When you hear Lean Healthcare do you think operational efficiency?  I frequently experience organizations where Lean is only focused on operational efficiency–eliminating waste in order to save time and money.  Generally in said organizations there is a separate team that focuses on clinical improvements and patient satisfaction.  Separating improvement in your organization by dividing the resources, methods and structures for improvement introduces complexity and confusion for operation’s leadership.  It also promotes trade off thinking in clinical quality and patient satisfaction versus efficiency and cost.

LeanHealthcare_PopulationHealthOutlined below is an example of improving the management of chronic opioid therapy.  This clinical improvement, especially in population health, will bring improvements in all four value quadrants of your organization. The intent of this example is not to provide the clinical expertise of chronic pain management, but to share the Lean Healthcare tools utilized in this improvement work.

Business case:  Opioids, a class of analgesics frequently used in high doses to manage chronic non-cancer pain, have been spiraling upward over the last ten years in the United States.  Use of more potent opioids (such as morphine, hydromorphone, oxycodone and fentanyl) have also increased.  At the same time drug overdose related deaths have been climbing as reported by the CDC data in 2014 to 14.7 per 100,000 deaths annually.  While death is the ultimate risk from high dose opioid use, myriad other complications impact the heath and quality of life for those suffering from chronic pain.  While harm represents the quality dimension of value for this population, there are equally devastating impacts to individual and community in terms of satisfaction, finance and efficiency.  The negative impact of chronic pain management in non-cancer pain has led various regulatory bodies, as well as professional organizations, establishing new standards intended to assist providers in mitigating harm from the use of high dose and potent opioids. 

Current condition:  Detailing out the current condition, would take a novel instead of a blog so I will summarize.  The group of primary care providers I had the privilege to work with recognized that integrating these standards into their daily practice required an interdisciplinary effort.  Key to the improvement was achieving consensus across their team around maximum dosing levels which were much lower than previous standards. This change also required support from other key specialties (such as orthopedics, neurology, emergency services) that frequently interact with chronic pain patients.  This particular group of primary care providers had the benefit of being a part of a large, integrated system whose patients generally were seen by providers within the system. 

Countermeasures:  Consensus requires documentation of standard work—for this particular group, this meant approval and publishing of internal practice guidelines.  Drafting guidelines without a process to support them generally is an exercise in futility.  This team investigated opportunities to utilize the concepts of mistake proofing to make it easier for clinicians to use the guidelines.  Requests were sent to the IT team to implement best practice alerts for chronic pain patients, including urine drug testing, visit schedules and patient contracting, among others. Documentation screens guided physicians to complete appropriate assessments and explain deviation from the accepted guidelines.  Resources for alternative therapies were identified in easily accessible documents available to the clinicians, clinic staff and patients.  Inspection methods were established across ambulatory clinics to assist providers in ensuring patient compliance.  Medical assistants check the status of best practice alerts, collect urine specimens and research documentation with each patient visit.  Nurses check the Prescription Drug Monitoring Program (PDMP) before patient visits and refill requests to confirm that patient did not obtain prescriptions for opioids and benzodiazepines from other sources.

Measurement: Implementation of the new guidelines required extensive training for all clinicians across the organization as well as patient education materials and community education.  Training without follow up coaching or a feedback loop generally succumbs to the Hawthorne effect. This organization historically utilized a pain management registry, however with the implementation of a new electronic medical record system, the registry system had to be rebuilt to meet the needs of measuring both the organization’s improvement and individual provider performance.  As this measurement is rebuilt, the process of utilizing the data is also being redesigned.  The organization routinely establishes clinical improvement goals for ambulatory care around preventative health.  These goals are then shared at the clinic to monitor and make further incremental improvements.  Medical directors coach individual providers to identify barriers to improved performance. 

Results:  Since this improvement is still in the midst of implementation, measured results are still to follow.  The redesigned registry will track the total number of patients on high-dose (>90 mg morphine equivalents) opioids, the total number of patients on the registry, and the number of new chronic opioid therapy starts with the goals of decreasing the volume in all three metrics.   The hypothesized outcomes include a decrease in drug related overdose deaths, decreased costs for opioid prescription use, and increased function and quality of life for chronic pain patients.

Making improvements in clinical issues utilizes the same scientific problem solving and many of the same tools and countermeasures as making improvements for operational efficiencies.  The critical component, as in any Lean Healthcare improvement, is getting the experts who do the work together to identify the waste and the solutions to eliminate waste.  While most clinical improvements will focus on the quality quadrant of value, the impact of quality improvements generally pays off in terms of satisfaction, efficiency and cost.


Maureen Sullivan, Senior Manager for Lean Healthcare and Process Improvement at HPPToday’s blog was written by Maureen Sullivan, RN, senior consultant at HPP.

Maureen has nearly 30 years of healthcare experience in clinical nursing, management and quality leadership.  As a registered nurse, Maureen’s clinical experience is in medical-surgical nursing with progressive responsibilities in nursing management at the front line, middle management, and administrative levels.

Maureen has a bachelor of science in nursing with an emphasis in healthcare management from Metropolitan State College in Denver, Colorado. Maureen achieved certification from the National Association for Healthcare Quality as a certified professional in healthcare quality (CPHQ).

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