1. INTRO:
My name is …
and I’m from …
My presentation today is about how we
Facilitating organisational change: The Hunter New England Health Smoke-free story
Prepared by: Carolyn Slattery, Rebecca Wyse, Jenny Knight, Inga Kasch, Lorraine Paras, Megan Freund HUNTER NEW ENGLAND POPULATION HEALTH 5 September 2007

2. Vision to Reality……..in 8 months
Background
NSW Health directive to go Smoke-free
March 2006 Hunter New England (HNE) set smoke free date
History in HNE of smoking cessation pilot programs
Organisational change required
HNE Health went Smoke-free on October 31st 2006
Vision to Reality……..in 8 months
HNE Health went Smoke-free on October 31st 2006
There was a directive from NSW Health which required Area Health Services to go totally smoke-free – which meant that there was to be no smoking anywhere on hospital grounds, include buildings, carparks, outdoor areas etc
February 2006 HNE set smoke free date
In February 2006 the Executive of HNE identified a smoke free date – this gave us 8 months to prepare to go smoke free
As HNE had a history of smoking cessation pilot programs we were are of the importance of organisational change if we were going to change care practice in HNE facilities.
How did this all come about?
. The Hunter New England
What we needed to do …
In order to successfully implement this policy we needed to develop and implement an Area-wide strategy for organisational change.
We knew ( from capacity building – organisational change literature) that a collaborative, top-down approach would be most suitable
The strategy would need to ensure that
- patients were supported not to smoke onsite
- clinical staff were provided with resources and training to support patients
Hunter New England went smoke-free on October 31st 2006*

3. What did we want to achieve
NSW Health mandates a comprehensive approach to implementing a Smoke Free Health Service Policy:
Patient support
Staff cessation support
Enforcement
Communication
Focus of presentation is:
Inpatient smoking care across all HNE facilities.
What did we want to achieve
To increase the provision of appropriate smoking cessation care across HNE facilities.

4. The Challenges … Challenges Large area (130,000 sq km)
Large no of facilities (54)
staff
Diversity – rural/remote/metro
Limited resources
No existing area-wide procedures
Organisation change was required to ensure increased provision of smoking cessation care across HNE facilities.
However, facilitating organisation change was going to be a challenge.
Some of the challenges being:
Large area - 130,000 sq km (size of England)
Diversity: eg Metropolitian hospitals of 550 beds to small, small community hospital of 10 beds
We needed to bring about across: - 54 Facilities, 93 inpatient wards
Limited resources (0.8 FTE Program Manager, 1.6 FTE Project Officers)
Limited area wide systems
Eg No standard admission recording practices
No existing area wide procedures
Eg No protocols for providing cessation care (e.g. NRT)
Base located here

5. Method - Intervention 1. Local consensus Systems change
Inpatient working group formed and:
Identified key smoking care practices
Developed a clinical practice guideline
Identified recording requirements
Developed Nurse Initiated Medication Protocol – NRT
Systems change
Nicotine dependent care assessment form
Incident Information Management System (IIMS)
Supply of 3 day post discharge medication
3. Training/skill development
2 nurse train the trainer sessions delivered
Multiple planned telephone contacts with Nurse Unit Manager’s (NUM) and Senior Nurse Mangers (SNM)
Medical officer’s information sheet
Method – intervention
How did we meet the challenges
Local consensus
Inpatient working group formed there were representatives from all levels of clinical structure and from different facilities across the area.
The inpatient working group:
Identified key smoking care practices (assessment, brief advice and referral)
Developed clinical practice guideline – for managing inpatient who smoke (based on NSW Health guideline – managing ND inpatients)
Identified recording requirements – basis of Nicotine Dependent Care assessment form
Developed Nurse Initiated Medication Protocol – NRT
Training/skill development
2 train the trainer sessions delivered
Training package – ed and posted on intranet
Medical officer’s information sheet disseminated
Reinforcing strategies
Prompts and incentives
Performance feedback
Organisational change to achieve population health outcomes lends itself to the application of the multi-strategic, sustainability driven, capacity building framework. The variation in stages of awareness, of the potential to reduce alcohol related crime within Police, demanded that the capacity building framework was applied in a manner that was sensitive to the stage of change of the targeted part of the organization. A multi-strategic plan was needed to ensure that change would be embedded in the organization and remain effective after the time frame of the initial funding.
Organisational Capacity Building Framework
Capacity Building frameworks suggest planning around the organisational components of
Leadership
Workforce development
Resource allocation
Organisational Infrastructure ( IT / policies / procedures / performance monitoring).

6. Method – Intervention cont’d
4. Communication
Staff eg staff newsletter, information sheets, website
Patient eg brochures, posters, Media, informed of the policy on admission
5. Prompts
NUM and SNM contacted for compliance with implementation protocols
6. Management support
Telephone contact with NUM’s and SNM’s
Smoke-free
7. Monitoring compliance and feedback
4 x Telephone contacts with NUM’s
Area wide bedside audit
Results of above feed back to wards and Nurse Management
SNM’s and NUM’s provided Smoke Free team feedback
Monitoring compliance and feedback
4 x Telephone contacts with Nursing Unit Managers (NUM)
Area wide bedside audit
Results of above feed back to wards and management
4. Prompts
Area wide nicotine dependent care assessment form – prompts the provision of care
Telephone contacts with NUM’s and Senior Nurse Mangers (SNM) – prompt to ensure procedures in place
5. Management support
Telephone contact with NUM’s and SNM’s - how they can delivery training
Smoke-free
6. Communication
Staff eg The latest, information sheets, website
Patient eg brochures, posters, Media, informed of the policy on admission

7. Method Pre - Post test design Care provision data collected from NUMs
Eligibility criteria
Wards with smokers admitted since Oct 31st
completed both (pre & post) telephone contacts
Measures:
% patients informed about SF policy
% smokers recorded as smokers
% smokers who had nicotine dependence assessed
% nicotine dependent smokers offered NRT
Response rate 100% (n=67)
Pre - Post test
Nurse unit managers self-report telephone contact
Baseline measures:
% patients informed about SF policy
% smokers recorded as smokers
% smokers who had nicotine dependence assessed
% nicotine dependent smokers offered NRT
Response rate 100%
Pre – post sample
had had smokers admitted since Oct 31st
completed both (pre & post) telephone contacts

8. Results

9. Results Cont’d

10. Summary
Large improvement in smoking cessation care across HNE facilities
Duplication of single facility results across a large Area Health Service (ie all patients in multiple facilities).
Validation data of self report from bed side audits currently being analysed
Intervention provides a feasible and effective way for facilitating change across a large, diverse area
Future Steps
Succession plan
Sustainable monitoring tool and system to facilitate sustainability of provision of smoking cessation care
Discussion
Large improvement in smoking cessation care across HNE facilities
Results similar to other studies that have been highly resourced at a small number of facilities
Intervention provides a feasible and effective way for facilitating change across a large, diverse area
Tips
Problem solving every day
Be available
Policy Directive
Future
Identification of a sustain monitoring tool and system to facilitate sustainability of provision of smoking cessation care

11. Key Messages Leadership required Consultation Tailored support
Top down
Bottom up
Consultation
Tailored support
Problem solve on a daily basis
Be available!

12. Acknowledgements With grateful acknowledgements of: Jenny Knight,
Rebecca Wyse
Sue Green
Christophe Lecathelinais,
Lynn Francis,
CATI interviewers
Bev Parker
Jenny Jackson
Olga Peers
Hunter New England Population Health is a unit of the Hunter New England Area Health Service.
Supported by funding from NSW Health through the Hunter Medical Research Institute.
Developed in partnership with the University of Newcastle.