Tobacco cessation program implementation-from plans to reality: skill building workshop-group model.

Group Health Cooperative of Puget Sound (GHC) is a not-for-profit, group model, consumer governed health maintenance organisation (HMO). GHC serves over 450 000 enrollees at 29 medical centres, two hospitals, and three specialty centres in the state of Washington, primarily in the Puget Sound area. The cooperative employs 900 physicians, more than 40% of whom are primary care providers. GHC reorganised its quality implementation structure in the early 1990s into a framework called the “clinical roadmap”. This population and evidence based approach was designed to identify and improve systematically key clinical processes, and then embed them into everyday care. Tobacco use was one of the first areas to receive such attention. In 1992, reduction of tobacco use in the adult population became GHC’s primary prevention priority as well as one of the initial four key clinical roadmaps. Using the National Cancer Institute’s recommendations as a base, GHC set the goal of decreasing tobacco prevalence to 12.5% by the year 2000. In support of this goal, intermediate process goals were set, including: (1) status identification of tobacco use on 95% of all charts; (2) chart documentation of intervention in at least 45% of identified smokers during their last clinical encounter; (3) increased participation in “Free & Clear”, GHC’s behavioural tobacco cessation program; and (4) achievement of less than 10% fair/poor rating in satisfaction surveys of patients who were oVered individual support and counselling on tobacco use by their providers. After more than a decade of implementing and regularly improving GHC’s tobacco reduction program, these intermediate process goals have been met and GHC’s tobacco prevalence has decreased from approximately 25% to 15% (significantly below the state of Washington’s reported tobacco use) (fig 1). Through this process seven key lessons were identified that optimise the success of a system wide tobacco reduction program.