Implementing Quality Improvement Projects with Medical Providers to Increase Smoking Cessation among Low Income Patients

State: IL Type: Model Practice Year: 2015

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As the Kane County Health Department prepared for accreditation over the past several years, a strong focus was on building a culture of QI within the organization. That culture took hold with staff at all levels of the agency, contributing to successfully becoming accredited in 2013. Staff were energized by the improvements they saw in programs implementing improvement cycles in their work. The decision was made to expand QI projects to community partners to address key issues identified in the County's Community Health Improvement Plan (CHIP). Tobacco use was one priority selected. Smoking rates in Kane County are quite low at 12%, however rates among residents living in poverty were identified as being nearly three times that. A strategy was sought that could engage medical providers at the system level to improve how resources are provided to low income tobacco users. In January of 2014, projects were undertaken with three medical providers (two hospitals and a Federally Qualified Healthcare Center) to formally implement quality improvement projects to increase smoking cessation attempts and utilization of the Illinois Tobacco Free Quitline among their patients. The health department utilized tobacco funding provided by the Illinois Department of Public Health to offer modest incentives for medical providers to conduct QI projects using the Plan, Do, Check, Act (PDCA) methodology. The department provided technical assistance to the providers and guided them as they worked through their own PDCAs. Each of the three projects was unique and proved successful in their own ways. The interventions included implementing a training program for staff and physicians, creating a health screening process for parents at a children's vaccine clinic and conducting follow-up calls to tobacco using patients after their visits. In addition to the increased cessation attempts noted in each case, another benefit was the expansion of the health department's QI culture out into the community in an effort to better serve the most vulnerable in the population.

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Kane County Health Department
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Implementing Quality Improvement Projects with Medical Providers to Increase Smoking Cessation among Low Income Patients
Kane County is the fifth largest county in Illinois, with an estimated 2013 population of 523,643. It has grown over 30% since 2000 and over 60% since 1990. Kane County is located about 35 miles west of Chicago, within the Chicago Metropolitan Area. Its land area is about 520 square miles, with a density of about 1,000 people per square mile. It has a small rural area (2.3% of total population). Most of its urban population is clustered around the Fox River. The largest community is Aurora, the second most populous city in Illinois with an estimated 2013 population of 199,963.Non-Hispanic Whites constitute 59% of total Kane County population, a drop from 68% in 2000, while Hispanics are now 31% of total population, an increase from 24% in 2000. Kane County has the largest proportion of Hispanics in the state. About 6% of residents are Black or African American, while 3.9% of the population is Asian. Almost one in five Kane County residents are foreign born.The unemployment rate, at 10.3% in 2010, reflects hard economic times. Poverty rates have increased to 11.1% in Kane County. When viewed by race/ethnicity, a third of African Americans living in Kane County are below poverty level compared to one in five Hispanics and one in twenty Whites. 17% of children less than 18 years lived below poverty level, while 24% of female-headed households were below poverty level.Chronic diseases continue to be the most common, costly, and preventable of all health problems in Kane County. Tobacco use contributes to the three leading causes of death in Kane County: cancer, heart disease and stroke. Although smoking rates in the County have decreased to 12%, meeting the HP 2020 objective for the first time, there is a major economic disparity, with those making under $10,000 smoking at rates above 30%. Local survey data showed that over 55% of smokers had gone at least a day with cigarettes over the past year in an attempt to quite. The key to this intervention was to reach the low income smokers through their medical providers to provide evidence-based interventions. The unique approach was implementing these interventions within formal quality improvement projects.The goal of this practice was to utilize the recent skills developed within the health department to successfully coordinate QI projects within clinical settings in the community to increase tobacco quit attempts and increase utilization of the Illinois Tobacco Free Quitline. The emphasis was on reaching those residents of the community who bear a disproportionate burden of tobacco use and the illnesses associated with it.The health department utilized tobacco settlement funding from the Illinois Department of Public Health to make grants available to clinical partners in the community. Eligible organizations needed to serve vulnerable populations and commit to forming a QI team within their organization to lead a QI project utilizing Plan, Do, Check, Act (PDCA). Proposals were reviewed and three organizations were selected to each receive $7,500 to implement projects. The health department conducted training on PDCAs and the use of other QI tools and offered technical assistance throughout the process. Resources and materials that had been developed for use within the health department were utilized to increase the QI capacity of participants. The health department held monthly meetings with the providers and walked them through the formal steps of their PDCA. Each group had the autonomy to explore the problem and solutions they would test for themselves.The results of the process in each of the three sites was an increase in the utilization of evidence based interventions to promote tobacco use cessation and use of a free quitline.The health department objective of guiding the community partners through each step of a PDCA was met. Two of the three projects met or exceeded their AIM Statements. The project that fell short, had some staffing changes mid-project that interfered, but they brought their numbers up quickly after the staffing issue was resolved.The provision of clear guidance to the providers was a key factor noted by participants. Using the individual steps of the PDCA process to guide the work facilitated great change within each organization. Developed training materials for specific QI tools were also noted as being helpful for success.In addition to yielding measurable results at each site in terms of patient behavior, this practice reinforced the importance of quality improvement for health department staff and positioned the health department as a resource for the medical community.www.kanehealth.com
In 2011, the Kane County Health Department coordinated innovative Community Health Assessment (CHA) work in the community that was jointly funded and completed with the five hospitals serving Kane County, two of the largest United Way chapters, and a local mental health 708 Board. There were three objectives to this effort:1. Leverage funding from various county partners to conduct a truly comprehensive community health assessment.2. Influence partners to align planning and funding decisions to maximize efforts across the county to improve the health of all residents.3. Share the findings of the assessment so it can be utilized by all residents and organizations serving Kane County.NACCHO recognized this assessment process in 2013 with a Model Practice Award. With much community input obtained through webinars, open houses and presentations to community groups, stakeholders identified the top five issues to include in the Community Health Improvement Plan (CHIP). Tobacco use was identified as one of those issues and the health department was identified as the lead organization to coordinate efforts to reduce the burden of tobacco.Chronic diseases continue to be the most common, costly, and preventable of all health problems in the Kane County and tobacco use contributes to the three leading causes of death in Kane County: cancer, heart disease and stroke. In reviewing the data, there is reason for optimism as the overall smoking rate in the County had decreased to 12%, meeting the HP 2020 objective for the first time. However, using telephone survey data and custom Nielsen Claritas tobacco analysis provided by the Illinois Department of Public Health, equity concerns became evident. There is a major economic disparity, with those making under $10,000 smoking at rates above 30%. The majority of heavy smokers in Kane County were located in the three urban areas of Kane County with the most ethic and socioeconomic diversity, including Aurora, Carpentersville and Elgin. The demographic profile provided by the Nielsen report showed that heavy smokers, smoking greater than 7 packs of cigarettes per week, in these three communities are more likely to be between the ages of 25 and 44. In Aurora and Elgin, like the general population, they are likely to be White, but Blacks/African Americans and Hispanics/Latinos are more likely to be heavy smokers and heavy smokers make up a large percentage of their populations. In Carpentersville, the heavy smokers are more likely to be Hispanic/Latino. Heavy smokers in all three communities are more likely to work in Blue Collar employment industries similar to the service & farm industry, or in fields like food services, construction, restaurant server, production, waste management, or building ground maintenance. Heavy smokers in these communities are most likely renters, rather than home owners.In Kane County, there are approximately 380,000 adults and current census estimates indicate that approximately 7.3% of that population makes $15,000 or less per year, putting them at higher risk of tobacco use. Based on CHA survey data about 30% of that population smokes, giving the health department a target population of roughly 8,500 smokers making under $15,000 per year. This intervention reached over 600 low-income smokers with an evidence-based intervention over a 6 month period.Previous efforts around promoting smoking cessation focused on providing in-person smoking cessation classes, working to increase smoke-free housing and advocating for smoke-free campus policies at community organizations. Efforts have also been made to train providers, including dental, medical and mental health organizations, on how they can implement the Treating Tobacco Use and Dependence: Clinical Practice Guidelines. Included in those training activities has been the active promotion of the Illinois Tobacco-Free Quitline. All of these efforts have yielded positive results with providers signing on to implement the guidelines and measurable increases in Quitline utilization. The smoking rate dropping to 12% shows that many smokers have become ex-smokers in this community. However, participation at in-person classes was steadily declining and it was decided that something more innovative needed to be done to assure high-risk residents were being reached.A positive finding from the CHA survey was that over 55% of smokers reported going at least one day without a cigarettes during the past year in an attempt to quit. This creates tremendous opportunity to reach populations potentially ready to make a behavior change. There were two primary objectives for the health department as staff developed this intervention. First, it was imperative to assure evidence-based practice was being conducted in the community. Second, the health department wanted to expand the culture of quality improvement that had taken hold within the organization and implement formal quality improvement projects in community organizations with staff acting as technical advisors and guides.To assure evidence-based practices were used, health department staff utilized Healthy People 2020, the Guide to Community Preventive Services, and the recommendations of the US Preventive Services Task Force to guide their strategy. The strategy selected was to provide small monetary incentives to medical providers that serve low-income populations to participate in a formal Plan, Do, Check, Act (PDCA) to improve how they provide evidence-based interventions to their clients to encourage and support cessation.Healthy People 2020 objectives this intervention addressed included:TU-1.1 Reduce cigarette smoking by adultsTU-4.1 Increase smoking cessation attempts by adult smokersTU-4.2 Increase smoking cessation attempts using evidence-based strategies by adult smokersTU-5.1 Increase recent smoking cessation success by adult smokersTU-5.2 Increase recent smoking cessation success by adult smokers using evidence-based strategiesTU-9.1 Increase tobacco screening in office-based ambulatory care settingsTU-10.1Increase tobacco cessation counseling in office-based ambulatory care settingsTU-10.2 Increase tobacco cessation counseling in hospital ambulatory care settingsThe evidence-based interventions identified in the Guide to Preventive Community Services included:1. Provider-Oriented Interventions that include the utilization of the Treating Tobacco Use and Dependence: Clinical Practice Guideline. These guidelines have been used by the Kane County Health department in training physicians and dentist for the past decade. This project allowed for the enhancement of the previous work to train providers by imbedding QI in the process for each office.2. Quitline Interventions. The Task Force recommends quitline interventions, particularly proactive quitlines (i.e. those that offer follow-up counseling calls), based on strong evidence of effectiveness in increasing tobacco cessation among clients interested in quitting. Three interventions effective at increasing use of quitlines are: Mass-reach health communication interventions that combine cessation messages with a quitline number, Provision of free evidence-based tobacco cessation medications for quitline clients interested in quitting and Quitline referral interventions for health care systems and providers. The latter two interventions were utilized as part of this project with providers making referrals directly to the quitline, which triggers follow-up calls, and linking clients with free nicotine replacement therapy.The US Preventive Services Task Force recommendation that proved helpful guidance that:1. Clinicians ask all adults about tobacco use and provide tobacco cessation interventions for those who use tobacco products. These recommendations are currently under review, however they reinforced for providers the utility of implementing the Treating Tobacco Use and Dependence: 2008 Update, a Public Health Service-sponsored Clinical Practice Guidelines.This intervention, the implementation of QI projects with medical providers to increase smoking cessation attempts among low-income patients using evidence-based practice, is innovative and improved upon past practice for six key reasons. This project:1. Expanded the QI culture from within the health department, out to other groups within the broader public health system2. Reinforced and enhanced health department staff’s appreciation of and competency in facilitating quality improvement projects 3. Utilized existing, evidence-based tools by presenting them to providers in a novel manner, as part of a QI project3. Built a level of evaluation and rapid improvement into clinician’s offices that did not exist around smoking cessation previously4. Yielded positive measurable behavioral results among the target population of low-income smokers5. Catalyzed change within medical organizations that can now be maintained to help patients into the future.
Tobacco
In 2011, the Kane County Health Department coordinated a collaborative Community Health Assessment (CHA) that was recognized by NACCHO in 2013 as being a Model Practice. Community partners and residents participated in identification of key health priorities based on the results of the CHA. A group of stakeholders representing a variety of disciplines including education, medicine, social services, transportation and many more… met for a full-day retreat to review and prioritize the CHA results and feedback from community partners. Public Health QI expert, Marni Mason, facilitated the discussion and led the group through several prioritization activities. By the end of the day, five key health issues were identified to be addressed immediately in the Community Health Improvement Plan (CHIP). This included a focus on reducing tobacco use. The Kane County Health Department was selected to lead the tobacco initiative because of its experience coordinating activities with schools and health providers around the issue of smoking. The health department led activities to reduce youth initiation, reduce exposure to second hand smoke, increase cessation and eliminate disparities. During the time between 2011 and 2013, the health department was also working actively toward accreditation through the Public Health Accreditation Board (PHAB). A strong QI culture developed within the Kane County Health Department during the accreditation process. The goal of this practice was to expand that culture into the medical community with a focus on implementing evidence-based interventions to increase smoking cessation attempts and quitline utilization among the low-income population that local data indicated was most at risk for smoking. The health department met this goal and based on the successes observed has adopted this practice as a regular strategy within the tobacco program. There are plans to test this practice in other priority health areas as well including childhood obesity, diabetes and early childhood health.The objectives of this practice included:OBJECTIVE 1- Create a request for proposals to solicit potential partners for this project through a competitive process by November of 2013. Criteria for selection included ability to reach vulnerable populations and experience working with the health department on collaborative projects.RESULT- A request for proposals was created and released publicly to dental, medical and mental health providers in the community with a deadline to apply of November 15, 2013.OBJECTIVE 2- Identify three medical providers by December 1, 2013 that were willing to participate in this quality improvement project from December 1, 2013 through June 30, 2014.RESULT- Applications were reviewed and three providers were selected to participate. A large Federally Qualified Healthcare Center, a hospital-based children’s immunization clinic (parents/caregivers were intended audience for intervention), and the cancer and heart institutes of another community hospital. Each project showed promise in reaching the vulnerable population most at risk for smoking in a unique manner. Agreements were signed between each organization and the Kane County Health Department. The agreements outlined the following four deliverables: A) “Active Participation in Quality Improvement Project- Staff time (with identified team leader and internal team members selected to match with the client subpopulation chosen for PDCA) will be allocated to allow for monthly meetings with the Health Department to work through the PDCA process. Team Leader and team members will carry out project activities between monthly meetings.” B) “Data Sharing- Clinic data (baseline and monthly thereafter) will be available and utilized through key QI tools to guide the implementation of the PDCA project through each stage.” C) “Sharing of Lessons Learned- A PDCA Storyboard will be created in cooperation with the Health Department to share lessons with others in the community. Team members will share progress and findings with internal organization leaders and clinical teams serving the patient subpopulation selected at midpoint and project completion.” D) “Team Leader will attend an orientation meeting in December.”OBJECTIVE 3- Provide refresher training in November 2013 to health department staff on facilitating Plan, Do, Check, Act (PDCA) process as well as train-the-trainer sessions on a variety of QI tools that could be used as part of the PDCA, such as Force Field Analysis, Flow Charts, Affinity Diagrams, etc…RESULT- The Assistant Director of Community Health coordinated training sessions for the tobacco staff that would be interfacing with the community partners. Excellent training materials had been developed by the agency’s QI and Data Coordinator leading up to accreditation. These tools, including train-the-trainer modules, were shared with staff to increase their confidence and competence to lead the projects with the providers. The QI and Data Coordinator and Assistant Director of Community Health Resources were both available through the process to assist with technical assistance.OBJECTIVE 4- Conduct orientation meetings with the designated QI team members for each of the selected vendors by the end of December 2013.RESULT- Each organization designated team members to participate on an internal QI team specific to this project. These teams each met with staff from the health department in December for an initial orientation to the PDCA process. The health department shared worksheets for each formal step of the PDCA process and facilitated initial discussions about the problem they were seeking to address. Each group was asked to create an AIM statement for their project, which they did.OBJECTIVE 5- Provide guidance and technical assistance leading to the successful completion of three collaborative PDCAs by the end of June 2014 that result in implementation of evidence-based strategies to promote cessation and quitline utilization among the vulnerable population. Evidence of completion included data from monthly meetings and the final story board created by each organization.RESULT- Each of the three providers actively participated in the PDCA process, completed each formal step and participated in monthly meetings with the health department. They collected data throughout and made adjustments to continue improving their own processes. Each team utilized a variety of QI tools with coaching from the health department to help them measure and adjust. At the end of the seven months, each organization created a storyboard that detailed their process and the subsequent results. Results are discussed in the evaluation section of this application.In summary, the health department was able to increase its capacity to provide technical assistance while the providers increased their knowledge and skills around implementing quality improvement cycles to promote cessation. The health department committed $22,500 to this project in cash, $7,500 to each participant. Additionally, staff spent an average of about four hours per week on this project preparing for and participating in meetings with the providers. Providers, as noted, were compensated with a monetary award, however they each provided in-kind time and materials that were estimated to be above the $7,500.
The evaluation below describes the two distinct components of this practice. First, the process objectives of the health department are restated. All objectives were successfully met and this practice, of coordinating community-based QI projects, has been adopted by the organization as a successful approach that will repeated annually with partners to address a variety of health issues. The second evaluation described below will share the results of two of the three projects. HEALTH DEPARTMENT PROCESS EVALUATIONThe five objectives detailed below reflect the critical steps that the health department decided in its planning process must be completed for a successful project. OBJECTIVE 1- Create a request for proposals to solicit potential partners for this project through a competitive process by November of 2013. RESULT- A request for proposals was created and released publicly to dental, medical and mental health providers in the community with a deadline to apply of November 15, 2013.OBJECTIVE 2- Identify three medical providers by December 1, 2013 that were willing to participate in this quality improvement project from December 1, 2013 through June 30, 2014.RESULT- Applications were reviewed and three providers were selected to participate. OBJECTIVE 3- Provide refresher training in November 2013 to health department staff on facilitating Plan, Do, Check, Act (PDCA) process as well as train-the-trainer sessions on a variety of QI tools that could be used as part of the PDCA, such as Force Field Analysis, Flow Charts, Affinity Diagrams, etc…RESULT- The Assistant Director of Community Health coordinated training sessions for the tobacco staff that would be interfacing with the community partners. Excellent training materials had been developed by the agency’s QI and Data Coordinator leading up to accreditation. These tools, including train-the-trainer modules, were shared with staff to increase their confidence and competence to lead the projects with the providers. OBJECTIVE 4- Conduct orientation meetings with the designated QI team members for each of the selected vendors by the end of December 2013.RESULT- Each organization designated team members to participate on an internal QI team specific to this project. These teams each met with staff from the health department in December for an initial orientation to the PDCA process. OBJECTIVE 5- Provide guidance and technical assistance leading to the successful completion of three collaborative PDCAs by the end of June 2014 that result in implementation of evidence-based strategies to promote cessation and quitline utilization among the vulnerable population. RESULT- Each of the three providers actively participated in the PDCA process, completed each formal step and participated in monthly meetings with the health department. INDIVIDUAL PROJECT RESULTS FOR TWO PROJECTS ARE PRESENTED BELOW DUE TO SPACE CONSTRAINTSPROJECT #1- HOSPITAL-BASED PROGRAM1. Getting StartedIn 2012, this hospital diagnosed 76 cases of new lung cancer. Forty-four percent of those cases were male and fifty-six percent were female. Additionally, 51% of those newly diagnosed were at stage IV. The medical center identified the need for programs and services aimed at helping individuals quit smoking. Aim Statement:By June 30, 2014, develop a standardized process for accessing tobacco usage, provide education on the Illinois Tobacco Quitline and Freedom From Smoking (FFS) program to Cancer Care and patients. In addition, increase the number of referrals to the Illinois Tobacco Quitline to an average of five per month.2. Assemble the Team- Members of the QI Team include: Physicians, FFS instructors, Nursing Professionals, Cancer Care Staff, Grant Team, Social Workers3. Examine the Current Approach- Currently, all patients provide a smoking history during physician and procedural visits. An assessment is performed for each patient based on smoking history. The QI Team collaborates with the rest of the medical center to offer FFS courses and community outreach and education.The QI Team has identified that 9,250 unduplicated clients are seen throughout the medical center. It is known that 24% of the total patients are smokers, 30% are of low socioeconomic status and 0% know to call the Illinois Tobacco Quitline. In order to successfully reach this population the QI Team will need increased physician involvement, staff follow-up, patient willingness and a more formalized smoking cessation program.The QI Team developed a Fishbone Cause and Effect Diagram to identify potential reasons for the low call volumes to the Illinois Tobacco Quitline.4. Identify Potential SolutionsFollowing review of the various root causes, the QI team participated in a brainstorming activity to generate a variety of solutions. By prioritizing these items the group was able to identify the top five:1. Formally educate staff2. Advertise the information3. Assessment & referral process4. On-going reinforcement5. Collaboration within the hospital/communityFormal education will occur for staff and physicians in the Cancer Care Center, Medical Group and Heart Center. The QI Team will work with marketing to promote smoking cessation and lung programs.5. Develop an Improvement TheoryThe QI Team reviewed the five potential solutions for feasibility and impact.The solution that aligned closest with the aim statement was to setup a formal program that required staff and physicians to discuss this information with patients and to obtain forms and Freedom From Smoking signups. By holding our staff to a higher standard we hope to draw more patients and community members which will increase participation.DO Test the Theory for Improvement6. Test the TheoryEducation was provided to staff, physicians, and the Heart Institute leadership. Illinois Tobacco Quitline forms were distributed to all areas.Following the distribution of this information the number of consent forms was documented by the Outreach Coordinator and Nurse Navigator.7. Check the ResultsThe data listed under step 6 shows that the Hospital QI Team did not meet its initial goal of 5 forms per month but the number of forms collected in April and June are signs of improvement. The ability to come close to the goal in June given the unintended side effects listed above is proof that this program can succeed with constant reinforcement and education.The department is now able to track the number of referrals to the Quitline for our patients and have documented numbers. The program and process will need to be tested in other departments of the hospital as well.The results have shown that the Hospital QI Team needs to continuously educate and review the process in order to ensure compliance. Additionally, the process for presenting the Tobacco Quitline form to the patient needs to be scripted to reduce/eliminate the lack of presentation or misinformation.ACT Standardize the Improvement and Establish Future Plans8. Standardize the Improvement or Develop New TheoryThe Hospital QI Team believes that the process in place has been successful outside of the unintended side effects. Moving forward, the QI Team needs to develop a scripted approach that discusses how this form will be communicated with patients. The next step will be to expand this program to other areas including the inpatient population.To ensure the success of this program hospital wide it’s imperative that the QI Team present at department meetings and educate/remind staff on a regular basis. In addition, designating a lead person in each area that can serve as a resource and filter any questions back to the QI Team is a way to strengthen this program.9. Establish Future PlansOnce the new process is established and all of the issues are flushed out the QI Team will look to reward successes. This will come in the form of incentives for staff involved in the process as well as recognition in core group meetings. The results will be tracked so that accomplishments can be presented at department and leadership meetings. The QI Team will also continue to provide updates to the Kane County Health Department and be willing to discuss as necessary. PROJECT #3- HOSPITAL-BASED IMMUNIZATION CLINICThis clinic was formed to provide immunizations to children who lack insurance coverage for vaccines or are covered by Medicaid. This ensured that no gap in vaccine protection appeared for the impacted families; about 600 families a year. In January 2014, the VC received a 7 month Quality Improvement (QI) Grant dedicated to identifying tobacco use and providing cessation support resources to families who utilize the VC. AIM Statement: By June 30, 2014 the VC will identify tobacco users, determine their readiness to quit, and educate about tobacco cessation resources, including direct referral from the clinic to the Illinois QuitLine, increasing Quit-Line referral from 0 to 25%.What We Did: Assembled a QI Team that included the Clinic Coordinator, Clinic Nurses, Clinic Reception and Scheduling and a Health Educator skilled in tobacco cessation and child health and wellness. Developed a health assessment that included specific questions about smoking behaviors and had each family complete it prior to the immunization. All VC staff attended a KCHD one hour training about the Illinois Quitline, 5 A’s and 5R’s. The training also included information about the QI Team and plans to incorporate education about the aforementioned to VC families.The clinic flow was observed to determine time available to provide cessation education and surveys were used to gauge family needs. Current State: The VC does not have a process to identify and provide support to adult caregivers that attend the clinic and use tobacco products. Ideal State: Effectively identify tobacco users and integrate the 5 A’s, 5 R’s and Quitline referral into best practice.Flowchart: A typical clinic visit was charted. The current state was then compared to the future ideal state.Test: The ideal state was trialed. Rapid experiments (Do, Check) were done after each clinic. The process was adjusted following each clinic using SWOT analysis and other QI tools. 1. Families rushed through the survey or were hesitant to record tobacco use. The QI Team decided to survey and ask all families about tobacco use to improve compliance. 2. Families resisted talking to nurses about topics other than vaccines. The Health Educator adopted that education role. 3. Feedback about Quitline from some patients was negative. Some reported not being contacted and/or not receiving NRT. Quitline communication with the clinic was poor, changes in their policies were not communicated. QI Team decided to add a clinic follow up to patients to confirm they are receiving Quitline support if requested. Translating data into action: Results from each experiment were used to improve the process. After each clinic staff share feedback to identify any gaps in service. Patient caregiver completes a paper survey prior to immunization. This is used by the Health Educator as a conversation launching pad, regardless of how the survey reads, the caregiver is asked about tobacco use and appropriate use of the 5 A’s and 5 R’s is executed. Referrals to Quitline are faxed after each clinic and recorded in a table for follow-up. Education and resources shared are noted on the survey and data is recorded in a master document. Data gathered from January to June indicated: That of 244 patient interactions, 34% were identified as smokers. Of those, 100% received information about services and the Illinois Tobacco Quitline, 96% took materials home with them and 38% agreed to be formally referred to the Quitline. Quitline Referrals generate automatic follow-up calls to the client.Lessons learned: The value in starting the conversation. Caregivers are utilizing the resources being shared/offered and reporting that they appreciate the additional service. The benefit of collaboration. KCHD support in PDCA process helped to keep us focused on the goal. Identifying other internal departments that had resources for the VC.Follow-Up: Contact those who received Quitline or other cessation services to determine if they were successful in stopping tobacco use
This practice proved to be successful beyond the expectations of staff who implemented it.  The modest investment of time and dollars yielded an increased role for the health department in the community, increased capacity of the participants and yielded measurable changes in the target population.  The Kane County Health Department will utilize community based PDCA projects in the future for a variety of health issues. The interventions validated the practices that the participants conducted.  Engaging providers per the Clinical Guidelines to Treat Tobacco Dependence does create action in patients.  Additionally, promoting a free quitline with free nicotine replacement therapy does engage patients and lead to higher cessation attempts and successes. A formal cost-benefit was not conducted, however all participants reported that this intervention was an effective and efficient use of resources. Stakeholders have committed to continue their participation.  As of today, two additional projects have been started with new providers to address smoking in the vulnerable populations identified.  Kane County is committed to continuing to make resources, both money and time, available to assist the community.  Thus far the community partners have agreed to continue with their participation. 
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