Table 3.

Qualitative Excerpts Demonstrating Pathways Linked to a ≥10-Point Gain in Smoking Outcome

Pathway	Excerpt
Process improvement: changed practice workflows including processes to ensure clinicians provided brief counseling, changed workflow to enable MAs to provide brief counseling/referral for patients AND Clinician ownership	Basically, they had a standing order for these tobacco users ... that will occur during the visit. There were some aspects of it that the MA can do or the person rooming. They had plenty of literature about tobacco cessation, as well as the state quitlines and different resources that are available, so they would do some of that. Then there was more counseling done within the visit, by the provider. (Facilitator interview; 2-5 clinicians; clinician owned)
Any of 3 operational changes: Process improvement: changed practice workflows including processes to ensure clinicians provided brief counseling, changed workflow to enable MAs to provide brief counseling/referral for patients Documentation: reported working to change documentation behavior after someone in practice learned they were not documenting correctly Identify referral resources: gave information about quitlines and other resources to patients AND 25-49.9 facilitation hours	Their smoking [assessment and counseling] was a little bit on the low side, so I made sure I went back to it just to tell them, this is the protocol you need to follow. Make sure every patient is being screened for smoking. If there is a patient that’s smoking, make sure they give all the information that’s needed for them to quit. (Facilitator interview; solo practice; clinician owned; facilitation duration 4 [25-49.9 hours with a facilitator]) What I focused on was helping them to document properly in [their EHR] because [their EHR] has a very specific way to document smoking cessation counseling. It has to be documented in a particular place. (Facilitator interview; 2-5 clinicians; FQHC; facilitation duration 4 [25-49.9 hours with a facilitator]) We were given a lot of brochures, and I was able to get a lot of free gums and patches for patients that couldn’t get them before.… We [previously] didn’t even know about [the quitline], that we can refer [patients] for that, and that they can receive free patches and gum. (Practice interview; 2-5 clinicians; clinician owned; facilitation duration 4 [25-49.9 hours with a facilitator])
Identify referral resources: gave information about quitlines and other resources to patients WITHOUT Tracking referrals: tracked patient’s referral and followed through on a referral to a quitline or another smoking cessation resource AND 10-24.9 hours of facilitation	With the smoking, we did a lot of patient education. We pushed that 1-800-QUITNOW smoke line that [our state] has. We had tear-out pages where you post it on the wall and people would just tear off the number; something that no one really notices, so we put some in the bathroom. We made sure that they were in the [examination] rooms. (Facilitator interview; 2-5 clinicians; clinician owned; facilitation duration 3 [10-24.9 hours with a facilitator])

EHR = electronic health record; FQHC = Federally Qualified Health Center; MA = medical assistant.