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Table 1 Systems change strategies chosen by each system

From: Facilitators of health systems change for tobacco dependence treatment: a qualitative study of stakeholders? perceptions

Systems change strategies System 1 System 2 System 3 System 4
Identification and documentation (required): Implement a clinic-wide system that ensures for every patient at every clinic visit, tobacco-use status is queried and documented. X X X X
Training and education: provide adequate training, resources and education to motivate clinic personnel to address tobacco and increase tobacco treatment knowledge and skills. X   X X
Referrals: establish a referral system for tobacco users interested in counseling. Referrals can be internal and/or to external, evidence-based cessation services as is most appropriate for the patient population being served by the system. X X X X
Brief interventions: Institutionalize brief tobacco cessation interventions into clinic protocols.     
Reporting and feedback: Establish a reporting and feedback system that facilitates regular retrieval of and consistent feedback on tobacco use and treatment data to clinic personnel and that can be used to track tobacco-related performance measures and quality improvement initiatives. X   X  
Follow up care: systematically follow up with patients who receive brief tobacco cessation interventions or referral to cessation services to determine actual provision of services and ongoing needs. X   X  
System integration: Integrate tobacco cessation approaches into disease management protocols. X   X  
Quality improvement, Accreditation and Standards: Systematically integrate tobacco cessation strategies into existing programs or initiatives that address quality improvement, accreditation and evaluative standards in a way that will lead to improvements in the use of selected cessation strategies.    X  
Organizational goals and policies: Ensure that organizational goals and policies related to tobacco cessation are consistent and supportive of systems change strategies and activities.   X   
Hospital policies and services: Implement hospital policies that support and facilitate inpatient tobacco dependence services.     
Performance measures and follow up: provide regular feedback to clinic personnel to ensure providers consistently deliver effective tobacco cessation treatment or referrals as per the established protocol. X X X  
Reimbursement: if relevant, establish a system to consistently seek and obtain reimbursement for tobacco cessation services. X    
Tobacco cessation coverage: Improve patient education about and use of existing cessation benefits (counseling and medication).   X