„„Go for GoldGo for Gold““::

Gute Praxis im europGute Praxis im europääischen ischen

VergleichVergleich

Tagung DNRfK 25.6.2008Tagung DNRfK 25.6.2008

H. SchH. Schääferfer

RehaReha--ZentrumZentrum

TodtmoosTodtmoos

RehaReha-- Zentrum Zentrum

Todtmoos/SchwarzwaldTodtmoos/Schwarzwald861 m 861 m üüber NNber NN

Rehabilitation CenterRehabilitation Center TodtmoosTodtmoos

OwnerOwner: German National Pension Fund : German National Pension Fund

(Deutsche Rentenversicherung Bund, (Deutsche Rentenversicherung Bund, „„BfABfA““))

MedicalMedical DirectorDirector: H. Sch: H. Schääfer, MDfer, MD

HematologistHematologist//OncologistOncologist, , InternalInternal MedicineMedicine

ChiefChief AdministratorAdministrator: Elmar Rebmann: Elmar Rebmann

SubspecialitiesSubspecialities:: OncologyOncology, , CardiologyCardiology ((i.ei.e. .

CHD, MI); CHD, MI); PulmonaryPulmonary diseasesdiseases ((i.ei.e. COLD, . COLD,

Asthma, Asthma, LungLung cancercancer))

Rehabilitation CenterRehabilitation Center TodtmoosTodtmoos

CapacityCapacity: 224 : 224 ptspts: for : for inin--patientpatient

rehabilitationrehabilitation ((e.ge.g. . afterafter MI, MI, cancercancer ptspts afterafter

chemotherapychemotherapy, , irradiationirradiation, , tumortumor resectionresection, ,

ptspts withwith lunglung diseasesdiseases as as asthmaasthma etc.)etc.)

DurationDuration of of staystay : 3 to 4 : 3 to 4 weeksweeks ((meanmean 24 d)24 d)

PaymentPayment: : German National Pension FundHealth insurance system

Rehabilitation CenterRehabilitation Center TodtmoosTodtmoos

Academic Academic staffstaff: 10 : 10 househouse officersofficers//registrarsregistrars; 3 ; 3

consultantsconsultants ((OncologistOncologist, , CardiologistCardiologist, ,

PulmonologistPulmonologist); 1 Med. ); 1 Med. DirectorDirector ((OncologistOncologist););

3 3 psychologistspsychologists ((psychologicalpsychological psychotherapypsychotherapy))

NonNon--academicacademic medicalmedical staffstaff: :

20 20 nursesnurses, 7 , 7 physiotherapistsphysiotherapists etc.etc.

FacilitiesFacilities:: large large inin--doordoor and and outout--doordoor trainingtraining

facilitiesfacilities ((walkingwalking, , spinningspinning, , mobilisationmobilisation etc.)etc.)

diagnosticdiagnostic facilitiesfacilities ((mandatorymandatory : : ergometricergometric

+ + spirometricspirometric dxdx. for all . for all ptspts; ; bodyplethysmogrbodyplethysmogr., .,

echocardiographyechocardiography etc.etc.

„„GesundheitstrainingGesundheitstraining““ in der Rehabilitationin der Rehabilitation

Rehabilitation CenterRehabilitation Center TodtmoosTodtmoosHistoryHistory: :

1901: 1901: FoundationFoundation „„Sanatorium Sanatorium WehrawaldWehrawald““

Treatment of Treatment of TuberculosisTuberculosis and Asthma and Asthma

((„„Der ZauberbergDer Zauberberg““ –– Th. Mann )Th. Mann )

SinceSince 19271927: Sanatory Hospital of : Sanatory Hospital of thethe National National

German Pension Fund (German Pension Fund (RfARfA/BfA); /BfA); sincesince aboutabout

1930 (!): 1930 (!): strictstrict nonnon--smokingsmoking policypolicy (for all (for all patientspatients))

SinceSince 19601960: Rehabilitation : Rehabilitation centercenter for for pulmonarypulmonary

And And heartheart diseasesdiseases, in , in additionaddition oncologicaloncological diseasesdiseases

SinceSince 19981998

2005/20062005/2006: Klinik : Klinik WehrawaldWehrawald ((newnew buildingbuilding))

LightLight

AirAir

SunSun

Rehabilitation CenterRehabilitation Center TodtmoosTodtmoos

HistoryHistory of of nonnon--smokingsmoking policypolicy::

sincesince aboutabout 1930: 1930: smokingsmoking banban for for inin--patientspatients withwith violationviolation rulerule (immediate (immediate dischargedischarge//expellationexpellation))(ebenso verboten: Schneeballwerfen; strenges Regime unter (ebenso verboten: Schneeballwerfen; strenges Regime unter Chefarzt Dr. Kaufmann)Chefarzt Dr. Kaufmann)

1970/801970/80: no : no systematicsystematic smokingsmoking cessationcessationprogramprogram; ; mostlymostly deterrentdeterrent strategystrategy ((diadia--showshowof of advancedadvanced lunglung cancercancer ptspts); ); cessationcessationprogramsprograms sometimessometimes psychologicallypsychologically basedbased((„„nonnon--smokersmoker in 10 in 10 stepssteps““))

Rehabilitation CenterRehabilitation Center TodtmoosTodtmoos

HistoryHistory of of nonnon--smokingsmoking policypolicy::

sincesince 1986: 1986: systematicsystematic smokingsmoking cessationcessation

trainingtraining programprogram withwith scientificscientific evalutionevalution basedbased

on on behaviouralbehavioural therapytherapy ((motivationmotivation and and relapserelapse

prophylaxisprophylaxis) and ) and deadlinedeadline for for smokingsmoking patientspatients

((inin--ptspts still still smokingsmoking afterafter 2 2 wkswks of of hospitalhospital staystay werewere

dischargeddischarged ((expelledexpelled for for disciplinarydisciplinary reasonsreasons))

1993, 1997 and 2003: 1993, 1997 and 2003: scientificscientific investigationinvestigation for for

cessationcessation ratesrates ((KatamnesisKatamnesis afterafter 6 6 momo., n > 1.500)., n > 1.500)

European NetworkEuropean Network

forfor

Smoke Free Healthcare Services Smoke Free Healthcare Services

ENSH Smoke-free standards(Kodex des Europ. Neztwerkes für Rauchfreie Einrichtungen im Gesundheitswesen)

Umsetzung im Rehabilitations-Zentrum Todtmoos

ENSH Standard 1: ENSH Standard 1: Engagement Engagement HCO HCO engagesengages decisiondecision makersmakers, , appointsappoints a smoke a smoke

free free policypolicy workingworking groupgroup and and rejectsrejects all all tobaccotobacco

industryindustry sponsorshipsponsorship

•• WrittenWritten smokesmoke--freefree policypolicy ((agreementagreement withwith

worksworks councilcouncil//laborlabor unionunion))

•• No No SponsorshipSponsorship from from tobaccotobacco industryindustry at allat all

•• Senior Senior membersmembers of of staffstaff constituteconstitute thethe nonnon--

smokingsmoking committeecommittee ((responsibleresponsible: : chiefchief hospitalhospital

administratoradministrator E.R., E.R., medicalmedical directordirector H. S.,H. S.,

psychologistpsychologist B. M.)B. M.)

•• All All staffstaff membersmembers acceptaccept responsibilityresponsibility for for

maintenancemaintenance of of strictstrict nonnon--smokingsmoking policypolicy

ENSH Standard 2: ENSH Standard 2: KommunikationKommunikationHCO has a HCO has a strategystrategy and and implementationimplementation plan for plan for thethe

smokesmoke--freefree policypolicy and and informsinforms all all personnelpersonnel, ,

patientspatients & & thethe communitycommunity

•• All All staffstaff ((contractcontract and and outsourcedoutsourced) ) areare informedinformed

of and of and commitedcommited to to thethe nonnon--smokingsmoking policypolicy

•• PatientsPatients areare informedinformed priorprior to to admissionadmission aboutabout

ourour strictstrict nonnon--smokingsmoking rulesrules ((e.ge.g. . dischargedischarge in in

casecase of of violationviolation) and ) and aboutabout ourour smokingsmoking

cessationcessation supportsupport ; ; VisitorsVisitors areare also also informedinformed

•• CommunityCommunity isis regularlyregularly informedinformed byby publicpublic

relationrelation ((regularregular meetingsmeetings withwith locallocal politicianspoliticians, ,

e.ge.g. . mayormayor, and , and locallocal press)press)

ENSH Standard 3: ENSH Standard 3: Schulung und TrainingSchulung und Training

HCO HCO setssets up a up a trainingtraining plan to plan to instructinstruct all all staffstaff on on

howhow best to best to approachapproach smokerssmokers and and supportsupport smokingsmoking

cessationcessation

•• StrategyStrategy plan/plan/instructionsinstructions for for nonnon--smokingsmoking

policypolicy areare knownknown byby all all staffstaff

•• Professionals (Professionals (psychologistspsychologists, , socialsocial workersworkers, ,

doctorsdoctors and and nursesnurses) ) areare trainedtrained in in smokingsmoking

cessationcessation techniquestechniques

•• Smoking Smoking cessationcessation programprogram isis notnot onlyonly offeredoffered

to to patientspatients, , butbut also to all also to all staffstaff and and eveneven to to thethe

publicpublic ((locallocal communitycommunity))

ENSH Standard 4: ENSH Standard 4: MaMaßßnahmen zur Entwnahmen zur Entwööhnunghnung

HCO HCO identifiesidentifies smokerssmokers, , providesprovides cessationcessation supportsupport

and and ensuresensures continuitycontinuity of of supportsupport afterafter dischargedischarge

• All smokers among the patients are identified by a triple survey system:

– Detailed written questionnaire (before admiss.)

– Medical history (taken by MD; pack years det.)

– Exhaled carbon monoxide (CO test; taken on d 0, d 7 and d14; „surprise effect“ straight afteradmission)

• Smoking cessation program is mandatory (!) for all identified smokers (about 250 – 300 pts p.a.)

ctd.

ENSH Standard 4: ENSH Standard 4: MaMaßßnahmen zur Entwnahmen zur Entwööhnunghnung

HCO HCO identifiesidentifies smokerssmokers, , providesprovides cessationcessation supportsupport

and and ensuresensures continuitycontinuity of of supportsupport afterafter dischargedischarge

• Continuous and systematic evaluation of smoking cessation program

• Individual outcome is documented in the ptchart and described in every discharge report

• Pharmacological therapy available (if necessary)

• Systematic follow-up after 6 mo./12 mo.

• Scientific evaluation of the smoking cessationprogram and publication of the results (n > 1.500 over 3 periods) )

ENSH Standard 5: ENSH Standard 5: RauchfreiheitRauchfreiheit

HCO has HCO has developeddeveloped and and isis maintainingmaintaining smoke free smoke free

groundsgrounds//campuscampus

• There is a total and complete tobacco ban on the Rehabilitation Center Todtmoos Campus

• Buildings (and also terraces and balconies) arecompletely smoke free (smokers among staff, pts and visitors have to leave the hospitalground)

• Violation is sanctioned strictly: expellation of pts after in-house smoking within 24 hrs; outsidesuppliers are banned in case of repeated violation

ENSH Standard 6: ENSH Standard 6: UmfeldgestaltungUmfeldgestaltung

HCO HCO displaysdisplays clearclear smoke free smoke free signagesignage and and bansbans all all

incentivesincentives to smoketo smoke

• The smoking ban and smoke free policy isclearly signed and communicated (signs, oral and written communication, introd. lecture)

• There are no smoking areas on campus

• Staff, pts and visitors are never exposed to passive smoking

• There is no merchandise at all (adverts, distribution, sale, eg. cigarette machines, kiosk) for tobacco products on campus

ENSH Standard 7: ENSH Standard 7: Gesunder ArbeitsplatzGesunder Arbeitsplatz

HCO has HCO has managementmanagement policiespolicies and and supportsupport systemssystems

to to protectprotect and and promotepromote thethe healthhealth of all of all staffstaff

• All staff are informed about and have to obeythe agreement with the works council

• Violation by staff leads to written warning and/orother disciplinary steps („Ermahnung“)

• During recruitment of employees the strict non-smoking policy is declared; smoking habits of theapplicant may be relevant for decision making

• Cessation program is offered to all staff; utilization by staff is documented regularly

ENSH Standard 8: ENSH Standard 8: GesundheitsfGesundheitsföörderungrderung

HCO HCO contibutescontibutes to and to and promotespromotes tobaccotobacco controlcontrol in in

thethe communitycommunity settingsetting

• Rehabilitation Center Todtmoos as a pioneeramong the Reha-Centers of the National German Pension Fund (n = 22); we were one of the firstinstitutions getting the „silver certificate“ of DNGfK /ENSH in 2005

• Supporter for other Reha-Centers and publichospitals during implementation of non-smokingpolicy

ENSH Standard 9: ENSH Standard 9: MonitoringMonitoring

Weiterentwicklung und QualitWeiterentwicklung und Qualitäätssicherung der tssicherung der

RauchfreiRauchfrei--PolitikPolitik

• Smoking-free policy is part of the „qualityaims“ of the rehabilitation center

• Internal quality management system of therehabilitation center reviews these „quality aims“regularly and updates the data base

• Members of the Non-smoking committee are all part of the quality management system

Umsetzung: Voraussetzungen und Chancen Umsetzung: Voraussetzungen und Chancen

MotivationMotivation,, KontinuitKontinuitäätt, , BeharrlichkeitBeharrlichkeit

• Motivation of all staff (not only the medical staff)

• Our chance: Relocation to the new hospital(„common goal“; common decision with whole staff)

• Definite, written agreements (with works council)

• Responsibility for the policy by senior management(chief administrator E.R. and medical director H.S.)

• Strict compliance with the rules; no exceptions(not for pts and not for staff – even not for thepresident (DRVB) at the opening ceremony)

„„DrawbacksDrawbacks““: Hindernisse bei der Umsetzung:: Hindernisse bei der Umsetzung:

DemotivationDemotivation, Diskontinuit, Diskontinuitäät, Inkonsequenzt, Inkonsequenz

• Critical patients („Doctors/staff are smoking morethan myself“ – give this argument no chance:medical staff must not smoke at working place)

• Critical staff („Why do we need such a strict policy?“„We have worked like this for most of our time“)

• Forced decision making in pts must be avoided

• At some days we are really at the limit (heavy snowfalls, pts cannot leave the building; staff starts at 6.30 a.m. for snow blowing !)

ENSH Standard 10: ENSH Standard 10: Langfristige UmsetzungLangfristige Umsetzung

Nachweis der Umsetzung und Nachweis der Umsetzung und

Zusammenfassung:Zusammenfassung:

• Smoking ban has a long tradition in the hospital(already since about 1930 for pts)

• Since 2005 total non-smoking policy (inside, outside and all grounds); sanction rules (pts, staff), written agreement with works council/laborunion (Dienstvereinbarung mit Personalrat)

• A systematically evaluated smoking cessationprogram is implemented since 1986; Results arepublished in scientific journals

• Smoking-free policy is part of our „quality aims“

Besonderer Dank: B. Meißner und Team

RehaReha--CenterCenter TodtmoosTodtmoos

Klinik Klinik WehrawaldWehrawald

VielenVielen Dank Dank ffüürr IhreIhre

AufmerksamkeitAufmerksamkeit !!