A Systems Approach for Prenatal Smoking Cessation

Research indicates that system-level changes can reduce smoking prevalence among patients.

Guideline recommendations for systems changes and systems strategies and actions are summarized below.

1. Implement a tobacco-user identification system in every clinic (see below)

2. Provide education, resources, and feedback to promote provider interventions

3. Dedicate staff to provide tobacco dependence treatment and assess the delivery of this treatment in staff performance evaluations

4. Promote clinic policies that support and provide tobacco dependence services

5. Reimburse clinicians (where available) for the delivery of effective tobacco dependence treatments and include them among the defined duties of clinicians.

Implement a tobacco-user identification system in every clinic

Action: Implement as office-wide system that ensures that, for every patient at every clinic visit, tobacco-use status is queried and documented.

Strategies for implementation:

Office system change: Expanding the Vital Signs to include tobacco use or implement an alternative universal identification.

Responsible staff: Nurse, medical assistant, receptionist, or other individual already responsible for measuring the vital signs.

• These staff must be instructed regarding the importance of this activity and serve as non-smoking role models.

Frequency of utilization: Every visit for each patient regardless of the reason they came to the clinic.

• Repeated assessment is not necessary in the case of the patient who has never used tobacco or not for many years, and for whom this information is clearly documented in the medical record.

System implementation steps: Prepare progress notepaper or computer record to include tobacco use along with the traditional vital signs for every patient visit.

• A vital sign stamp could be used to identify smokers on the patient charts;
• A tobacco-use status sticker could be placed on all patient charts to indicate smoking status.

Provide education, resources, and feedback to promote provider interventions

Action: Health care providers should ensure that clinicians have sufficient training to treat tobacco dependence, clinicians and patients have cessation resources, and clinicians are given feedback about their tobacco dependence treatment practices.

Strategies for implementation:

• Educate - Offer continuing medical education via lectures, seminars or in-services;

• Provide resources - Have patient self-help materials readily available in every exam room;

• Report - Include the provision of tobacco dependence treatment on "report cards" for managed care organizations and other insurers;

• Provide Feedback - Drawing on data from chart audits, electronic medical records, and computerized patient databases, evaluate the degree to which clinicians are identifying, documenting, and treating patients who use tobacco, and provide feedback to clinicians about their performance.

Dedicate staff to provide tobacco dependence treatment and assess the delivery of this treatment in staff performance evaluations

Action: Clinical sites should communicate to all staff the importance of intervening with tobacco users and should designate a staff person (e.g., nurse, medical assistant, or other clinician) to coordinate tobacco dependence treatments.

Strategies for implementation:

• Designate a tobacco treatment coordinator for every clinical site;

• Delineate the responsibilities of the tobacco dependence treatment coordinator. Including instructing patients on the effective use of treatments, for example:
  • Pharmacology;
  • Telephone calls to and from prospective quitters;
  • Scheduled follow-up visits, especially immediately after quitting.

• Communicate to each staff member his or her responsibilities in the delivery of tobacco dependence services. Incorporate a discussion of these staff responsibilities into training of new and temporary staff.

Promote clinic policies that support and provide tobacco dependence services

Action: Provide tobacco dependence treatment to all tobacco users admitted to a clinic.

Strategies for implementation:

• Implement a system to identify and document the tobacco-use status of all clinic patients;

• Identify a clinician(s) to deliver tobacco dependence consultation services for the clinic;

• Offer tobacco dependence treatment to all clinic patients who use tobacco;

• Reimburse clinicians for tobacco dependence in-patient consultation services;

• Ensure compliance with regulations mandating that the clinic be entirely smoke-free;

• Educate clinic staff about the importance of first-line medications to reduce withdrawal symptoms.

Reimburse clinicians (where available) for the delivery of effective tobacco dependence treatments and include them among the defined duties of clinicians

Action: Reimburse fee-for-service clinicians and specialists for delivery of effective tobacco dependence treatments. Include tobacco dependence treatments in the defined duties of salaried clinicians and those working in [clinical] environments.

Strategies for implementation:

• Include tobacco dependence treatment as a reimbursable activity for fee-for-service providers;

• Inform fee-for-service clinicians and specialists that they will be reimbursed for using effective tobacco dependence treatments;

• Include tobacco dependence intervention in the job descriptions and performance evaluations of salaried clinicians.

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