Gundersen Lutheran Uses System-Wide Standards to Treat Tobacco Dependence at its Hospital and Clinics

It’s challenging enough to get an entire staff at one hospital or clinic to treat tobacco use. It’s quite another to get thousands of employees throughout an entire healthcare system to work together to ensure all patients who use tobacco get the help they need to quit.

That’s the behemoth accomplishment of Gundersen Lutheran, a major healthcare network with more than 6,000 employees. It is one of the nation's largest multi-specialty group medical practices, regional community clinics, hospitals, nursing homes, home care, behavioral health services, vision centers, pharmacies, and air and ground ambulances. It serves patients in 19 counties in Wisconsin, Minnesota and Iowa.

Every Patient, Every Visit
You’d think with all that responsibility and patients’ myriad immediate healthcare needs network employees would easily forget to treat tobacco use. But not Gundersen Lutheran. Every employee who sees patients is encouraged to ask every patient about tobacco use at every visit.

They know that the U.S. Public Health Service Clinical Practice Guideline: Treating Tobacco Use and Dependence recommends tobacco use as a vital sign. While Gundersen hasn’t made it a required vital sign yet—it’s voluntary—and the exact process for tobacco treatment has yet to be standardized for every department and clinic, Gundersen Lutheran is working to ensure each unit addresses tobacco use in some way. “We have not established a consistent method yet,” said Susan Lundsten, wellness education specialist, “but are getting closer to our goal of a system-wide standard.”

“It’s everybody’s responsibility,” said Terresa Bubbers, clinical exercise physiologist at Gundersen Lutheran Medical Center in La Crosse. Bubbers said their system works well because patients hear the message to quit multiple times from multiple professionals—in some cases, from a nurse, doctor, pharmacist and rehab specialist. “When they hear it from multiple people, the impact is greater,” Bubbers said. Parents and caregivers of pediatrics patients also are encouraged to quit for their health and the health of the child patient.

According to Dr. Chris Miller, a longtime member of the Gundersen Lutheran Tobacco Dependence Advisory Council, having all staff treat tobacco use enables the system to seize the teachable moment when the patient is suffering effects from tobacco use. “Now more employees are energized and feel comfortable treating it.”

“They might not be ready the first or second time they hear it,” Bubbers said, “but then become ready later.”

Dr. Edward Winga knows how important it is to follow up with patients. He remembers a patient who refused time and again to consider quitting with his help. A few years later, the patient returned and said,
“I quit smoking, Doc.”

“What changed your mind?” Dr. Winga said.

“Well, Doc, you kept after me, so I figured you must be serious.” That anecdote rings true with the Clinical Practice Guideline, which advises doctors to talk up quitting smoking because it can more than double a patient’s chances of breaking the addiction.


Tobacco treatment is truly a team approach at Gundersen Lutheran. Left to right: Jim Engh, HR operations manager; Jane O’Brien, department secretary at the Prairie du Chien clinic; Joan Curran, executive director of external affairs; Nancy Stuart, RN, CDE at the Prairie du Chien clinic; Dr. Edward Winga; Dr. Chris Miller; Kristine Hayden, UW-CTRI outreach specialist; Susan Lundsten, Wellness Education Specialist; Terresa Bubbers, clinical exercise physiologist. Other members of the Gundersen Lutheran Tobacco Dependence Advisory Council were not available for this picture.

How They Help Patients Quit
During a patient visit, Gundersen Lutheran follows the U.S. Public Health Service “5 A’s” of tobacco treatment:

1. Ask about tobacco use (and document results).
2. Advise all tobacco users to quit. Every patient who uses tobacco gets a copy of Gundersen Lutheran’s “Nicotine Cessation Workbook.”
3. Assess the patient’s willingness to make a quit attempt.
4. Assist by:

a. Expressing your support.
b. Helping the patient set a quit date.
c. Prescribing appropriate medications.
d. Referring the patient to the Wisconsin Tobacco Quit Line, 1-800-QUIT-NOW. This can involve signing up for Fax to Quit so the Quit Line coach makes the first phone call. Gundersen Lutheran also has a successful in-person class called “Journey to Freedom.”

5. Arrange follow-up contact to assess and support the quit attempt.

At clinics, medical assistants typically handle steps one through three. At the medical center, it’s the nursing staff. Nancy Stuart, a nurse at the Prairie Du Chien Gundersen Clinic, reports that patients rave about the classes. “We’ve had so many people that say they couldn’t have quit without the group.”

“The first thing is to get them interested,” said Dr. Winga, “which isn’t always easy.”

“Try to get at where the patient is at,” Dr. Miller said. “That knowledge about their readiness to quit is critical. I let them know ‘I’ll be here for you.’ I always give the message that I want them to quit.” She gives patients homework assignments to think about why they smoke and motivation to quit. “I always have my nurse follow up.”While Gundersen Lutheran moves to an EPIC electronic medical record, it uses PDFs,  clinic notes, and an expanded vitals application to document tobacco use and track each patient’s road to smokefree living.

Tips on Building a Program of Excellence
While Gundersen Lutheran has an excellent system that treats nearly 100 percent of patients who smoke or chew tobacco, it wasn’t always this way. Drs. Winga and Miller remember the early days on the Tobacco Dependence Advisory Council.

Dr. Winga said he encouraged tobacco treatment and smoke-free air back in the 1970s when the head of respiratory therapy smoked. The respiratory therapy department was the first to go smoke-free, Dr. Winga said. “The nurses hated me. Most of them smoked.”

“We were concerned about secondhand smoke first,” Dr. Miller said. Then they turned to tobacco treatment. “It’s critical to get higher-ups on board soon. We started small and all of a sudden it got really big.” Having a plan and data to back it up is a must.

Bubbers said a key is to understand the system’s disease-management goals. “Any tie into the big strategic plan improves your chances,” she said. Hospitals can fill community-service requirements with free tobacco-treatment programs. Gundersen Lutheran has even partnered with local businesses to spread the word as a public-relations campaign.

It’s also wise to prepare for slow but steady progress, Dr. Miller said. “I remember going into the meetings expecting everyone to buy in right away. But I learned you can’t expect everyone to be as passionate as you are about tobacco cessation.”

“Don’t quit,” Bubbers said. “It took us years.”

And, once the system is in place, maintenance is necessary. The advisory council reviews tobacco treatment every year and updates best practices to include new FDA-approved medications, guideline updates or more streamlined procedures.

Staff turnover is another challenge, especially when a tobacco-treatment champion leaves. Jim Engh, Human Resources operations manager, said tobacco treatment is covered during orientation for new staff. If they smoke, new employees are offered an 80-percent discount on medications to help them quit. And they’re advised that the only place they can smoke is in their cars. Most new employees, however, don’t smoke.

“Recruit new staff to be tobacco-treatment champions,” Dr. Miller said. Encourage, empower and remind them that tobacco dependency is a chemical addiction, not just a habit or matter of willpower.

Leveraging Existing Help
“The Clinical Practice Guidelines are there,” Dr. Miller said. “You don’t have to start from scratch.” And the UW Center for Tobacco Research and Intervention (UW-CTRI) offers in-person training and technical assistance by local outreach specialists, including the latest news and updates on what’s covered, what codes to bill and how best to treat.

“We appreciate what UW-CTRI does so much,” Dr. Miller said. “We couldn’t believe UW-CTRI is there, that this work has been given so much credence. What validation. That was our biggest boost.”

“Systems changes take practice,” said Dr. Miller. “Just as you’d tell a tobacco user, ‘Don’t give up, try again,’ it’s the same with treating tobacco use.”

Other Case Studies