Figure 1, this page, is an
overview of the key data over
the course of the project.
We encountered several
setbacks in implementing
this program, including
extreme time demands on
clinic and perioperative areas
and difficulty in capturing all
smoking cessation referrals,
with some direct local referrals
leaving no signal in the EHR.
Selected workflows continue
to be hard to measure, but we
are probably doing better than
we think. We also are finding
that CO measure orders are
inconsistently executed, and
this is now a quality target
for our perioperative areas.
Some facilities are at 90 percent
success with this measure.
And lastly, we need to clearly
define when a case should be
canceled based on CO results.
Solutions to these barriers
include development of simple,
automated workflow and decision
support cards, which are based
on the Mayo Clinic model and
given to patients in the clinic
to focus the conversation on
the importance of preoperative
smoking cessation (see Figure
2, page 53). Other effective
means for addressing these
setbacks include standardization
of referral pathways and
measurement and asking patient-specific queries when CO is
not completed or documented.
In the near future, a single
electronic smoking referral will
be generated for all patients and
should assist with reliability
and data capture, and staff-specific reports will help
managers identify and coach
when CO measures are missed.
The cancelation of elective
cases is evidence-based but
highly disruptive and will be the
focus for upcoming work.
4 It is
important to note that the initial
phase of this activity is to get
people to willingly stop smoking.
Kaiser has had to make
minimal revisions to date in the
original QI plan due to limitations
encountered during the process.
However, it should be noted that
substances smoked other than
tobacco, vaping, and chewing
tobacco could not be addressed at
this time due to lack of resources.
The total cost of
implementation during the first
two years across the 21-hospital
system was $70,000, including
cost of disposable measurement
device, counseling, and nicotine
replacement. It is too soon to
determine actual cost savings for
this project; however, our goal
was a 25 percent quit rate, and
we are seeing an approximate
50 percent reduction in active
smoking by the day of surgery.
For those institutions and health
care systems seeking to start a
preoperative smoking cessation
program, the authors offer the
•Identify a surgical champion and
•Have reliable data