JHQ 316: Decreasing the Use of As-Needed Antihypertensive Therapy in Hospitalized Patients with Asymptomatic Hypertension-JHQ 316 Article

JHQ 316 Article

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This article describes a department-wide quality improvement (QI) initiative to increase smoking cessation counseling (SCC) and referrals to a nicotine cessation program (NCP) across a large academic internal medicine department. Smoking is a leading preventable cause of death, yet many smokers do not receive cessation counseling in routine care. Baseline performance for a composite metric—documented SCC or an NCP referral for new patients who were current smokers—was low (8.6% in the prior year).<br /><br />Using a Plan-Do-Study-Act framework, the department implemented low-cost, scalable interventions across 52 outpatient internal medicine clinics over 12 months (Sept 2022–Aug 2023). The metric was tied to a faculty financial incentive, increasing stakeholder attention. Key interventions included: leadership outreach, a monthly QI newsletter with goals and performance updates, a staff-facing infographic outlining suggested workflows, and targeted follow-up with low-performing clinics.<br /><br />The workflow emphasized a clinic staff-driven “opt-out”-style approach during rooming: medical office assistants (MOAs) identified smokers, offered NCP referral, and (if accepted) pended an electronic referral order for the clinician to sign. If declined, cessation materials could be added to the after-visit summary. Staff documented counseling via a discrete EHR checkbox. Performance was monitored monthly using a Tableau dashboard populated from Epic EHR data.<br /><br />During the intervention period, 1,773 new patients who were active smokers were seen. The composite SCC/referral rate increased from 8.6% to 25.6% (about a threefold improvement). Signed referrals increased early in the project but declined in the later months; only about 26% of referrals resulted in an NCP visit. Limitations included single-center design, measurement limited to new-patient encounters, lack of direct observation of clinic workflows, and possible mismatch between documentation and actual counseling. The authors conclude that dashboards plus simple communication and staff-driven workflows can substantially improve documented smoking cessation care at scale without external funding.

Keywords

quality improvement initiative

smoking cessation counseling

nicotine cessation program referral

Plan-Do-Study-Act (PDSA)

internal medicine outpatient clinics

Epic EHR documentation

Tableau performance dashboard

opt-out workflow rooming

faculty financial incentive metric

workflow standardization and monitoring