Virginia Mason Medical Center, Seattle, WA

Taking on Opioids: Establishing an Organizational Initiative

Case Overview

In 2017, the Virginia Mason Medical Center launched an initiative called Taking on Opioids. This collaborative effort involves all patient care disciplines within the organization including ambulatory, surgery, inpatient, and emergency services. Other program contributors include the Washington Department of Health, external content experts, and neighboring health care entities. The goal of the initiative is to reduce opioid-related adverse events, improve the safety of opioid prescribing practices, and reduce the quantity of new and overall opioid prescriptions for non-cancer pain.

Key Elements of Success

The initiative is managed by an interdisciplinary guiding team made up of representatives from the above noted departments, with the addition of analytics and informatics. The guiding team is led by the Driving Team which consists of the Executive Medical Director, Deputy Chief Chief of Anesthesiology,  Ambulatory Pharmacy Manager, and Administrative Director of Clinical Quality. It is managed through a quality improvement specialist. Our organizational Pain Management Guiding Team developed a plan to address persistent pain management and prescription opioid use with the formation of best practice standards and associated tools. Examples of standards include use of non-opioid treatment modalities prior to opioid initiation, limiting acute prescriptions to a 7-day supply, and assessing and monitoring patient functional status.

Impact on Patient Outcomes

Our guiding team created standardized electronic health record (EHR) documentation tools, templates, and colocation of all pain management related documents within the EHR. Quality improvement events were developed to focus on the perioperative pain management plan for opioid-familiar and opioid-naive patients. After creating the standardized HER, we developed a Chronic Opioid Therapy Registry for prescribers. We also coordinated risk stratification for patients with persistent pain, those currently taking opioids, and those with opioid use disorder. We also provided organization wide education programs and continuing education courses for medical, pharmacy, and nursing staff.

Pharmacy and Pharmacist Roles

Pharmacy leadership is part of the interdisciplinary guiding team and serve as accountable leaders of the initiative. Under our general collaborative drug therapy agreement, which includes non-controlled substances, credentialed and privileged pharmacists manage patients on chronic opioid therapy in primary care and the physical medicine and rehabilitation clinic settings. They are also involved in managing post-operative medication plans and tapering efforts. All team members completed an internally developed training plan which involved primary care providers and physiatrist mentors. Select pharmacists are privileged with DEA numbers to prescribe controlled substances under a specific collaborative drug therapy agreement.

Lessons Learned

The implementation of new best practice standards requires a dramatic culture shift at the organizational, regional, and national level. A multidisciplinary approach is essential for success. Colocation of documentation facilitates visibility and transparency of patient pain management, including history, assessment, and treatment plan. A coordinated and collaborative approach which allows all team members to practice at the top of their license is essential for effective implementation. Evidence of results will help inform, inspire, and drive change. This data must be relevant, visible, and available to all team members and not operator specific. Executive physician leadership served as the biggest champion of our initiative.

Budget & Resource Allocation

This program is an organizational goal, therefore budgeted resources are included. The work required of this initiative was added to the responsibilities of all accountable leaders (physician, pharmacy, and operational). Virginia Mason provided a 1.0 FTE quality improvement specialist. Required resources included physician, pharmacy, and nursing leadership, support from executive and board members, and planned continuing education all team members.

Future Goals

A manuscript was prepared for publication on the pharmacist’s role in a physical medicine and rehabilitation clinic. There are three on-going studies within the organization’s surrounding spine surgery and associated discharge opioids, as well as opioid prescribing patterns by orthopedic and urology providers.