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Systems Change 101

Contributing staff: Traci Capesius


More and more we are seeing health care systems shift their focus further upstream, using a systems change approach to address behaviors, such as tobacco use, that are the cause of or exacerbate many chronic health conditions. A systems change approach can be defined as permanently altering protocols, policies, and infrastructure so that addressing a target behavior (e.g. helping tobacco users quit) becomes systematic and part of daily practice.  Systems change may occur within an agency, between multiple departments, or across an entire health system.


Why systems change?

Health systems are engaging in more systems change work in order to systematically improve the health of their patient population and, ultimately, reduce the cost of care. Treating tobacco use dependence, for example, is becoming more important to improving patient health and reducing the cost of care, as tobacco use can cause or contribute to the worsening of many chronic health conditions.  Implementation of tobacco-related systems change strategies can enhance health systems’ ability to identify and treat tobacco use, therefore reducing health care costs. In 2014 PDA co-authored a journal article with ClearWay MinnesotaSM that summarized how health systems were able to make systematic changes to address tobacco use dependence among their patient populations and provided recommendations for health systems and funders of systems change initiatives.


Systems change strategies

The following are a few examples of key systems change strategies that have the potential to increase the sustainability of tobacco dependence treatment interventions.  While some of these strategies are more suited to clinical environments, some could also be applicable to community or social service-based organizations.

  • Obtain buy-in from providers, clinical staff, other front-line personnel via trainings and on-going communication (e.g. via daily “huddles” or meetings) regarding the importance of tobacco user identification and treatment.
  • Recruit project champions from multiple levels who fully support the systems change effort, are willing to provide leadership and are in a position to influence colleagues and decision makers.
  • Integrate brief intervention into clinic standard practice; this includes regularly asking tobacco use status during clinic visits and making conversations with clients about tobacco use, treatment options (including cessation pharmacotherapy) a standard part of care with all tobacco dependent clients.
  • Continually monitor clinic and provider performance in implementing screening, referral, service provision, and follow-up. Regularly reviewing data and report results back to key stakeholders.


Evaluating systems change initiatives

PDA has evaluated several systems change initiatives in multiple states. In our evaluation approach, we often conduct interviews with key staff members at the start and end of the initiative (and perhaps at a midpoint as well). The interviews help determine where programs are starting and ending, what the facilitators and barriers to making changes were, and what lessons they learned along the way. We also review the literature on systems change (such as those shown below) to help inform our methods, protocols, results, and conclusions.



Centers for Disease Control and Prevention. Best Practices for Comprehensive Tobacco Control Programs — 2014. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014.

Fiore MC, Jaen CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. May 2008.

LaPelle N, Zapka J, Ockene J. Sustainability of public health programs: the example of tobacco treatment services in Massachusetts. Am J Public Health. 2006;96(8):1363-1369.

Savaya R, Spiro SE. Predictors of sustainability of social programs. Am J Evaluation. 2012;33(1):26-43.

Scheirer MA, Dearing JW. An agenda for research on the sustainability of public health programs. Am J Public Health. 2011;101(11):2059–2067.


Posted in General, Sustainability