Background Smoking increases the severity and cardiopulmonary complications of many rheumatologic conditions. Yet despite tobacco assessment in many rheumatology clinics, we reported that <10% of eligible notes documented cessation counselling. New models show increased efficacy with Ask-Advise-Connect approaches using non-physician staff protocols. Under protocols, front-line clinic staff assessing pre-visit vital signs and tobacco use are cued to recommend and refer patients electronically to telephone tobacco quit line support. Such approaches increased uptake of cessation support 13-fold in primary care studies but have not been adapted for rheumatology clinics.
Objectives Our objective was to engage clinic staff in participatory work system redesign to develop and plan implementing an Ask-Advise-Connect tobacco protocol in rheumatology clinics. We report the results of this redesign study under the Systems Engineering In Patient Safety (SEIPS) model's five work system domains: people, organization, technology, environment, and tasks.
Methods Our multidisciplinary team facilitated participatory work system redesign with medical assistants (MA) and nurses (RN) from three US academic rheumatology clinics. Staff participated in one of two hour-long focus groups. Trained facilitators used semi-structured interview questions informed by the SEIPS domains to appraise pre-visit assessment workflows, educational needs, proposed protocols, brochures, electronic health record (EHR) tools, and implementation plans.
Results Over 80% (9 MAs, 5 RNs) of clinic nursing staff participated in focus groups. SEIPS domain questions facilitated discussions on intervention design, implementation, and sustainability planning (Table 1). The work system redesign included training (people); a protocol and workflows adapted to specialty care (organization, tasks); customized EHR alerts for assessing tobacco status and an EHR order set for e-referral to quit line services (technology); and physical cues like a desktop patient brochure linking rheumatologic conditions, tobacco use, and cardiovascular risk (environment).
Focus group participants reported routinely assessing tobacco use, but most had not asked about readiness to quit. A few had asked such questions, but noted low outcome expectancy and not knowing what to do next. One nurse said, “I'd ask, `Are you ready to quit?' and they'd say `No' and then I'd stop.” Staff groups identified that education about links between tobacco use and rheumatologic diseases and stepwise support from our Ask-Advise-Connect protocol would help them overcome barriers to tobacco cessation counselling. They requested specific best-practice language in the EHR tools and appreciated rheumatology-specific brochures with printed conversational prompts.
Conclusions We engaged rheumatology clinic staff in participatory work system redesign to plan implementing a tobacco cessation protocol. The participatory redesign process resulted in a tailored implementation plan for a quasi-experimental trial of a tobacco cessation e-referral protocol in rheumatology clinics.
Disclosure of Interest C. Bartels Grant/research support from: Independent Grants for Learning and Change (Pfizer), A. Gilmore: None declared, D. Panyard: None declared, C. Maxcy: None declared, R. Adsit: None declared, A. Skora: None declared, E. Ramly: None declared