Smoke Free For Me Wave 2 – Practice Checklist

Smoke Free For Me Learning Collaborative

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Thank you for your willingness to participate in the Smoke Free For Me Learning Collaborative.  The Ohio Chapter of the American Academy of Pediatrics will coordinate the project’s planning, implementation, and evaluation. This project will assist pediatric primary care providers in decreasing in-home smoke exposure for infants age 0-12 months.  Participating providers will screen infants 0-12 months of age at every well visit appointment, using a smoke exposure screening tool.   Additionally, providers will implement the 5As (Ask, Assess, Advise, Assist, Arrange) of smoking cessation during the well visit appointment for infants exposed to smoke in their home environment.

Participating practices will work with a multi-disciplinary “core team” of clinical and administrative staff from their office to provide infants with the opportunity to grow up to reach their full potential, by identifying those exposed to smoke early in life and reducing the serious health risks associated with early smoke exposure.  Practice teams will participate in a Learning Session to learn screening strategies, risk to infants of smoke exposure, 5As of smoking cessation, basic quality improvement science, and practice implementation strategies.  Practice teams will be supported by the Ohio AAP Smoke Free For Me project team and will be introduced to various community resources in the state. Practices will utilize an easy to use screening/data collection tool that is efficiently completed and scanned into a database.  Monthly calls with the Ohio AAP Smoke Free For Me project team and other participating practices will provide data feedback and project support.  Participating providers will receive the following benefits:

  • Training in the 5A approach to smoking cessation
  • Easy to use screening tool/data collection sheet to assess smoke exposure in the home and capture outcome data regarding smoking cessation and/or reduction of smoke exposure
  • Maintenance of Certification (MOC) Part IV credit for up to 21 medical specialties participating as part of the American Board of Medical Specialties (including 25 points by the American Board of Pediatrics and 20 points by the American Board of Family Medicine)
  • Networking opportunities with other healthcare providers interested in smoking cessation
  • Resources for caregiver and family referral to address smoking cessation
  • Guidance and quality improvement coaching from the Ohio AAP
  • Assistance developing a process to track behavior change over time
  • Resources for families

For specific information about the project requirements, please review this recruitment packet, which includes a checklist to help you understand the requirements and a link to enroll your practice in the learning collaborative. Should you have any questions, please do not hesitate to contact any of the project team listed below.

We look forward to partnering with you to build smoke free homes for Ohio’s children!

Mike Gittelman, MD – Medical Director
Cincinnati Children’s Hospital
(513) 636-2274

Kristen Fluitt, MS – Program Manager
Ohio Chapter, AAP
(614) 846-6258


Practice Checklist

This checklist serves as a guide to help you understand the requirements of the Smoke Free For Me Learning Collaborative, and to gauge your practice’s readiness for participation.

Important Dates for Wave 2 – Smoke Free for Me Learning Collaborative

Registration Deadline:

  • September 10, 2018
  • Pre-Work Call:

o   The Smoke Free For Me Learning Collaborative will host one pre-work calls prior to the Learning Session to answer questions from practices regarding the project, as well as to review the work that is required of practices in preparation for the Learning Session.  The Pre-Work Call will be announced to enrolled practices in advance.

  • Pre-Work Calls are anticipated to last an hour, but could run longer or shorter depending on the questions asked by the participants. Practice leaders and identified Quality Improvement Core Team members are all invited to participate. Additional calls can be scheduled upon request.
  • Pre-Work call information, including the phone number to access the call as well as the link to access the webinar portion, will be sent out upon registering for the project (see below).
  • Learning Session:
    • The Smoke Free For Me Learning Session will be held on Saturday, September 22, 2018 from 10:15 am – 12:45 pm.
    • The Smoke Free For Me Learning Session will be held at the Crowne Plaza – Dublin OH, 600 Metro Pl N, Dublin OH 43017 (ample free parking is available onsite).
  • Action Period Calls:
    • Monthly Action Period Calls/Webinars will be held from October – April; exact dates and times will be announced prior to the Learning Session.
  • Data Due Dates:
    • Data sheets will be scanned daily or weekly depending on practice preference with all monthly data due by the 3rd of the following month.
  • PDSA Cycle Worksheet Submission:
    • Teams will be expected to submit 3 PDSA cycle worksheets showing their tests of change during the project.
    • PDSA worksheets will be due in the months of November, January, and February.
    • Training on using PDSAs will be provided.
  • Part IV MOC Attestation:
    • Practices seeking Part IV MOC credit will be assisted in completing attestation of Meaningful Participation to claim credit by December 1, 2019.


Consent Form Administration

All physicians within a practice, and members of the QI core team, will be asked to complete a consent form.  Practices will be provided with the consent form prior to the Learning Session.

The rationale for the signing of the consent form by all practice physicians is to assure that all members of the practice are aware of the project and understand the role of the practice within the project.

Please note that all physicians within a practice are not required to sign the consent form and are not required to actively participate in the project, but should be informed of the project and offered a consent form.

Physicians who are actively participating in the project will be required to:

  • Attend monthly Action Period calls
  • Oversee screening and data collection
  • Intend to complete the requirements for American Board of Pediatrics, Maintenance of Certification Part 4 Credit by participating in the project
  • When necessary, represent the practice at learning sessions

Definitions for ABP Maintenance of Certification Meaningful Participation Requirements

The following definitions for meaningful participation requirements will be helpful to share with each physician as they are enrolled in the project so that they are clear as to what is expected of them to obtain American Board of Pediatrics Maintenance of Certification Part 4 credit.

The team leader within the practice will need to attest for each physician’s meaningful participation using the criteria below. This includes ensuring that data is entered monthly by all active physicians in the practice.

Participating practices are expected to:

  1. Organize a core team of at least 3 team members (includes Physician Leader, Nurse/Nurse Practitioner or Medical Assistant, Administrative Staff/Office Manager – one of whom must commit to being the day-to-day team contact).  As many members of the team as possible attend the learning session and meets at least bi-weekly to plan and carry out tests of change using the Change Package
  1. Secure senior leadership’s commitment for the improvement team’s work in the Collaborative
  2. Perform pre-work activities to prepare for the Learning Session
  3. Align the goals of the Collaborative work to the strategic plan of the participating organization
  4. Perform 3 tests of changes that lead to improvements towards the desired outcomes and submit PDSA worksheets demonstrating these tests
  5. Collect data at all infant (age 0-12 months) well visit appointments
  6. Participate in webinars, teleconferences, and emails to learn from one another and share improvement ideas, tools and methodologies
  7. Scan and submit weekly data for Smoke Free for Me Collaborative
  8. Share and review practice-identified data transparently across the collaborative (identifiable practice data cannot be shared outside of the collaborative without permission from the involved practices and from the Medical Director)
  9. Physician practice leaders attest to other physicians’ meeting participation requirements for ABP MOC Part 4 credits
  10. Submission of monthly progress reports to the Collaborative leadership as requested

The project team is expected to:

  1. Provide evidence-based information on reducing in-home smoke exposure for pediatric patients 0-12 months of age
  2. Offer coaching to improvement teams on applying the Model for Improvement to implement key changes at the Learning Session, on monthly conference calls, and through email communications
  3. Provide each team monthly feedback on data and narrative reports
  4. Provide a library of tools and training materials
  5. Provide documentation of project results to meet American Board of Pediatrics Maintenance of Certification standards
  6. Provide communication support to keep teams connected to faculty and colleagues during the Collaborative

Smoke Free for Me Project Goal and Outcomes

Goal:  Reduce smoking exposure to infants in the home setting (making OH homes smoke free)

Target Population:  Families with infants age 0 – 1 yr

Interventions:  Screening for smoke exposure in the home and implementation of 5As when appropriate

 Quality Improvement Outcomes:

1)  > 90% of caregivers presenting to a PCP office will be screened for smoking in the home setting.
2) > 90% of caregivers who screen + for smoking in the home setting will have received the 5As plan to quit smoking
3) > 90% of those who identify smoking in the home by others than the caregiver will receive smoking cessation information
4)  > 90% of caregivers who smoke/vape will be referred to Quit Line

Research Improvement Outcomes:

1) If caregiver presenting to infant’s well-visit appointment is a smoker – reduction of self-reported smoke exposure to infants in the home measured via # cigarettes or vapes per day smoked in the past week
2) 25% of those referred to Quit Line in the pediatric office visit will have quit smoking by self-report captured at subsequent pediatric visits.
3) 25% of sleep practices will be changed to be appropriate by self-report at subsequent visits when recognized inappropriate