hospital-Based•Inpatient Program•Behavioral Health/CD
Evaluation•C.O.R.E.•Clinical programs
SMOKER(who wants to quit)
Treating Tobacco Dependence : 2005
Providers•5 A’s Training/Education•Reimbursement •Physician Leadership
Cessation•Group Classes•Free Medications•Telephone Support•Self-Help Materials•Prov-RN
Clinics•5 A’s Training•EMR Resources•Resources: Primary Care, Specialties, Pediatrics, OB/GYN•TAR SOFTWARE outreach
Health System•Research > $800K•H.S.I. Program•Leadership: CMS•4th National Award
Target Groups•Disease Management•PHS campus policy•Web-Based•Women & Children•Clinical Programs
Community•Oregon Quit Line•MIYB grant•TOFCO/Chest Watch
Hospital-Based•Inpatient Program•Behavioral Health/CD
Evaluation•C.O.R.E.•Clinical programs•Publications
SMOKER(who wants to quit)
Treating Tobacco Dependence : 2006
Providers•Provider Education•Reimbursement •Physician Leadership
Cessation•Group Classes•Free Medications•Telephone Support•Self-Help Materials•Nurse Help Line
Clinics•5 A’s Training•Electronic Health Record•Connection to Quit Line
Health System•National Awards•National Benchmark•NCQA Accreditation
Target Groups•PHP Disease Mgmnt•PHS employees•Web-Based•Women & Children•Clinical Programs (TOP)
Community•Tobacco Tax•Oregon Quit Line•TOFCO (MIYB)
Hospital-Based•Inpatient Program•Behavioral Health/CD
Evaluation•Tobacco a QI•Research
SMOKER(who wants to quit)
Treating Tobacco Dependence : 2007
Providers•Education•Reimbursement •Physician Leadership
Cessation•Group Classes•Free Medications•Telephone Support•Self-Help Materials•Nurse Help Line
Clinics•5 A’s Training•Electronic Health Record•Quit Line Connection
Health System•National Benchmark•CDC, RWJF, SCLC•NCQA, ATHC, LA
Target Groups•Disease Management•PHS employees•Web-Based•Women & Children•Clinical Programs
Community•Oregon Quit Line•TOFCO (MIYB)•Step Up!
Hospital-Based•Inpatient Program•Behavioral Health/CD
Evaluation•Research•Tobacco as QI•GWTG, CMS
SMOKER(who wants to quit)
Smoking Prevalence in PHP vs. Oregon
15%16%17%18%19%20%21%22%23%24%
State of Oregon (BRFS) Providence Health Plan: Oregon
“The program at Providence is the platinum standard
for tobacco cessation in health systems”
Steve Schroeder MDDistinguished Professor of Health and Health Care
Director: Smoking Cessation Leadership CenterUniversity of California San Francisco
September 24, 2004
It takes a clearly identified goal…
“At every point where patients come into contact with our health
system, tobacco use will be assessed and addressed.”
Providence Tobacco Task Force, 1994
How can we do a better job of addressing tobacco?
Clinic: It starts by making tobacco-use a vital sign…
Then you progress to the Five A’s of Tobacco Cessation
• ASK: about tobacco use at every visit
• ADVISE: urge all tobacco users to quit
• ASSESS: willingness to quit
• ASSIST: aid the patient in quitting
• ARRANGE: schedule follow-up
The “Motel Syndrome”
“Many group-practices are really solo-practices in disguise”
5 A’s in Providence
• ASK: Nurse (vital sign)
• ADVISE: Provider (brief, clear)
• ASSESS: Provider (ready to quit?)
– NO: Message and move on
• ASSIST: – Refer to the Oregon Quit-Line
– Counseling and Medication
– Referral to Behavioral Program
• Cessation classes
• Providence Resource Line
• www.providence.org/classes
• ARRANGE: – Quit Line refers to programs
– Make a follow-up appointment
ASKASKADVISEADVISE
Two Options for Two Options for Connection with Connection with
QuitlineQuitline
Diagram of “Quit Line Connection” in Primary Care
ARRANGEARRANGE
ClinicClinic
ClinicClinic
Patient completes Form. Form faxed to Quit Line. Quit Line contacts patient.
After initial smoking cessationintervention, QuitLine staff refer patients to appropriate resources
and return fax form to clinic
PatientPatient
Oregon Quit LineOregon Quit Line
Brochure givenPatient contacts quitline
at their convenience.
PatientPatient
Tobacco Use Documented in
Chart Advice to quit and Stage of readiness to quit Documented in ChartProvider refers to Quit Line
ASSESSASSESS
ASSISTASSIST
Free & ClearFree & Clearoror
Local ProgramsLocal Programs
ProgramProgram
Bentz CJ, et al. American Journal of Preventive Medicine,2006. 30(1): 31-37.
Paper Quit LineFax Form
Electronic Quit Line Fax Form
“Quit Line Connection”
• This is a best practice for cessation• Offloads providers and streamlines process• Inexpensive, feasible, well accepted• “Front-Door” to Providence tobacco
program• Oregon DHS has resources available
– DHS can send someone to your office– 5 A’s training– Set up a “Quit Line Connection”
Am J Prev Med 2006;30(1)
Type of Connection
Cost per
connect
Comment
Physician Office
Year 1$15-38 This varies depending upon whether
you include the cost of reimbursement for provider time and food (pizza).
Physician Office
Subsequent years$4 This is based upon the assumption
that referral rates remain relatively stable in subsequent years.
Media-Driven campaign $100-400 This does not include production costs, royalty fees, contract management, media coordination.
Louisiana Tobacco Quit Line In operation since September 2000
Website: www.mytfl.org
Number: 1 (800) QUIT NOW Languages: English, Mandarin, Cantonese, Korean, Vietnamese, French, Russian, over 150 languages Hours of Operation:Counseling available: Mon 6:00 to 23:00Tues 6:00 to 23:00Wed 6:00 to 23:00Thurs 6:00 to 23:00Fri 6:00 to 20:00Sat 8:00 to 18:00Sun 8:00 to 18:00
Live pickup of incoming calls: Mon 24 hoursTues 24 hoursWed 24 hoursThurs 24 hoursFri 24 hoursSat 24 hoursSun 24 hours
Louisiana Tobacco Quitline
• Counseling: – Unlimited sessions– 1st session: 30 min– Follow-up: 10-15 min
• Web Services– Cessation Information – Web-based cessation
intervention– chat room
• Other Services– Voice mail with call back, referral
to other services– Fax referral for providers and
others– Mail or email self-help information
Who should call the Quit Line?
• Teen tobacco users
• Pregnant tobacco users
• Smokeless tobacco users
• Former smokers who need relapse prevention
• Providers who require information for patients
• Friends and relatives of tobacco users
• Non-English speaking tobacco users
You can lead a horse to water…
but you can't make him drink.
John Heywood (c.1497-1580)
Changing Provider Behavior
• Passive strategies are ineffective (CME)• Active approaches are more effective
– Educational Outreach– Audit and Feedback– Prompts and Reminders– Multi-faceted approaches are most effective
• Not much is known about the specifics• Incentives are effective ($$)
5 A’s Tobacco Cessation Using A Primary Care EMR
Portland, Oregon
Principal Investigator: Charles J. Bentz MD, FACP
Co-Investigators & Research Team: K. Bruce Bayley, PhDErik BergstromKerry Bonin, MPHNancy Davis, MPHLori FlemingJack Hollis, PhDJacquelyn Hunt, PharmDBenjamin H. LeBlanc, MDTimothy McAfee, MD, MPH Joseph Siemienczuk, MD
Feedback Study: Design
20 EMR Clinics:Quitline Connection
Training in 5 A’sMatched based on
Clinic Size, Payor mix,Baseline Ask rates
Intervention: Monthly Feedback on 5 A’s that are
documented in EMR
Control:No Feedback
R
Primary Outcome:
Number of patients connecting with the Tobacco Quit Line
Secondary Outcomes:
EMR rates of 5 A’s, Qualitative analysis, Cost Effectiveness analysis
Results: EMR Documentation
*Adjusted for cluster effects, presence of clinic champion, case mix, baseline ask rates, insurance mix, clinic size, volume
Bentz CJ, et al. Nic & Tob Res. March 2007 9(3)
Results: Quit Line Contact
Bentz CJ, et al. Nic & Tob Res. March 2007 9(3)
Conclusions: • EHR-generated feedback increases documentation
of assistance with tobacco cessation. • Two important predictors:
– patient case mix – presence of a local clinic champion
• Feedback is more effective when combined with alerts and reminders
• The feedback instrument should focus on a single key measure
Quit Line Disruption • Due to budget crisis, funding ceased April 2003 • This disruption had a major impact on referral• This highlights the need for stable funding • Any health system considering the use of a state-
level quit line as the prime referral source:– Should meet with the state agencies and the service
provider to ensure stability of funding and service
– If funding is not secure, other mechanisms such as direct contracting for service should be considered
What about the hospitals?
Step Up!
• Cessation benefits for all hospital employees
• The Five-A’s for all hospitalized patients
• Pharmacist-assisted cessation classes
• Hospital tobacco-free campus policies
• Help hospitals provide leadership for local businesses to curb tobacco use
State of Oregon TPEP, OAHHS, Acumentra Health, ONA, SCLC, hospitals, and health systems and professional associations in Oregon
Providence Health System Pharmacist-Assisted Cessation Classes
• Three Portland Hospitals• 11-sessions over 8 weeks• Medication included
– Patch, bupropion, or varenicline– No out-of-pocket expense– Pharmacist leads first class, attends the
second class, remains available – Partial fill (every 2-3 weeks)
• PHP $15, General Public $225• 33-35% 1 year quit rates
Patients can register online at www.providence.org/classesor call the Providence Resource Line at 503-574-6595
Inpatient Smoking Cessation
In terventionM o tiva tio n a l
C o g n it ive / B eh a vio ra l
R eso urces"S u rv iva l K it"
R e fe rra l In fo rm a tion
P h arm aco th erapyP re -p rin te d O rd er S e t
N R T / N on -n ico tine
N o tifica tio n o f P CPP e rso n a l L e tte r
R e so u rces
INTERVENTIONAssessment by T rained Therapis t
"D o you need he lp w h ile in Hosp ita l?""A re you in te rested in rem a in ing S m oke-F ree?"
RESPIRATORY CAREDaily Census of Inpatient Smokers
P rin ted e very m orn in g in R esp ira to ry C a re D e p a rtm e nt
ACCESS SERVICESSystematic Identification of Current Smokers
E very pa tien t asked "H ave you sm oked in the past yea r?"Ask
Advise
Assess
Assist
Arrange
It starts at admitting…
Tobacco Use Status Ascertainment at Admission: Portland Service Area Hospitals
0%
20%
40%
60%
80%
100%
Aug-9
8
Oct-9
8
Dec-9
8
Feb-9
9
Apr-9
9
Jun-9
9
Aug-9
9
Nov-9
9
Jan-0
0
Mar
-00
May
-00
Jul-0
0
Sep-0
0
Nov-0
0
Jan, 0
1
Mar
,01
May
, 01
Jul, 0
1
Sept,
01
Nov, 0
1
Jan, 0
2
Mar
, 02
May
, 02
July,
02
Sept,
02
PMH PPMC PSVMC
ProvidenceTobacco Dependent Patient Dosing Guideline
Systematic vs. Non-Systematic: PHS Inpatient Cessation Program
Data: HBOC
0
2000
4000
6000
8000
10000
1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Inpatient smokers counseled in 3 PSA hospitals
You can’t change what you can’t measure…
W. Edwards Deming (1900-1993)
Key Points on Measurement
1. Use sampling – frequent, small samples
2. Define quantitative vs. qualitative measures
3. Use outcome, intermediate and process measures
4. Don’t let unsophisticated systems slow you down
5. Plot data over time, with short time intervals
6. Seek usefulness not perfection
7. Integrate measurement into the daily work
Nelson EC, Annals Int Med. 1998, 128:460-466
Being a “Change Agent”
‘Change’ is not so much about overcoming resistance as it is about creating attraction…
‘Resistance’ is really attraction to factors in the current system that we might not fully appreciate
Paul Plsek
Being a “Change Agent”• Learn to recognize naturally occurring change• Identify “Attractors”• Explore rationality of other’s point of view• Reduce Risk for those involved• Understand the issues of those you wish to change• Create changes that are “Exothermic”• Produce system changes• Accept responsibility and learn from failures• Focus on building relationships of trust
Health System Conclusions…
• Starts with enlightened administrators– If no ‘top-down’ try ‘sideways-in’– The ‘Deep Throat’ analogy: “Follow the Money…”
• Multi-Disciplinary Group/Physician Champion• Start with comprehensive cessation benefits• Do one thing at a time and do it well• The Oregon analogy: If you plant enough trees,
pretty soon you will have a forest….• Community focus
Lessons we learned…
• Local Ownership of Process
• Coordination and Sharing of Resources
• Focus on the customer
• Understanding Change Agency
• Patience and Optimism
• Tobacco Cessation is a team sport
Step Up!
• Every Hospital in Oregon– Robust Cessation Benefits– 5 A’s for All Hospitalized Patients– Pharmacist-Assisted Cessation Classes– Tobacco-Free Hospital Campus– Community Leadership in Cessation
State of Oregon TPEP, OAHHS, Acumentra Health, ONA, SCLC, hospitals, and Providence Health System and many other health systems and professional associations in Oregon
NorthamptonWarren
Lee
Wilkes
Henderson
Watauga
Scotland
Guilford
Rockingham
Moore
AnsonRichmond
Cabarrus
Stanly
Surry
Forsyth
Stokes
Davidson
RandolphRowan
Lincoln
Gaston
Iredell
CaldwellAlexander
Catawba
Burke
McDowell
Buncombe
Polk
MadisonYancey
Cherokee
Graham
ClayMacon
Jackson
Swain
Avery
Davie
Montgomery
Mitchell
Haywood
Wake
Granville
Person
Orange
Hoke
Robeson
Columbus
Brunswick
PenderBladen
Sampson
Duplin
Onslow
Jones
Lenoir
Johnston
Harnett
Carteret
CravenPamlico
BeaufortHyde
Tyrrell Dare
Gates
Hertford
Bertie
Martin
PittGreene
Wilson
NashFranklin
Halifax
Edgecombe
Vance
DurhamAlamance
Cumberland
Washington
Perquimans
Currituck
Chowan
NewHanover
Chatham
Caswell
Union
Mecklenburg
Ashe
Rutherford
Transylvania Cleveland
Alleghany
PasquotankYadkin
Camden
Wayne
Hospitals that have passed a 100% tobacco-free campus wide policy
Hospitals that have publicly announced that they will become 100% tobacco-free campus wide
Hospitals that have not yet passed the 100% tobacco-free campus wide policy
For more information, contact Melva Fager Okun DrPH, NC Prevention Partners, 88 Vilcom Circle, Suite 110, Chapel Hill NC 27514, 919 969-7022 ext. 3#, [email protected]. The Healthy Hospital Initiative is managed by NC Prevention Partners. The initiative is funded by The
Duke Endowment and in partnership with the NC Hospital Foundation.
Last updated on 10/30/06
© 2006 NC Prevention Partners
The Healthy Hospital Initiative supports hospitals to establish campuses that are 100% tobacco-free.
12-month Timeline Month OneCOO of each acute care facility commits to 100% tobacco-free campus wide policyPHS Tobacco Program Strategic Planning session Examine other hospital smoke free policies promotional materials and signage, Establish an Tobacco-Free Policy committee (include at least one tobacco user)
HR, Security, physicians, nursing, pharmacy, health education, PR, community relations, Facilities manager, tobacco cessation expert, and legal counsel
Develop a communication plan and timeline for the coming year.Present to Board of Trustees, get input and notify them of policy development
Month TwoPromotion to current employees about tobacco benefitsDetermine any and all costs of Tobacco-Free policy implementation, submit budget requestsDetermine if we need to expand tobacco benefit coverage (counseling and medication)Ensure that access to medication and counseling is at low or no-cost, renewable every yearEstablish standing orders for counseling and medication for patients in every clinical area (5 A’s)Establish Quit Line Connections from all clinical settings.
Month ThreeReview other hospital’s policies and analyze applicability.Evaluate every aspect of acute care facility where smoking occursCreate list of other buildings and areas to be included in the policy (where you have employees located off-site)Evaluate and Consider employee incentives. Decide if smoking will be available in cars, or if employees will be able to go off-site during breaks.
Month FourWrite policy and present policy to legal counsel for review, changes, and approval.
12-month Timeline Month Five
Develop FAQ sheet
Develop and implement procedure for informing all patients about new policy and cessation benefits
Develop materials for in-take personnel to use when admitting patients
Develop and distribute materials for promoting the Tobacco Quit line.
Develop communication plan for announcing the policy initiative
Month Six
Presentations to all in-house and referring physicians, nurses, and allied professionals
Presentations to all support staff, other employees, and managers
Month Seven
Present the policy to hospital board for discussion and input and sign off.
Inform all employees of the expected policy and solicit their support
Walk campus to determine where signage is needed, including large signs at main entries to the campus.
Develop signage to put tobacco use is allowed and near all cigarette butt receptacles.
Prepare letter from CEO to go out to all employees informing them of the new policy
Prepare promotional campaign for cessation benefits for smokers.
Have hospital PR department begin outreach to all community media outlets
Graphics for major banner for hanging in main lobby or on side of hospital building at the main entrance.
Develop two sets of signs; one for posting upon passage of the policy and a second set after policy enactment. Signage should be omnipresent, attractive, and bold. You should have a sense of tripping over the signs. Good signage is a fundamental part of communicating the new policy.
Seek input from tobacco users about signage and promotional materials.
Order signage.
12-month Timeline Month Eight
Present the policy to hospital board of trustees for passage.
Mail letter from CEO to all hospital employees.
Mount all signage and banner.
Promote the counseling and tobacco cessation pharmaceutical products and services available to all employees.
Share information on incentives to quit (? lower premiums for health insurance coverage, free resources, $$)
Communicate with and make presentations to community leaders and groups
Medical, civic, governmental, business, and religious organizations.
Meet with media representatives, including editorial boards.
Month Nine
Distribute patient flyers about new policy in all appointment reminders.
Promote tobacco cessation resources – including in-house group and individual sessions
Distribute suggestion boxes in key locations asking for employee suggestions and feedback.
Month Ten
Conduct staff training to prepare management-level staff for the enactment of the new policy.
Develop a program to encourage employees to help and consider rewarding such efforts.
writing a Letter to the Editor
submitting a church bulletin notice
serving as a tobacco quitting buddy
helping to assure the campus is tobacco-butt free
helping with survey of employees about policy
asking for suggestions for improvement
approaching community businesses to donate prizes
12-month Timeline Month Eleven
Repeat promotion of cessation interventions for all tobacco-using employees
Develop patient intake document to verify (signature) that patients are aware of policy
Make copy for patient, family and copy to go into patient folder.
Develop materials for employees to give to tobacco users
Conduct a senior management training session on the new policy.
Begin countdown to launch – ten days out.
Celebrate upcoming new policy with fun event for all employees
Ice cream social
Walk around the campus
Hospital CEO and conducts a Q&A session with all employees
Develop a new FAQ sheet.
Contact, educate, and assist adjacent community neighbors
Work with them on concerns in anticipation of the new policy
Discuss possible impact on their property.
Determine compliance measures
Create job descriptions, expectations, and schedule for ongoing assessment and reporting
Month 12:
GO LIVE
Celebrate with a Large Health Fair on each campus
tobacco cessation
healthy weight
substance abuse prevention
mental health awareness
Potential Pitfalls
• Top level leadership• Clinical champions• Starts and ends with cessation benefits• Link every policy to cessation intervention• Nursing role is crucial• It takes teamwork• Impact on community (neighbors, unions, etc…)• Strong Project Management
Be the change you want to see in the world
Mohandas K. Gandhi (1869-1948)
Thank You