No Ifs, Ands or Butts: Improving Tobacco Abuse Documentation in a Resident PCP Clinic

From the 2019 HVPAA National Conference

Dr. Kelley Chen (Cleveland Clinic Foundation), Dr. Kevin Harris (Cleveland Clinic Foundation), Dr. Matthew Hoscheit (Cleveland Clinic Foundation), Dr. Madison Conces (Cleveland Clinic Foundation), Dr. Chantelle Carneiro (Cleveland Clinic Foundation), Dr. Carl Gillombardo (Cleveland Clinic Foundation), Dr. Andrei Brateanu (Cleveland Clinic Foundation)


Cigarette smoking is associated with numerous health conditions including pulmonary and cardiovascular disease. In the United States, 15.5% of adults are current smokers and 68% are interested in quitting. As primary care providers (PCPs), we are well-positioned to provide support to patients interested in quitting smoking. Studies have shown that taking less than 5 minutes to advise quitting smoking improves abstinence rates. However, as PCPs we only advise smoking cessation if we identify the patient is a current smoker. To appropriately identify current smokers, it is important to document smoking status in the electronic health record (EHR). This documentation reminds physicians to discuss smoking status, cessation and willingness to quit at subsequent visits and encourages collaboration among all the patient’s providers.


We aim to improve smoking status documentation in a senior medical resident (SMR) PCP continuity clinic at Stephanie Tubbs Jones Health Center (STJHC) during a 2-month period.


Baseline data was obtained through retrospective chart review of all patients seen in the SMR PCP continuity clinic at STJHC from July-August 2018. Data was pooled from 6 SMR patient panels. We determined the percentage of current smokers that have documentation of smoking on their visit problem list. These months were selected for baseline data to reduce bias, as they were prior to choosing smoking cessation as our variable of interest. Using multiple validated process improvement tools, we implemented three interventions to improve smoking cessation documentation. The first intervention was a group huddle among all SMRs prior to each clinic day. The second intervention was paper reminders to document smoking status posted at each resident workstation. The third intervention utilized both group huddles and paper reminders simultaneously. After each intervention, we compared the percentage of current smokers that have documentation of smoking on their visit problem list to the baseline data.


In our baseline data, 28% of patients seen were current smokers. Of those current smokers, only 60% had tobacco abuse documented in their visit problem list. With group huddles (intervention #1), 78% of current smokers had documentation of tobacco abuse, an 18% increase from baseline. Paper reminders (intervention #2) increased tobacco abuse documentation to 73%, a 13% increase from baseline. With a combination of both group huddles and paper reminders (intervention #3), 90% of current smokers had documentation of tobacco abuse, a 30% increase from baseline.


Cigarette smoking is an important public health issue and PCPs are well-situated to provide smoking cessation counseling. However, this is only done if the PCP is aware the patient is a current smoker. By themselves, daily resident huddles and paper reminders at resident workstations improved documentation of tobacco abuse at our resident PCP clinic. Both interventions implemented simultaneously improved documentation even further, with an additive effect in this study. Improving processes at multiple points in the workflow can significantly improve outcomes, and this strategy can be applied to other quality improvement initiatives.

Clinical Implications

Daily group huddles prior to the beginning of clinic and paper reminders posted at resident workstations improve documentation of smoking status. This is the first step in offering appropriate interventions and resources to current smokers to promote cessation.

What are academic medical centers across the country doing to improve healthcare value?

Value improvement guides: Published reviews in JAMA Internal Medicine coauthored by experienced faculty from multiple leading medical centers, with safety outcomes data and an implementation blue print.

Review article detailing 25 labs to refine for high value quality improvement | July 2020

MAVEN campaign: Free 4 year high value care curriculum online.

Join the Alliance! Membership is free with institutional approval and commitment to improving value in your medical center.

Learn more about HVPA on Health Affairs Blog