Implement a Systematic Process to Deliver and Document a Brief Tobacco Cessation Intervention To All Clients Seeking Family Planning and Sexual Health Services in the Denver Metro Health Clinic

Summary

Impact Statement:

Denver Health used rapid cycle improvement to implement a brief tobacco cessation intervention (2As &R) in a high risk urban family planning and sexual health clinic. The intervention was enhanced by modifications to the electronic medical record system. They plan to spread this intervention to all departments and clinics within DPH that provide client services.

Summary:

Smoking rates in Denver have been slowly declining. Assistance such as physician advice, counseling, or nicotine replacement therapy (NRT) improves chances of quitting. Currently, those who enroll with the Colorado QuitLine receive 5 personalized coaching calls and 8 weeks of NRT at no cost.

Denver Metro Health Clinic (DMHC) operates under Denver Public Health (DPH), providing low-cost family planning and sexual health care to Denver adults and youths. The clinic population is at high risk for tobacco use; many are poor. The clinic currently uses an easily modifiable electronic medical record (EMR) system, making the clinic an ideal venue for the quality improvement (QI) initiative.

The specific aim was to implement and standardize a documented process to assess tobacco use, advise users to quit, and refer those who are ready to quit to cessation programs (Ask, Advise, Refer; 2As+R). The team used Plan, Do, Study, Act (PDSA) to implement the initiative. A team of clinic representatives, an informatics supervisor, and the QI coordinator defined current and ideal states and brainstormed potential barriers (and solutions) to implementation. Once they identified the ideal state, they modified the EMR to document steps of the 2As+R process.

Overall, the QI initiative was successful. Measuring change with subsequent steps was difficult; baseline data did not exist. However, 68% of tobacco users were advised to quit. Subsequent cycles revealed that clinicians required additional training for the Advise portion, and the choice set in the EMR was incomplete.

The QI team will keep monitoring outcomes and working with clinic staff to meet and maintain 100% for Ask and Advise. Long-range plans include implementation of 2As+R in all clinics/departments within DPH that provide client services. DPH and the QuitLine are developing an electronic referral system, so clinicians can refer clients to the QuitLine from the patient’s EMR.

Organization that conducted the QI initiative:

DPH, DMHC

Citation:

Mickiewicz, T. Public Health Quality Improvement Exchange. Implement a Systematic Process to Deliver and Document a Brief Tobacco Cessation Intervention To All Clients Seeking Family Planning and Sexual Health Services in the Denver Metro Health Clinic. Mon, 02/27/2017 - 12:23. Available at http://www.phqix.org/content/implement-systematic-process-deliver-and-document-brief-tobacco-cessation-intervention-all. Accessed April 23, 2024.

Background and Aim

Aim statement:

By December 31, 2012, standardize and implement a documented process to assess tobacco use, advise current users to quit, and refer those who are ready to quit to cessation programs (2As+R) for 100% of clients seen for family planning and sexual health services in DMHC.

Need For The QI Initiative:

DPH leadership feels that tobacco prevention and cessation services should be part of the package of essential services for any client presenting at a DPH clinic. This prioritization aligns well with strategic plans that emanated from the community health assessment, the Health of Denver 2011 report, and the Colorado Department of Public Health and Environment.

Area for Improvement:

Smoking rates in Denver have been steadily but slowly declining from 21.5% in 2003–2004 to 18.3% in 2009–2010 (Behavioral Risk Factor Surveillance System). In 2008, the Tobacco Attitudes and Behaviors Survey, conducted throughout the state, reported the state-level smoking rate among adults at 18.1% but identified at-risk populations that experience elevated smoking rates, including those aged 18–24 (35.6%); those of low socioeconomic status (29.2%); and those who identify as gay, lesbian, bisexual, or transgender (GLBT, 38.4%). The same report, however, indicates that smokers want to stop smoking. Overall, 65.4% of Colorado smokers report having made at least one serious quit attempt (24 hours or more) in the previous year. Although prevention messages, programs, and policies are woven into the clinical care provided at all clinics at DPH, including DMHC, the agency as a whole has neither provided any specific education around tobacco nor offered cessation services to treat tobacco addiction. Tobacco use is the single most preventable cause of premature death in the United States (U.S. Department of Health and Human Services) and approximately 4,300 Colorado residents die every year as a result of a tobacco-related illness (Vital Statistics). Clinic patients at DMHC are at high risk for tobacco use, thus making it an ideal pilot clinic for this initiative. Approximately 34% are 24 years old or younger, 17% identify as GLBT, and many lack insurance. Overall, 35% report tobacco use.

Root Cause:

DPH has not formally incorporated tobacco prevention messages and cessation services into clinical services for several reasons. At the clinic level, clinicians lacked the time and training to address tobacco addiction. Many providers felt that clients were seeking care for an acute sexual health problem and preventive services would not be received well. At the systems level, all clinics throughout the department electronically document patient care, but these systems have been created in clinic silos, making a standardized system for implementation and documentation of services difficult. Last, availability of cessation services had waned over the past several years, and providers were reluctant to ask about a behavior for which services did not exist.

Planning and Execution Details

QI Implementation:

The initial PDSA cycle was anticipated to be 100% successful. However, the QI team monitored the rates at each step of 2As+R throughout the project and performed subsequent, smaller cycles before the QI project was standardized for all clinic visits. Each stage is described as follows: • Plan: In mid-September 2012, the team met for half a day to examine current clinic processes in the context of incorporating 2As+R. This examination included defining the current and ideal states using a flowchart of the clinic processes, identifying barriers to and potential solutions for implementation using a fishbone diagram, and discussing exact data elements to be included in the EMR. At a subsequent clinic staff meeting in October, staff members were apprised of the pending changes, and they received a brief (30-minute) training in the 2As+R process. The project was implemented on November 1, 2012. For subsequent cycles, the QI team met to study results and strategize meaningful amendments to the process. • Do: Within 1 week of the staff training, the QI coordinator met briefly with clinic staff to remind them of the initiative timeline and answer any questions. In late October 2012, the clinic participated in a practice implementation for 4 hours, using a paper mock-up to document the 2As+R process. During this time, staff were able to ask questions about the process; most of the questions focused on the Advise portion of the intervention. Some staff were unclear about how strongly they should encourage the client to quit and were reminded of motivational interviewing techniques. During this time, staff also made decisions about where paper referrals would be stored and who was responsible for faxing them to the QuitLine at the end of each day. • Study: The clinic team debriefed at the end of the half-day paper pilot and agreed that the process proceeded smoothly. All clients were asked about tobacco use, all users were advised to quit, and five users accepted a referral to the Quitline. Subsequent one-on-one discussions between the QI coordinator and individual staff indicated great enthusiasm for the intervention overall and a perceived ease of implementation and usability. Staff felt that identifying type and frequency of tobacco use made the Advise portion of the intervention easier. There was some confusion about how to classify those who report social smoking (i.e., smokes cigarettes when socializing with friends). Many requested QuitLine promotional materials that were easy to store and dispense (e.g., cards versus brochures). Cycles after the November 1, 2012 launch date revealed that (1) although staff were comfortable asking clients about tobacco use and referring smokers who were willing to quit, many were not as confident about advising, and (2) in the EMR, the choice set for Advise was not comprehensive enough. • Act: On November 1, 2012, the changes to the EMR went live and staff began to officially deliver the 2As+R intervention. The subsequent, smaller cycles precipitated two significant improvements. First, the QI team attended weekly staff huddles to reinforce processes and techniques. Second, the EMR was amended to expand the choices a clinician could choose for the Advise part of the intervention. The process standardization was complete on December 31, 2012.

Focus activities

Data collection, Epidemiology and Surveillance:

Behavioral risk factors

Population-based Primary Prevention :

Tobacco

Administration:

Data collection and management/Information Technology

QI Methods:

PDCA/PDSA Cycle (Plan, Do, Check/Study, Act)

QI Tools:

Brainstorming

Flow chart

Process maps

Other QI tools:

Define the current and ideal states.

Debrief and conduct one-to-one interviews with clinic staff.

Initiative Dates:

4/1/12 to 12/31/12

Initiative Duration:

Between 6-12 months

Methods of evaluation:

Process evaluation includes the following: • Key participant interviews with DMHC clinic staff both immediately post-implementation and subsequently, at regular intervals, to identify emerging issues or the need for additional training. • Reports generated from the EMR that assess the following: o that each client is asked about tobacco use, o percentage of tobacco users who are advised to quit, and o the number of people who are provided a referral to the QuitLine. • Customer satisfaction surveys are administered quarterly and allow for the addition of additional questions. In the next cycle, we will assess client satisfaction with the 2As+R intervention. Outcome evaluation can be conducted in two ways: • Among clients seen at the DMHC clinic (using EMR data) o rate of tobacco use, and o rate of referral acceptance. • Among those referred to the Colorado QuitLine (derived from information and reports created by QuitLine analysts): o number and percentage who enroll in the Colorado QuitLine, o number and percentage who receive NRT, o number and percentage who have still quit at 6-month follow-up, and o number and percentage who have still quit at 12-month follow-up.

Supplemental Materials:

Sample of materials produced

Storyboard

Supplemental Files:

Attachment	Size
HealthDoc ScreenShot.pdf	239.78 KB
Denver Health Expert_Panel_Combined_Feedback TM Response.doc	136 KB
Storyboard_final.pdf	266.03 KB

Implement a Systematic Process to Deliver and Document a Brief Tobacco Cessation Intervention To All Clients Seeking Family Planning and Sexual Health Services in the Denver Metro Health Clinic

Summary

Background and Aim

Planning and Execution Details

Results

Training and Preparation

Information about the Community

Information about the Health Department

QI Staff Information

Accreditation Details

Collaborations

Contact Information of the Submitter

Comments

Thanks for sharing! I'm

QI Spotlight

quality improvement together.

Search form

You are here

Implement a Systematic Process to Deliver and Document a Brief Tobacco Cessation Intervention To All Clients Seeking Family Planning and Sexual Health Services in the Denver Metro Health Clinic

Summary

Background and Aim

Planning and Execution Details

Results

Training and Preparation

Information about the Community

Information about the Health Department

QI Staff Information

Accreditation Details

Collaborations

Contact Information of the Submitter

Comments

QI Spotlight