Hospitals - Gold Star Standards Application

The Gold Star Standards of Excellence program recognizes Maine’s hospitals that are addressing smoking and tobacco use by creating and maintaining smoke and tobacco-free policies.

All hospitals are encouraged to apply. Organizations that meet a minimum of seven of the ten standards will be recognized with an award during a celebration event.

6-7 Stars: Bronze Award Status
8-9 Stars: Silver Award Status
10 Stars: Gold Award Status
10+ Stars: Platinum Award Status

To apply, complete the application below answering all questions applicable, write “not applicable” for the standard(s) your organization does not meet.

Please note this form cannot be saved. Best practice is to complete the word document version then copy and paste your answers into the online form. You can email any questions to [email protected].

Need help? View the 2018 Guidance Document for model answers for the application or contact us for additional assistance.

Applications are due by August 31, 2018.

Contact Information

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1. Tobacco-Free Policy

The hospital has a 100% tobacco-free campus policy that prohibits the smoking and use of all tobacco products including cigarettes, electronic cigarettes, smokeless tobacco, snuff, chew, snus, cigars, pipes and non-FDA approved nicotine delivery systems. Smoking and tobacco use by employees, patients, visitors and contractors is prohibited at all times on the hospital campus, including in parking lots, in vehicles parked on campus, at all satellite sites and at other properties the hospital owns and/or rents. The policy extends to all off-site meetings, conferences and in all hospital vehicles.

Include the written policy for the hospital.

Upload the hospital tobacco policy (PDF or Word Doc):

2. Thirdhand Smoke Policy

The hospital has a policy and clearly defined procedures to reduce patient and employee exposure to thirdhand tobacco smoke. Procedures and materials are available for patient and visitor education regarding thirdhand smoke.

Include the written policy for the hospital. Indicate how it is communicated to employees, patients, and visitors. For example, tobacco smoke odor is included in the hospital's scent-free policy and/or language in the tobacco policy which prohibits employees from reporting to work with notable thirdhand smoke odor.

Upload the hospital policy (PDF or Word Doc):

3. Policy Communication and Enforcement

Written policies and procedures exist that detail the hospital’s policy (whether it is 100% tobacco-free or not) including a plan for enforcement and employee expectations. The tobacco-free policy defines the staff members or departments responsible for enforcing the policy and handling employee infractions; including non-compliance.

Include a copy of any policies/procedures that document meeting this standard with your application. At least five of the following strategies must be met in order to achieve this standard.

All staff are required to acknowledge in writing, on an annual basis, that they have read/understand the tobacco-free policy.New staff orientations include education about the hospital’s tobacco-free policy.Progressive discipline for employee violations is written into the policy and made clear to all employees.Information about the tobacco-free policy is readily available on the hospital website and/or through the HR department.Employee training on how to handle policy violations with other employees, patients, and visitors is provided for all staff.Patients receive information on the hospital’s tobacco-free policy on admission and again during their hospitalization as necessary.Leadership walkabouts on the grounds are conducted during different times and days to approach staff, visitors, and contractors using tobacco to offer education and request compliance with the policy.Staff involvement in regular cleanup efforts to reduce tobacco-related waste on the hospital campus.Policy signage can be found throughout the grounds including at all entrances to the campus and buildings, in parking lots, near picnic tables and other outside seating areas, other areas where people tend to gather, etc.Other (please describe below)

Upload the written policies/procedure for the hospital (PDF or Word Doc):

4. Tobacco Advertising

Advertisement or promotion of tobacco products is prohibited on the hospital's campus and satellite facilities. This includes hospital publications and magazines subscribed to by the hospital for placement in waiting rooms.

Describe efforts your hospital has taken to regulate publications and magazines that have tobacco advertising. At least one strategy must be included to achieve this standard.

Hospital only allows magazines without tobacco advertising.Maine Tobacco-Free Hospital Network stickers are placed on all donated or subscribed magazines that may contain tobacco advertising.Hospital removes tobacco advertising from magazines before allowing them in waiting rooms or other facility areas.Notices (posters, flyers, tent cards, signage, etc.) are placed in magazine areas stating that the hospital does not support tobacco advertising.Other (please describe below)

5. Tobacco Prevention & Treatment Education for Patients & Visitors

Information about tobacco dependence and treatment, secondhand smoke, thirdhand smoke and local/statewide treatment resources are readily available to patients and visitors. For example: brochures about the Maine Tobacco Helpline are displayed in patient or visitor areas, patients are offered a proactive fax referral to the Maine Tobacco Helpline, hospital discharge paperwork includes treatment options and resources, patients are given information on the harmful effects of tobacco use and secondhand/thirdhand smoke, and information on tobacco treatment methods and where to find resources are available to patients and families.

Describe how these materials are accessed by patients and visitors.

6. Evidence-Based Tobacco Treatment Training for Staff

The hospital supports evidence-based tobacco treatment training for staff by offering in-services on tobacco treatment and supports staff financially to attend trainings. Literature and resources are available on-site for staff. Trained staff are available to provide treatment and counseling to tobacco-dependent patients.

List the number of employees who have been trained to deliver evidence-based tobacco treatment counseling and education and/or the number of tobacco treatment related activities held over the past year.

7. Patient Screening & Assistance for Tobacco Dependence

All patients admitted to the hospital are screened for tobacco use, tobacco status is documented and patients are offered comprehensive treatment services during their stay, by designated staff. This includes tobacco dependence counseling/education at the bedside, clinical assessment and management for patients experiencing nicotine withdrawal, offering FDA-approved tobacco treatment medications, and referral to counseling post-discharge. Tobacco treatment services are evidence-based, as reflected in the Public Health Service Guideline: Treating Tobacco Use and Dependence, 2008 Update.

Describe how patients are made aware of these services; the ways your hospital delivers them and how designated staff members are responsible for implementation.

8. Tobacco Treatment Benefits

Tobacco treatment services are a covered benefit in the hospital health insurance package for employees and their dependents. Benefits include coverage for counseling and medication for quitting tobacco, with minimal, or no barriers to utilization (i.e. co-pays, out of pocket costs, limits).

Describe tobacco treatment benefits provided and how they are promoted to employees.

9. Smoke-Free Community Lodging

The hospital provides a list of local 100% smoke-free lodging for visiting patients and families in order to make healthy choices regarding their lodging. The list should be easily accessible and reviewed and updated annually.

Include the lodging list provided to visitors and patients.

Upload hospital lodging list (PDF or Word Doc):

10. Tobacco Funding & Donations

The hospital has a written policy stating it refuses all donations from the tobacco industry, and divests itself of all tobacco company stock.

Provide policy language, procedures and/or guidelines that explain the hospital position on tobacco industry donations.