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Creating a Smoke-Free Hospital…In Tobacco Country
By Grace E. Terrell, MD, MMM, CPE
A Sunday New York Times recently
featured an article about the anxiety being experienced in
France right now where there is soon to be a nationwide ban on
smoking in public places.
“How can the French give up their beloved
cigarettes and still be French?” ponders the Times.
Their answer: ask the Italians, who underwent a similar
transformation in 2005, discovering much to their surprise
that they can still be Italian without smoking in public.
In fact, the Italians saw a measurable
decrease in acute myocardial infarctions in hospital emergency
rooms within a few days of their public smoking ban, just as
was seen in American cities which had previously implemented
such a public policy.
The same weekend of the New York
Times article, my husband and I watched our daughter’s
soccer game from the side lines when one of the other parents
lit up a cigarette.
Although it was a very windy day the smoke
was noticeable to the other 40 parents who moved away and
upwind from the smoking parent, glaring icily at him for the
rest of the game. On the way back from the game my husband and
I spoke about the change in our North Carolina culture since
our childhood, when all the public spaces were filled with
tobacco and tobacco was called “king.”
Along with textiles and furniture, it was one
of the three industrial pillars that sustained the local
economy. Less than a generation later the public culture, even
in North Carolina, has radically changed, but this change has
been so imperceptible over time that the “tipping point”
cannot be determined.
So how can it be that in 2006 physician
executives are still writing queries on the ACPE online
networks seeking advice about hospital no smoking policies? If
North Carolina soccer moms and the entire French population
are transforming society, why are not hospitals, whose very
missions are based upon health and wellness, leading the way
in this social goal?
In a recent ACPE network conversation, a
physician leader at one hospital sought the advice of others
because patients had left the hospital to go across the street
and smoke at their doctors’ office! He was appropriately
concerned about the hospital’s liability, but obviously more
concerned with how to create a culture conducive to accepting
a campus-free ban on smoking.
One explanation may be the conflict in our
culture between our value of individual autonomy and public
health concerns. The “smoker’s rights” backlash in North
Carolina somehow gets tied in our minds with patient’s rights,
leading to a lukewarm stance to a ban on smoking at best. The
risk aversion we all experience in health care due to the
medical liability climate also probably influences the timid
responses to a full smoking ban on hospital campuses.
The patient escaping to the doctors’ office
across the street, due to a hospital policy that prohibits
smoking, creates immediate heart palpitations in any good risk
manager. Yet we wouldn’t think twice about the same concern
for other addictive substances, so long as we had taken
appropriate measures for patient safety.
In some medical communities, there has been a
tipping point that has allowed a successful cultural
transformation to tobacco-free campuses, even in the heart of
tobacco country. The key to this success was not luck, nor
waiting expectantly for some cultural tipping point to
magically happen. Rather, the successful cultural
transformation required leadership, planning and coordination
of the change, and cooperation among all stakeholders in the
medical community.
In 2004, High Point Regional Health System in
began their effort to become the third hospital system in
North Carolina, and the first in their area of the state, to
have an entirely tobacco-free campus. Two years later, like
the Italian change described in the New York Times
article, the cultural transformation has been complete.
No longer are nurses and respiratory
therapists seen standing outside the emergency department door
in the pouring rain on break, guiltily puffing away before
returning to work to treat the another patient with COPD.
Patients and staff alike are barred from using tobacco
products on the campuses of any health care facility
associated with the health system, including the doctors’
offices of all affiliated medical staff.
An analysis of the process by which this
successful transformation occurred may help us learn other
ways we can lead needed cultural change in our health care
systems, particularly as we face escalating pressures in the
health care delivery system.
Sue Cumpston, High Point Regional’s Wellness
Coordinator/Employment Specialist, who led the health system’s
successful transformation efforts, describes the process we
followed:
- High Point Regional Health System’s leadership
determined that commitment to creating and sustaining a
healthy community meant creating a healthier environment on
their campus and setting the tobacco-free standard for other
organizations to follow.
- Before presenting this idea to the board of trustees,
High Point Regional researched tobacco-free campus
initiatives at the University of Michigan Health Systems,
the Mayo Clinic, and other health systems outside North
Carolina, then site visited one of the two other
tobacco-free health care institutions within North Carolina
to learn from their successes and challenges. Then, once
unanimous approval was received from High Point Regional’s
board, work began on the actual implementation of the
tobacco-free campus policy.
- A tobacco-free campus task force was carefully selected,
including employee representatives who were smokers,
non-smokers, and former smokers. This task force eventually
split into work teams which addressed how the new policy
would be written and communicated, how employee tobacco
users would receive cessation assistance, and how the policy
change would be enforced.
- The tobacco-free initiative at High Point Regional was
not just that health system’s event; it became a way to
unite the entire medical community for a common goal of
encouraging healthier living. The leadership at the health
system got buy-in from all the physician partners in the
High Point area to have all physician offices become
tobacco-free along with the hospital, setting the “go-live”
date as July 4, 2005— Independence Day.
- Employees were informed of the tobacco-free campus plans
on March 1st and press releases reached the local media a
few days later. Despite fears that the policy change would
be negatively received, public response was very positive,
with the predictable few “smoker's rights” commentaries.
- High Point Regional Health System felt it was very
important to give its employees plenty of time to plan for
the day that they could no longer use tobacco products at
their work site. Employees and their immediate household
members were able to receive free smoking cessation
counseling and employees could also receive free nicotine
replacement therapy in conjunction with completing either
group or individual counseling. Some of the medical
community did likewise for their employees.
- While firmly maintaining its policy, the health system
was nonetheless empathetic to patients with nicotine
dependence. Proactive nicotine patch standing orders were
added where appropriate for general medical patients to help
them with nicotine withdrawal symptoms during their hospital
stay.
- Terminal cancer patients with nicotine dependence were
handled empathetically and, in the event that nicotine
replacement therapy was attempted and was ineffective, one
special exception was made to alleviate unnecessary
suffering during their death.
- In addition to a much healthier environment for
employees, visitors and patients, High Point Regional Health
System’s tobacco-free campus culture change led to another
very positive consequence: a phenomenal increase in the
number of employees and their family members who have made
the attempt to quit smoking.
- In the 10 years prior to the implementation of the
tobacco-free policy, only about one employee per year
actually requested help in quitting smoking. Yet since March
of 2005, more than 175 employees and their family members
have stepped forward to receive help. That’s quite an
increase— a 17,500% increase. Add to this the number of
employees who decided to quit on their own and the results
are even more impressive. And remember this was all due to
the fact that a health care organization stepped up to the
plate to create the healthy environment its employees and
the community deserved.
For those of you from other parts of the
nation where the victory at High Point Regional Health System
does not seem so radical, I would suggest we all take a
different tact and behave like the Italians, who are said to
be gently encouraging the French in their national efforts at
a total public smoking ban.
The North Carolina in which I live is not
that of my childhood. It is multi-ethnic, multi-racial, and
multi-cultural. By learning how to approach an issue as
culturally polemical as tobacco within our health care
community, we may learn techniques that will aid us in other
important results-based change efforts in the future.
Grace E. Terrell, MD, MMM,
CPE, is a general internist in private practice
at Cornerstone Medical Associates, High Point, NC. She can be
reached at Grace.Terrell@cornerstonehealthcare.com
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