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Ugalde A, White V, Rankin NM, Paul C, Segan C, Aranda S, Wong Shee A, Hutchinson AM, Livingston PM. How can hospitals change practice to better implement smoking cessation interventions? A systematic review. CA Cancer J Clin 2022; 72:266-286. [PMID: 34797562 DOI: 10.3322/caac.21709] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 09/27/2021] [Accepted: 10/07/2021] [Indexed: 01/07/2023] Open
Abstract
Smoking cessation reduces the risk of death, improves recovery, and reduces the risk of hospital readmission. Evidence and policy support hospital admission as an ideal time to deliver smoking-cessation interventions. However, this is not well implemented in practice. In this systematic review, the authors summarize the literature on smoking-cessation implementation strategies and evaluate their success to guide the implementation of best-practice smoking interventions into hospital settings. The CINAHL Complete, Embase, MEDLINE Complete, and PsycInfo databases were searched using terms associated with the following topics: smoking cessation, hospitals, and implementation. In total, 14,287 original records were identified and screened, resulting in 63 eligible articles from 56 studies. Data were extracted on the study characteristics, implementation strategies, and implementation outcomes. Implementation outcomes were guided by Proctor and colleagues' framework and included acceptability, adoption, appropriateness, cost, feasibility, fidelity, penetration, and sustainability. The findings demonstrate that studies predominantly focused on the training of staff to achieve implementation. Brief implementation approaches using a small number of implementation strategies were less successful and poorly sustained compared with well resourced and multicomponent approaches. Although brief implementation approaches may be viewed as advantageous because they are less resource-intensive, their capacity to change practice in a sustained way lacks evidence. Attempts to change clinician behavior or introduce new models of care are challenging in a short time frame, and implementation efforts should be designed for long-term success. There is a need to embrace strategic, well planned implementation approaches to embed smoking-cessation interventions into hospitals and to reap and sustain the benefits for people who smoke.
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Affiliation(s)
- Anna Ugalde
- School of Nursing and Midwifery, Center for Quality and Patient Safety Research and Institute for Health Transformation, Faculty of Health, Deakin University, Geelong, Victoria, Australia
| | - Victoria White
- School of Psychology, Faculty of Health, Deakin University, Geelong, Victoria, Australia
| | - Nicole M Rankin
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Christine Paul
- School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
| | - Catherine Segan
- Cancer Council Victoria, Melbourne, Victoria, Australia
- Center for Health Policy, School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Sanchia Aranda
- Department of Nursing, University of Melbourne, Parkville, Victoria, Australia
| | - Anna Wong Shee
- Ballarat Health Services, Ballarat, Victoria, Australia
- Department of Medicine, Deakin University, Geelong, Victoria, Australia
| | - Alison M Hutchinson
- School of Nursing and Midwifery, Center for Quality and Patient Safety Research and Institute for Health Transformation, Faculty of Health, Deakin University, Geelong, Victoria, Australia
- Monash Health, Melbourne, Victoria, Australia
| | - Patricia M Livingston
- School of Nursing and Midwifery, Center for Quality and Patient Safety Research and Institute for Health Transformation, Faculty of Health, Deakin University, Geelong, Victoria, Australia
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Wiseman KP, Hauser L, Clark C, Odumosu O, Dahl N, Peregoy J, Sheffield CW, Klesges RC, Anderson RT. An Evaluation of the Process and Quality Improvement Measures of the University of Virginia Cancer Center Tobacco Treatment Program. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E4707. [PMID: 32629953 PMCID: PMC7369775 DOI: 10.3390/ijerph17134707] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 06/22/2020] [Accepted: 06/25/2020] [Indexed: 01/25/2023]
Abstract
Tobacco use after a cancer diagnosis can increase risk of disease recurrence, increase the likelihood of a second primary cancer, and negatively impact treatment efficacy. The implementation of system-wide comprehensive tobacco cessation in the oncology setting has historically been low, with over half of cancer clinicians reporting that they do not treat or provide a referral to cessation resources. This quality improvement study evaluated the procedures for assessing and documenting tobacco use among cancer survivors and referring current smokers to cessation resources at the University of Virginia Cancer Center. Process mapping revealed 20 gaps across two major domains: electronic health record (EHR), and personnel barriers. The top identified priority was inconsistent documentation of tobacco use status as it impacted several downstream gaps. Eleven of the 20 gaps were deemed a high priority, and all were addressed during the implementation of the resulting Tobacco Treatment Program. Prioritized gaps were addressed using a combination of provider training, modifications to clinical workflow, and EHR modifications. Since implementation of solutions, the number of unique survivors receiving cessation treatment has increased from 284 survivors receiving cessation support during Year 1 of the initiative to 487 in Year 3. The resulting Tobacco Treatment Program provides a systematic, personalized, and sustainable comprehensive cessation program that optimizes the multifaceted workflow of the Cancer Center and has the potential to reduce tobacco use in a population most in need of cessation support.
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Affiliation(s)
- Kara P. Wiseman
- Department of Public Health Sciences, School of Medicine, University of Virginia, Charlottesville, VA 22908, USA; (R.C.K.); (R.T.A.)
| | - Lindsay Hauser
- Cancer Center, University of Virginia, Charlottesville, VA 22908, USA; (L.H.); (C.C.); (O.O.); (N.D.); (J.P.); (C.W.S.)
| | - Connie Clark
- Cancer Center, University of Virginia, Charlottesville, VA 22908, USA; (L.H.); (C.C.); (O.O.); (N.D.); (J.P.); (C.W.S.)
| | - Onyiyoza Odumosu
- Cancer Center, University of Virginia, Charlottesville, VA 22908, USA; (L.H.); (C.C.); (O.O.); (N.D.); (J.P.); (C.W.S.)
| | - Neely Dahl
- Cancer Center, University of Virginia, Charlottesville, VA 22908, USA; (L.H.); (C.C.); (O.O.); (N.D.); (J.P.); (C.W.S.)
| | - Jennifer Peregoy
- Cancer Center, University of Virginia, Charlottesville, VA 22908, USA; (L.H.); (C.C.); (O.O.); (N.D.); (J.P.); (C.W.S.)
| | - Christina W. Sheffield
- Cancer Center, University of Virginia, Charlottesville, VA 22908, USA; (L.H.); (C.C.); (O.O.); (N.D.); (J.P.); (C.W.S.)
| | - Robert C. Klesges
- Department of Public Health Sciences, School of Medicine, University of Virginia, Charlottesville, VA 22908, USA; (R.C.K.); (R.T.A.)
- Cancer Center, University of Virginia, Charlottesville, VA 22908, USA; (L.H.); (C.C.); (O.O.); (N.D.); (J.P.); (C.W.S.)
- Center for Addiction Prevention Research, University of Virginia, Charlottesville, VA 22908, USA
| | - Roger T. Anderson
- Department of Public Health Sciences, School of Medicine, University of Virginia, Charlottesville, VA 22908, USA; (R.C.K.); (R.T.A.)
- Cancer Center, University of Virginia, Charlottesville, VA 22908, USA; (L.H.); (C.C.); (O.O.); (N.D.); (J.P.); (C.W.S.)
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Meyer C, Mitra S, Ruebush E, Sisler L, Wang K, Goldstein AO. A Lean Quality Improvement Initiative to Enhance Tobacco Use Treatment in a Cancer Hospital. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17062165. [PMID: 32213994 PMCID: PMC7143787 DOI: 10.3390/ijerph17062165] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 03/18/2020] [Accepted: 03/20/2020] [Indexed: 11/16/2022]
Abstract
Sustained tobacco use after cancer diagnosis decreases treatment effectiveness while increasing treatment side effects, primary cancer recurrence, and the occurrence of secondary cancers. Delivering tobacco use treatment to fewer patients due to inefficient workflow represents missed opportunities to deliver life-saving care. In 2017, the National Cancer Institute initiated the Cancer Cessation Initiative (C3I) to push new tobacco cessation resources into cancer centers across the United States. This grant allowed the University of North Carolina Tobacco Treatment Program (UNC TTP) to dramatically expand tobacco use treatment (TUT) services to patients at the North Carolina Cancer Hospital (NCCH). With this push, the team saw an opportunity to utilize Lean Six Sigma, a set of quality improvement (QI) tools, to streamline their processes and uncover the root causes of program inefficiencies. A 12-month QI project using the Lean A3 problem-solving tool was implemented to examine the team's workflow. The study team mapped out the processes and, as a result, developed multiple "experiments" to test within the NCCH to address workflow efficiency and clinical reach. Outcome measures from the baseline to follow-up included: (1) the number of new patient referrals per month, and (2) the number of counseling sessions delivered per month. From the baseline to final state, the team's referrals increased from a mean of 10 to 24 per month, and counseling sessions increased from a mean of 74 to 84 per month. This project provided a deeper understanding of how workflow inefficiencies can be eliminated in the clinical setting, how technology can be harnessed to increase reach, and finally, that soliciting and using feedback from NCCH leadership can remove barriers and improve patient care.
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Affiliation(s)
- Colleen Meyer
- Department of Family Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27759, USA; (L.S.); (A.O.G.)
- Correspondence: (C.M.); (E.R.)
| | - Sara Mitra
- Lineberger Comprehensive Cancer Center, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA; (S.M.); (K.W.)
| | - Ellen Ruebush
- Lineberger Comprehensive Cancer Center, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA; (S.M.); (K.W.)
- Correspondence: (C.M.); (E.R.)
| | - Laurel Sisler
- Department of Family Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27759, USA; (L.S.); (A.O.G.)
| | - Kyle Wang
- Lineberger Comprehensive Cancer Center, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA; (S.M.); (K.W.)
| | - Adam O. Goldstein
- Department of Family Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27759, USA; (L.S.); (A.O.G.)
- Lineberger Comprehensive Cancer Center, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA; (S.M.); (K.W.)
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Cohen RI. Lean Methodology in Health Care. Chest 2018; 154:1448-1454. [PMID: 29909284 DOI: 10.1016/j.chest.2018.06.005] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Revised: 05/27/2018] [Accepted: 06/06/2018] [Indexed: 11/25/2022] Open
Abstract
To improve the delivery of patient care, governments and health-care institutions adopted quality improvement methods that had been developed decades earlier in manufacturing industries. Many health-care practitioners are either unaware or are inexperienced about what these practices entail and whether they are successful in health care. This article reviews Lean, an improvement philosophy made famous by the Toyota Motor Company. Lean uses a set of instruments and incorporates a long-term vision aiming for continuous improvement. It focuses on eliminating waste as perceived by the patient, thereby maximizing quality and safety for the patient. However, the effort required for the attainment of Lean's goals is often not appreciated. Indeed, successful and sustainable implementation requires immense institutional culture change combined with innovative leadership and motivated frontline health-care professionals.
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Affiliation(s)
- Rubin I Cohen
- Division of Pulmonary and Critical Medicine, Amarillo Veterans Affairs Health Care System, Texas Tech University Health Sciences Center at Amarillo, Amarillo, TX.
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