The Addressing Tobacco Through Organizational Change (ATTOC) Approach

Addressing tobacco addiction in mental health and addiction treatment settings requires changing the culture and recognizing the urgency of changing our practices to help individuals quit tobacco. Tobacco addiction shortens the lives of our patients/clients and staff who smoke; it causes or worsens medical diseases; and it slows down recovery. As with other addictions, tobacco use is a trigger for those trying to quit because of its association with other substances. Staff and patients/clients all need to clearly understand why we must address tobacco now and how it affects both recovery and lifespan. The first step in the change process is to acknowledge the problem of tobacco, agree to change the culture, and select initial broad goals.

Change is more likely to occur if the leadership of your agency strongly and openly supports this initiative. In the ATTOC Approach, a “Champion” is selected to lead the initiative. Often one or two “co-Champions” provide additional help. The Champion / project manager helps the agency develop the initial broad goals (including patient, staff, and environment goals), a leadership team, and ongoing project management. If funds are available, the champion may also contact / hire a consulting team to help with the whole initiative. The UNM ATTOC consultation team has helped hundreds of agencies across the nation and also worked internationally.

Once an agency’s leadership recognizes that addressing tobacco is critical to its mission of promoting well-being and recovery in its clients, the agency is ready to begin work on the major tasks included in the ATTOC intervention. The first step includes five tasks.

Tasks:

1. Consider retaining the assistance of the ATTOC consultation team. Many agencies found it helpful to work with knowledgeable consultants who can provide technical assistance as they develop and implement a strategic plan for change.
2. Identify project leader (Champion) and co-Champions. The Agency Leader or designee must identify a project leader (Champion) and potentially one or two co-Champions to guide the change process and create a Leadership Team. It is important to inform and gain the support of key “sponsors” on the Board of Directors, Unions, staff leaders, etc. The commitment to the need for culture change at your institution should be clear and explicit. Sponsors’ support is vital for success.
3. Articulate a preliminary vision for organizational change. Champions discuss and document a tentative vision of a changed agency that addresses tobacco use and addiction. A vision describes how your organization will look in the future, including what is motivating this change. It should convey an urgency for addressing tobacco, reference the areas to change, and inspire staff.
4. Identify tentative strategic goals in three areas: patient, staff, and environment. The agency should have broad patient/client, staff, and environment goals that will lead to the development of specific strategies and tactics to achieve the goals. These goals will be refined as change moves forward and more staff become involved.
5. Test goals through internal communication. Once tentative goals are identified, these should be discussed with staff to assess readiness and ways to achieve the goals. Staff need to know why this initiative is happening, what they will do differently, and what benefits they can expect as a result of these changes.

Changing leadershiping the treatment culture to address tobacco will require a team effort, and involving key stakeholders related to the agency goals is important. To maximize chances of success, key administrative, clinical, and nonclinical leaders who are already leaders at different levels within the agency will help the Tobacco Leadership Group be more effective. The agency’s goals will influence who should be on the Tobacco Leadership Group.

Working closely with the Tobacco Leadership Group, the Champions will refine and clearly write out the tentative vision and broad goals. Later, in ATTOC Step 4, the Tobacco Leadership Group will identify specific strategies and tactics to achieve these goals as they develop a Change Plan for the agency. The broad goals will help the ATTOC consultation team evaluate and discuss the agency’s plans during their on-site visit (if this consultation is requested).

Tasks

1. Identify members of the Tobacco Leadership Group. Members should include people who relate to the broad goals. For example, if the goals are mostly clinical (aimed at reducing rates of smoking among patients/clients), then clinicians will be heavily represented. If goals include creating a tobacco-free campus, then all departments of staff (clinical, housekeeping, security, food services, human resources, etc) might be included. Including tobacco treatment experts, smokers and nonsmokers, and clients may be important. Select individuals who work well in teams (as shown through prior committee service and continuous quality improvement) and who are well respected in their work areas and within the agency.
2. Refine vision and goals. Development of vision and goals is an iterative process, involving a wider circle at each phase and culminating in a very specific set of time-framed goals, strategies, and tactics that guides implementation effort (ATTOC Step 4). The Tobacco Leadership Group should review the vision statement and the draft goals developed, adding input to improve their clarity and contributing their perspectives on how best to achieve them.
3. Assure key leaders are committed to change. Coordinate closely with the key administrative, clinical, and nonclinical leaders who have authority and power in the change process. Ensure that they are in agreement with the Tobacco Leadership Group’s plans and will stand firmly behind them.
4. Collaborate with ATTOC consultant team to plan on-site visit. The Champion works closely with one of the members of the ATTOC consultant team to set the dates of the on-site consultation (if desired). This consultation typically includes technical assistance to the Tobacco Leadership Group, doing an Environmental Scan (ATTOC Step 3), and staff training.
5. Prepare staff for on-site work with consultation team. Champions and the Tobacco Leadership Group can work to ensure the success of the on-site visit by the ATTOC team. In addition to the logistical and other steps, the staff should ensure that the groundwork for the intervention is laid as well as possible. This includes demonstrating administrative support for the effort, providing a clear explanation of the rationale for the changes made and anticipated, and making preliminary efforts to publicize the process and engage key staff. To maximize cooperation, be transparent with your communications.

The ATTOC Environmental Scan includes a walk-around the campus, interviews with staff and patients, and a review of the clinical charts for evidence of documentation about tobacco use, addiction, and treatment. This evaluation creates a baseline assessment of the core goal areas for the ATTOC intervention: patient, staff, and environment. The findings help assess organizational readiness and also provide important information for the ATTOC Change Plan (ATTOC Step 4).

• The patient-level assessment evaluates what clinical services are offered, how they are documented, and what referral information is provided;
• The staff-level assessment evaluates what tobacco addiction treatment services are available for staff, the level of prior training, whether staff are Tobacco Treatment Specialists, and staff attitudes towards this initiative; and
• The environmental assessment evaluates the indoor and outdoor spaces of the agency for evidence of tobacco use, as well as health promotion literature to support and encourage recovery from tobacco addiction

At the end of the assessment, the ATTOC consultants determine the level of organizational readiness at your agency and determine the implications of this information for your change and communication plans. Written Feedback is provided for sites to use in their Change Plan. A self-evaluation is possible and can also be helpful.

Tasks:

1. Assess organizational strengths and weaknesses in adopting change. Your agency’s past experiences in implementing change are a valuable source of information that can help you complete on-target planning as you address tobacco addiction. ATTOC consultants will seek information about the history of any changes that your agency has made so that they can assess the organizational strengths and weaknesses that may come into play during the transition. For example:
   
   • What are the changes that have been made lately in your agency?
   • Has your agency been successful in adopting any new ideas in treatment programs?
   • What factors helped your agency succeed in other similar change efforts?
   • What factors have hindered your ability to implement changes?
   • As an organization, at what stage does your agency typically adopt innovations?
2. Assess agency strengths and vulnerabilities in addressing nicotine dependency. It is important for you and the ATTOC team to understand the baseline from which you are currently addressing tobacco addiction, including any past experiences that may suggest barriers, resources, or incentives that will affect the likelihood of success. The scan covers the key areas that will affect the organization’s readiness to change:
   
   1. Environmental tobacco control effects,
   2. Patient assessment and treatment, and
   3. Staff competencies, smoking, and attitude.
3. Hold a series of on-site meetings with the ATTOC consultants. The ATTOC consultants will hold a series of meetings to assess and discuss the readiness for change. They will shed light on how your agency’s readiness to change compares with that of other agencies they have assisted, including the implications of these similarities or differences for your Change Plan and Communication Plan. These meetings also provide an opportunity to communicate the new plans.

This step is an integrative process based on all the work that has been implemented so far. Informed by the ATTOC Environmental Scan and the assessment of organizational readiness for change in Step 3, Champions and members of the leadership group are now revisiting the preliminary organizational goals established in Steps 1 and 2 in order to develop a fully articulated change plan. Each broad goal is expanded to include specific strategies and tactics to achieve the broad goals. What is learned in Step 3 about the organization’s readiness to change may lead to adjustments in timing or priority, or help to refine planners’ understanding of the most effective tactics to achieve goals. The Change Plan includes: Strategic Priorities; Implementation Plan, and Monitoring Plan.

Tasks:

1. Refine vision of changed organization. Capture the choices that express what the facility would like to have, to do, and to be in the near or distant future. You and others in the Tobacco Leadership Group need to revise the vision to reflect the commitments your agency is making to achieve its goals. For example, the vision may make clear that nicotine dependence will be treated the same as other types of addiction that are assessed and treated to promote the health, well being, and recovery of all patients who seek help at the facility. At this stage, the vision should be disseminated widely to clearly demonstrate the agency’s commitment to realize this vision.
2. Finalize SMART Goals, Strategies, and Tactics. Dahl’s acronym “SMART” is a useful way to remember the critical components of goals: Specific; Measurable; Attainable; Relevant; and Time Bound. Goals will be needed for each area in which the organization intends to move forward. For each goal, identify both general strategies and specific tactics to achieve it.
3. Identify and charge work groups to achieve the goals. Create work groups that consist of people at administrative and staff levels who represent all the agency departments involved in implementing the goals in question. Those who have been known as opinion leaders should be invited to join the work groups. Each work group will oversee the activities needed to achieve goals, reporting back to the Tobacco Leadership Group on their progress.
4. Identify steps to achieve goals, including changes in policy. Break tasks into smaller and attainable steps. Achieving these smaller steps will be seen by leadership and other stakeholder groups as early successes in the process, which will help the agency gain strength and momentum to move forward.
5. Develop one-page strategic planner for each task. Dahl (2003) developed the structure of one-page strategic planner that is built around “Top 10” task questions. Some of the questions are basic, obvious, and easy to answer; others are deeper and more complex, requiring more time and effort. For example, in one agency, a one-page strategic planner for task “Assessing and Documenting CO levels at Admission” was formulated. Planners like these provide at-a-glance tools for monitoring achievements on the work group level.

Virtually every goal within the Change Plan must be communicated to the stakeholders it affects – staff, clients, family members, and other agencies. Persuasive, clear communication maximizes the potential for positive response and empowers participants to become part of the change process.

External and internal communications must be built on and support the change plan for the successful implementation of the ATTOC intervention documented in the previous step. A good communication plan will keep communication focused, timely, and on target, preventing unwanted surprises (either for those affected or for persons involved in planning).

As for any plan, persons with key roles in communication should be specifically identified and the expectations of each should be clearly stated.

The agency website, newsletters, patient brochures, and other methods should be used to describe the initiative. Signage both inside and outside the campus is helpful.

Tasks:

1. Identify clear messaging and the best communication channels to communicate with stakeholders. Identify those who will be affected by changes in the agency (both internal and external) and the best communication channel(s) to reach them. Employees and others will be more willing to contribute their time and effort if they think and believe that addressing tobacco benefits all the staff, patients, and the program itself. Not only printed messages, but actions, will communicate whether or not the changes leaders announce in bulletins are true expectations executed with commitment and passion.
2. Determine channels for feedback from patients and staff. Provide a feedback loop so that you know how the changes are being received. In addition to encouraging people to participate in the implementation of the change, listen to what they have to say and consider whether you can make adjustments that will facilitate the change process for them and for others whose opinion they may represent.
3. Communicate new policies and procedures. As you communicate new policies and procedures, take care that you are not only using the right channel of communication for each group of stakeholders – e.g., staff, patients, family members, community members, and referral sources – but also that you are conveying to each a consistent message. No audience’s response should be taken for granted. Explain specifically how the new policies and procedures will affect each group. Provide support for difficult changes and publicize alternatives, where relevant. For example, if there will no longer be a smoking break, be sure that staff do not lose break time. Anticipate how people will react, the questions they are likely to raise, and the issues that may result. Be prepared with clear concise answers that will speak to the common obstacles that can be expected and address known concerns “up front.”

Step 6 includes implementing strategies and tactics to address patients’ nicotine addiction, such as reducing the rate of tobacco addiction amongst your patients and increasing motivation to seek treatment. The ATTOC Approach provides specific tools to help with screening, assessment, diagnosis, treatment planning, discharge planning, referral to quit lines, and motivation-based treatment interventions that can be delivered at the agency in individual or group format. Review how patients flow in and out of your program to determine when and where tobacco use and addiction should be assessed and treated and by whom.

Three achievable goals are

1. Add tobacco addiction to the treatment plan for all tobacco users.

2. Refer all tobacco users to Quit Lines and/or Nicotine Anonymous,

3. Start a new treatment option (medication, group treatment, individual treatment, education) on site.

Tasks:

1. Assess how a patient flows through your agency and identify opportunities to prevent, treat on site, and refer for tobacco addiction treatment outside the agency. The Tobacco Leadership Group or a work group can focus on what services are provided and what are already provided and refine plans to implement agency goals. Some agencies will provide extensive treatment; others will provide assessment, treatment planning, referral, and ongoing encouragement for recovery. To be successful, provide excellent education, training, and communication to staff who will need to perform new functions. Once the Champion and key managers create the new treatment model and intervention points, revise existing policies and procedures (such as requirements for documentation) to incorporate tobacco addiction.

2. Require assessments and treatment planning to be documented in charts. Develop intake assessment and discharge forms. Discharge/Referrals might be made to your state’s Quit Line for treatment medications (such as nicotine patch) or psychosocial treatment (Nic A, support groups, quitters groups, etc). Purchase a CO meter and be sure staff know how to use it.

3. Provide treatment and recovery assistance for patients. Include tobacco addiction on the treatment plan for all tobacco users. Match treatment to motivational level to quit. Provide motivational literature, referral information, and treatment option information. Identify treatment needs, barriers, and motivation to quit. Increase medication options on site if staffing and resources are available.

4. Incorporate tobacco issues into patient education. Patient education on hazards of use, impact on others, and treatment options can be provided in many ways (for example, through brochures, posters, and treatment groups).

5. Empower patients to help each other and help develop Peer Specialists. Peer Specialists can help clients recover from nicotine dependence, just as they help clients recover from alcoholism or drug use. Nicotine Anonymous can be started on site and also may be available in the community.

6. Track progress in this work area and adjust the plan as needed. A key principle is to keep moving in areas where you can move, even when you are blocked in others. When major problems develop in one area, the Champion and Tobacco Leadership Group should not allow themselves to be so distracted that they forget to monitor, encourage, and support progress in other areas.

Staff goals can promote wellness and provide training to help more patients quit smoking. Staff training should match the plans for the agency to provide better treatment planning, referrals to community resources, and the planned treatment options for on-site. Agencies can require staff to “appear as non-smokers” at work and include this as a factor in hiring new staff. Some agencies create tobacco-free campuses and offer a range of services (such as Employee Assistance Programs, medications, and health insurance support) to help staff who use to quit.

Lack of staff training is one of the major barriers to implementing tobacco addiction treatment successfully. Providing training for staff enhances their knowledge and skills, helps change attitudes, and enables them to assist clients with more confidence and hope. Organizations that address staff tobacco use successfully have been shown to reduce their rates of involuntary turnover, accidents, injuries, discipline problems, and absentee rates.

Tasks:

1. Provide basic training. All clinical staff should have a basic knowledge on how to assess, develop a treatment plan, and refer patients to on-site and community treatment options. The ATTOC consultation and training team can provide basic training for all staff members, including prescribers. Prescribers need to be able to provide medication options if available.

2. Provide advanced training. Initially one or a few staff may be the designated tobacco treatment specialists. They can provide specific psychosocial treatment interventions in group or individual format, including treatment designed to increase awareness / motivation and help with quitting. The ATTOC consultation team can provide extensive advanced trainings either (or recommend other trainings) at the agency institution or at the University of New Mexico School of Medicine in Albuquerque, NM. Training can be offered via internet or phone. We encourage agencies to support a few individuals to become certified Tobacco Treatment Specialists.

3. Provide ongoing and “refresher” training on nicotine dependency treatment. Delivery of ongoing training is consistent with strategies to upgrade staff skills to address other health care challenges, such as HIV, AIDS, Hepatitis C, and Tuberculosis (TB), as well as incorporating opiate maintenance therapy. Many organizations have made it mandatory for nurses and other staff to receive yearly tobacco training.

4. Analyze staff interest in recovery assistance and plan interventions. Many staff will want and benefit from medications, psychosocial treatment, and social supports. Many just want medications, but we strongly encourage psychosocial treatment support (for example, Quit Lines, Nicotine Anonymous, or in-person treatment). Evaluate your staff benefits for tobacco addiction treatment with the agency health plan providers.

5. Communicate changes and opportunities in this area to staff. Communicate new policies and opportunities to staff. Engage with your Human Resources Office and Employee Assistance Program Office to align their work with this effort.

6. Provide treatment and recovery assistance for interested staff. By offering staff a variety of options to stop smoking, the agency enables each staff person to design a program that is suited to meet his or her particular needs and situation.

7. Track progress in this work area and adjust the plan as needed. Barriers encountered should be communicated to the consultant team in order to get expert feedback and reflections. Progress in each area (patients, staff, and environment) should be evaluated so that challenges can be met and accomplishments publicized.

Most agencies are now considering Tobacco-Free Campuses, and environmental changes to discourage or end smoking use generally take three forms:

1. Tobacco-Free Campus For Everyone – in buildings, cars, and on the campus grounds.

2. Tobacco-Free Campus for Staff Only and Restricted Use for Patients.

3. Restricted Tobacco Use for everyone, identifying a few locations with low visibility. Provide clear signage for no-smoking and smoking areas. Encourage wellness and discourage tobacco use through signage and related health promotion and education activities.

Environmental changes are aimed at eliminating or reducing exposure to hazardous chemicals associated with smoking tobacco. Environmental Tobacco Smoke also shortens life spans, can cause immediate serious consequences to those who had a recent heart attack, and can be a powerful trigger for those trying to quit smoking.

A Tobacco-Free Campus for all is best for promoting wellness and recovery. Patient and staff goals can still be achieved if this option is not chosen, but success is greatly facilitated by the context of a Tobacco-Free Campus.

Tasks:

1. Develop strategies and tactics to match one of the three campus / outside environmental goals described above. The Environmental Scan provides a map of your campus and where smoking use and signage currently exists. Set a date for the Tobacco-Free Campus that is realistic (if this is your goal). Sometimes there is no time for a phased-in change due to external policy mandates (often from the State, County, or City). Will tobacco use be limited to specific locations? Determine where and how to make smoking less visible. To whom will the policy apply? How will the policy be monitored and what are the consequences for noncompliance? Develop an educational communication effort first, link it with recovery support, and develop a due process to manage noncompliance, working closely with Human Resources and Unions when possible.

2. Communicate changes in this area to staff, patients, and others as appropriate. As soon as the date to implement partial or complete tobacco-free grounds is determined, inform staff, clients, and other facility users of the change through the formal and informal channels. Develop and document a Communication Plan.

3. Implement messaging to promote wellness and tobacco addiction recovery inside the buildings of your agency. State laws may require agencies to have smoke-free buildings. If your agency is not in compliance with applicable laws, this is a critical issue to address. Provide signage and messaging within the building to communicate wellness and promote recovery, promoting outside resources (Quit Lines, Nic A) and agency resources (group treatments, Nic A, medication support, etc). Create posters, brochures, handouts, memos to staff, publicity for programs, and program newsletters. You will also want to change the agency website to reinforce the desired change, influence motivation, and raise awareness.

4. Track progress in this work area and adjust the plan as needed. It is important to actively solicit feedback from members of work groups and others carrying out changes so that you can track progress and adjust the plan as needed.

As an agency achieves its Patient, Staff, and Environmental goals there will be a need to communicate, provide education, and enforce these changes through policies and standard operating procedures. This step is critical to maintaining change.

The policies and procedures should be documented in a manner that is consistent with both the Change Plan and with documentation for other similar issues that the agency must address. For example, health care systems generally have policies for a wide variety of clinical and nonclinical issues such as prohibiting clients to sell drugs to each other, banning drug use on the grounds, describing procedures for detoxifying patients, and monitoring appropriate documentation. Tobacco policies in addiction treatment settings should be equally clear and well documented, defining both the boundaries on tobacco-related behaviors and the consequences if these boundaries are violated.

Tasks:

1. Document policies and procedures. These are needed for Patient, Staff, and Environment Goals. The agency’s expectations of employees, clients, and visitors should be clearly documented. Ensuring that these changes occur across the board where appropriate is often the charge of a work group on policies and procedures, which drafts language and recommends specific changes to the Tobacco Leadership Group.

2. Integrate new policies and procedures in staff training and patient education. Change takes time to become a natural and expected part of organizational culture. A frequent error on the part of organizations when they institute major changes is to train and publicize the change intensively at one point in time, but fail to provide the reinforcement needed to integrate the change. In so doing, they neglect existing employees, some of whom may need time to overcome their initial resistance, as well as new employees entering the agency.

3. Integrate new policies and procedures in performance review. If expectations of employees regarding the agency’s new antismoking policies are formalized in staff job descriptions, it is fair and logical to consider how well they have performed these responsibilities. This will help ensure that each staff member is incorporating the new policy into daily routine practice. Supervisors should be prepared to provide feedback to staff on their performance.

4. Communicate new policies externally to increase impact and understanding. 

   There are many reasons to communicate your agency’s commitment to addressing tobacco addiction externally as well as internally. Some of the most important ones are:

   • To anticipate and proactively address problems that may arise with neighbors,

   • To bring in partners who can reinforce and broaden your agency’s efforts,

   • To coordinate with sources of referrals to your agency and help your clients stay tobacco-free after completing treatment, and

   • To model and encourage healthy change in health care providers and businesses.

   Anticipate and proactively address problems that may arise with neighbors. Bring in partners who can reinforce and broaden your agency’s efforts.

Initial progress on addressing tobacco is achievable and motivating. Having some early victories furthers motivation; however there is a need to anticipate some of the potential ongoing issues, barriers to fully addressing this issue, and plan to sustain long-term recovery and change. The final step of the ATTOC intervention focuses on how to support, encourage, and sustain organizational change – a level of change at which addressing tobacco is fully integrated as part of routine practices in addiction treatment programs.

Addressing Tobacco is about culture change and organizational change. Such changes take time. Therefore, although recognizing improvements and successes is important, ATTOC Champion(s) and members of work groups cannot declare victory too early. Opportunities, challenges, and barriers will continue to arise. Many organizational changes are reversed when leadership changes, when environmental pressures are removed, or when, for whatever reason, the going gets tough. At such times, take a deep breath and remind yourself of the profound changes we have already experienced:

• Remember when agencies only treated alcohol dependence or only drug addiction or only mental illness?

• Remember when 75% of men in America smoked?

• Remember when we smoked in all buildings and it was normal to smoke? It is now becoming normal not to smoke. Only 3% of doctors now smoke.

Champions and the Tobacco Leadership Group need to continue their collaborative work over time, monitoring practice, publicizing successes, and providing meaningful supports to sustain change.

Tasks:

1. Publicize successes. It is important to make the most of successes that your agency achieves during the ATTOC intervention. To keep momentum growing and the change anchored, ATTOC Champion and members of the leadership team need to inform patients and staff at your agency, as well as community residents, about successes in addressing tobacco.

2. Establish an infrastructure to sustain change. Keep the Tobacco Leadership Team or integrate its work into the fabric of the agency’s culture and work. Create a Standing Committee to Address Tobacco. Get Human Resources, Employee Assistance Programs, and other key components of the agency to integrate this issue in their routine work. Provide all staff with “messaging” to help them tell others why tobacco is being addressed, what treatment options are available, and that there is hope for recovery. Link the agency’s work to other local and state-based tobacco initiative groups for ongoing training and support. Enforce the due process when needed.

3. Maintain ongoing monitoring and feedback/adjustment loop. Add tobacco addiction / recovery outcomes to the outcomes monitored by the agency. Performance Improvement / Continuous Quality Improvement efforts provide a framework for ongoing improvement. The Standing Committee to Address Tobacco may be the focus for an ongoing feedback and adjustment loop based on a regularly scheduled evaluation of the progress made. Most importantly, assess the causes of any shortcomings and take thoughtful action to address them. Periodically, you should:

   • Assess your progress,

   • Monitor your outcomes,

   • Consider your lessons learned, and

   • Forge recommendations to address problem areas.