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Smoking as a vital sign: a work in progress
  1. Jodi Jessen
  1. Vallejo Medical Center, 975 Sereno Drive, 7th Floor Hospital, Vallejo, California 94589, USA;jodi.jessen{at}

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These are the plans of Kaiser Permanente Northern California for implementing smoking as a vital sign; that is, assessing smoking status and offering patients information and advice at every primary care visit.

It is a “work in progress” because we have not yet begun to implement this programme throughout the region. This paper concerns what has worked in the past and the model we intend to implement in the future. We expect, however, that the process of implementation will alter this model, and our end product may be very different. I shall also suggest how to improve provider participation.

HEDIS tobacco measure

The current status of our Health Plan Employer Data and Information Set (HEDIS) tobacco measure (35–37%) reflects the relatively little staff time dedicated to tobacco issues at a regional level (although we have excellent smoking cessation materials and programmes available to all our members). Recently, the HEDIS tobacco measure has been chosen as one of the top five quality measures in the United States. That means that every Kaiser Permanente organisation in the country will be monitored and evaluated on their progress on this measure.

When, at our Regional Health Education facility in Richmond, Virginia, we began to consider implementing smoking as a vital sign, I started by looking for programmes already in place. What I found was a very simple and easy-to-implement programme, designed by one of our nurse practitioners. This method takes very little training, can be done in 15–20 seconds and is primarily the responsibility of the medical assistants. What follows is the summary.

The medical assistant greets the patient, and asks two questions: “Do you currently use tobacco?”. If the answer is yes, then: “Are you interested in quitting?”. If the answer is yes again, the patient is offered information on quitting smoking (a one-page, stage-based tear-sheet developed by Regional Health Education) and referred to the local health education department for smoking cessation programmes. The medical assistant also suggests that the patient talks to his or her doctor about smoking or quitting. The medical assistant then documents that the patient was “counselled” (“counselled” at the Richmond facility means that the patient got information, referral, and a suggestion to talk to the doctor, but no “counselling” is necessarily occurring). The doctors are instructed to address smoking with patients who are in possession of smoking cessation literature.

The response of the doctors and staff to the implementation of this programme was positive. The doctors did not feel “pressured” to give advice or counselling if it did not seem appropriate during the patient visit. Although the medical assistants were nervous at first, they got over it very quickly and found that patients began to regard them as part of the healthcare team. After a month, there was a follow-up chart review. The results, based on 50 random charts, were as follows: 16% of the patients were smokers (we expected a 17% smoking rate overall, so perhaps Richmond has fewer smokers, some were not telling the truth, or the smokers were not coming in as often); the documentation of smoking status was 90% (as compared with blood pressure, another vital sign, at 88%); 80% of the members were “counselled”; and attendance in the smoking cessation programme more than doubled in one month. These were fairly impressive results from such a simple programme.

The next step was to consider how implementing a programme like Richmond’s would affect our HEDIS measures. When I actually read the measures (outlined in the previous papers) I found that HEDIS does not measure patient smoking status documentation, or distribution of cessation information, or referral to smoking cessation resources. What HEDIS does measure is the following: of the number of adult members, over age 18, who are continuously enrolled in our health plan, and who are current smokers or recent quitters (quit in the last year), who actually come in for an office visit—ofthose members—how many received advice to quit smoking at least once?

When comparing what the Richmond programme was actually doing with what HEDIS is actually measuring, I discovered two problems. First, patients have to remember that they were advised to quit, and second, what constitutes “advice to quit”? The medical assistant giving information and referral? The doctor mentioning smoking? Or only actual advice by the doctor? What the HEDIS measure willactually be measuring is unclear.

Despite this lack of clarity, there are clearly some keys we can use to improve our HEDIS measures. Cessation messages must be memorable and delivered consistently by a variety of health professionals at every clinic visit. As we know that people learn and remember differently, a variety of messages should be encountered—for example, verbal messages from all health plan providers (not just the doctor), messages on posters, and information handouts. A variety of media should be used, and all health plan staff must reinforce the message. Consistency is also important: even if the patient comes in only once a year, he or she should be queried and given advice during that visit. Involving a variety of health professionals will improve the chances of success.

We have now figured out what will maximise our HEDIS measures. To ensure success, do we now enlarge the programme to include all Kaiser staff, perform a lot of training, make posters and newsletters, have a big kickoff and implement it in every department? No—in our experience, the chances of success are greater if you take a programme that is working, alter it slightly, making sure that it is still acceptable and easy to implement, and then build on and improve the programme over time. We plan to change the questions the medical assistants ask to: “Are you currently using tobacco?” and “Are you planning to quit in the next six months?” We are also going to write these questions out in full (and include a checkbox next to them) to improve consistency in message and focus on the people who are actually interested in quitting. We have also added extra boxes below these questions to identify what kinds of interventions occurred (information given, referral, advice or counselling), so that we might examine these issues in the future.

We are also planning to improve the training process. The training at Richmond was done via memorandum (yes, it was that simple). We do plan to train the entire healthcare team in primary care departments, including the receptionist, so that they all know what is going on and what messages the patients are receiving. We are going to use role play to allow them to experience the process upfront. We are also going to train the doctors and nurse practitioners in a “30-second version” of advice, so they can include it in any patient visit.

One of the reasons that the Agency for Health Care Policy and Research smoking cessation guideline1 is not being implemented is, in my opinion, that there are “two questions in three minutes”. Our providers said that they frequently do not have three minutes. In fact, there is no guarantee that there will be an opportunity to talk about smoking—patients are coming for all sorts of problems, and doctors are very busy. They might not have an opportunity to address tobacco use. We are therefore giving them a 30-second version to start with. We shall also be educating them in the basics of stages of change,2 so they can easily identify at which stage a smoker is, and give appropriate advice based on that stage.

Provider participation

Decide who is your primary customer. We often market to the health plan member, the patient, but to implement a patient intervention, you need the cooperation of the medical teams;they are your audience and primary customer. You may need to alter the programme to fit their needs, which may affect the “perfect programme” you have envisioned. You also need to be clear about one thing: which part of your programme/intervention is essential and must be maintained intact. Once you have decided that, stand firm and be willing to negotiate everything else. I have found that much more is negotiable (and can be successfully implemented with good outcomes) than I originally thought.

Provide on-site training and implementation assistance. Because of already heavy workloads, you have to do most of the work and make it easy for them. By developing a personal relationship with the medical teams, you will find working with them increasingly easy and collaborative in the future.

Implement your project first, then perfect it later. This is extremely important—first make your programme easy to implement. Once you have it in place you can improve it with new tools and training. A typical mistake is to try to implement the “perfect” programme all at once.

Work with the people who want to work with you.Use the interest and energy of those whodo see the value in what you are doing, and learn everything you can from them about how to make the programme work. By working with the interested parties first, you can build success upon success and use that to do internal marketing to the more resistant groups. Applaud the providers who have implemented your programmes and describe their successes. Use whatever communication resources you have, such as newsletters—if you do not have a newsletter, create one. Internal marketing makes slow and gradual progress; then suddenly, everyone is on the telephone, and wants to use your programme at their office.

Create incentives. It takes a lot of creativity to figure out which incentives might work. Effective incentives include financial rewards, “goodies” for the staff, and good press. For example, one incentive could be recognition of the providers that could be brought to the attention of their patients or of prospective patients. Perhaps they could be given an award that they could put in their waiting room—or their names could be listed in a publication that is circulated to patients. Little things can work as well as big things.

Remember, you are the champions of the tobacco programmes that will make a difference in the your healthcare systems and in people’s lives.