Smoke Free Families Past Participant Survey

Thank you for sharing feedback on your experience in the Smoke Free Families (SFF) Project! Your input will assist us in making important program decisions for future waves. Please complete any and all questions for which you are comfortable sharing; no answers are required or will be shared outside of the project team.

If you would like to receive the available handouts/materials for your participation, please ensure the practice name and your name is provided. If you have questions about this survey, please contact Hayley Southworth at hsouthworth@ohioaap.org.

The Smoke Free for Me Learning Collaborative is funded by the Ohio Department of Health, Ohio Department of Medicaid, and the Medicaid Technical Assistance and Policy Program administered by the Ohio Colleges of Medicine GovernmentResource Center.

Site/Practice Name:

Name:

Role in Project Team:

Wave participated in (select all that apply):

Wave 1

Wave 2

Sustainability Questions

Have you sustained any changes in practice made as a result of the Smoke Free Families project since the end of the Learning Collaborative? (Select one)

Yes

What changes were sustained (select all that apply):

Continue to identify families with in home smoke exposure

Continue using the screening tool in its entirety

Continue using some questions from the screening in our EMR

Continue using some questions from the screening verbally or on paper

Continue having discussions about smoke exposure when identified

Continue using handouts/materials with families when smoke exposure is identified

Continued sending referrals to the Ohio Quit Line

OtherOther

How often do you use at least one of the changes made in the practice (select all that apply):

Have the changes made as a result of the SFF project improved efficiency related to identifying smoke exposure and made discussions with families more efficient (reduced waste, avoided duplication, made things run smoother)? (Select one)

Yes

Cannot Tell/Unsure

Why did your practice stop any changes made during the SFF project (select all that apply):

Families complained about repeat surveys

Screening tool took too long to complete

It was too difficult to incorporate changes into EMR

Information was not appropriate for our patient population

Only participated for the MOC Part IV credit

Project champion at practice left or changed focus area

Other topics or QI projects took priority

OtherOther

Are there any resources that could have helped sustain changes made during the SFF project?

What have you learned most about improvement that you believe other teams should know when they start their improvement work?

What suggestions would you make to improve the SFF project for future waves?

What additional resources would you have liked at the start of the project?

Do you have any other comments you would like to share?

Smoke Free Families Past Participant Survey

Please rate the degree to which your practice now does the following items:

Sustainability Questions

Project Impact Questions

Which components of the monthly action period calls were most helpful? (Please assign a number for each topic from 1-4, with 1 being the most helpful and 4 the least helpful)