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An A3 Antidote to the Opiate Epidemic

by Ryan Howard
December 15, 2016

An A3 Antidote to the Opiate Epidemic

by Ryan Howard
December 15, 2016 | Comments (15)

At the beginning of my fourth year in medical school at the University of Michigan, I was given the opportunity to lead a quality improvement project that would address the growing opioid epidemic in the state of Michigan. Specifically, I’d be partnering with the newly-established Michigan Opioid Prescribing and Engagement Network (M-OPEN) to find a way to prevent excess pills from entering our community. Diversion of excess opioid painkillers is a major driver of misuse and abuse, with 70 percent of individuals who use opioids non-medically obtaining the medication from a friend or relative. What’s more, since 50 percent of the opioids in Michigan enter the community after surgery, we decided to focus on post-operative prescribing.

At the outset, we picked a common, generalizable surgical procedure (gallbladder removal) and looked at how many narcotic pills were typically prescribed to patients. What we found was a tremendous amount of variation. Some patients were walking out with as few as 12 pills and some with as many as 100. Root cause analysis helped us hone in on the problem: Why was there so much variation? Because there were no standard prescribing guidelines. Why no guidelines? Because they had never been developed. Why? Because nobody had ever looked at how much pain medication patients typically needed. Why? Because giving more than enough wasn’t considered a problem.

So we began surveying patients on how much pain medication they needed after this surgery, and found that half of patients used five pills or less. This was shocking to say the least – patients were going home with upwards of 100 pills and taking only five. What’s more, we found that 70 percent of patients did not dispose of leftover pills. As a result, we developed prescribing guidelines that were more consistent with what patients actually needed, not just what we thought they needed.

We also wanted to improve patient education regarding pain after surgery. This part of the project relied heavily on gemba. I spent a good portion of my time literally sitting in on clinic visits or watching nurses discharge patients after surgery. The information gained here was invaluable. For example, patients often did not know that they should dispose of leftover medication; if they did ask about disposal, nurses did not have a good resource to tell patients where to take leftover pills. Therefore, we created an online map where patients can now search for opioid disposal sites near their home address. It can be found at http://umhealth.me/takebackmap.

Value stream mapping the patient’s journey of getting gallbladder surgery allowed us to identify all of the stakeholders that would have to be involved if our new guidelines were to be successful. So we made sure to meet and speak with providers in the preoperative clinic, the faculty and residents who performed the actual surgery and wrote the prescriptions, and nursing staff who discharged and followed-up with patients after surgery.



To prepare for piloting our guidelines, I compiled all of the information on the background of our issue, the root cause analysis, and the owners of each area of implementation into an A3. As a student who had never created an A3 before, I found this process incredibly helpful. Not only did it help me organize my plan for conducting this project, but it provided me with a communication tool to use when meeting with staff to implement our new prescribing guidelines. What’s more, as others made contributions, we were able to improve our project in ways we hadn’t anticipated.


In just the first month since implementing our prescribing guidelines, prescription sizes following gallbladder surgery have decreased by more than half. This means that compared to historic prescription sizes, we have prevented roughly one thousand pills from entering the community. Despite dramatically reducing prescription size, there has been no increase in calls for refills. We hope that by continuing this work and expanding it to other procedures, the number of pills kept out of our communities will grow exponentially.

How has lean helped you tackle a problem bigger than your organization?

The views expressed in this post do not necessarily represent the views or policies of The Lean Enterprise Institute.
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15 Comments | Post a Comment
Karen Martin December 15, 2016
3 People AGREE with this comment

Hi Ryan - Excellent work! Is there a way we can see the full A3 report? Thank you. -- Karen



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Renee December 15, 2016

My guess patients received 100 pills was to "lower" the cost per bill so insurance would cover the prescription. When only 5 pills were prescribed, the cost per pill was probably $10-$15 each. I believe that pharmacies have a "filling" charge and then add on the pill cost. For prescriptions with only a few pills, the cost per pill is extreme vs. for a large prescription, the cost per pill is much lower and results in large number of pills being dosed. Check out the root cause to verify.



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Cam Ford December 15, 2016

Hi Karen - The full A3 is now available by clicking on the image in the article.



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Mark Graban December 15, 2016
1 Person AGREES with this comment

Ryan - this is great on so many levels.

Who coached you through this process, given that it was your first A3? How did the coaching help?



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Ryan Howard December 15, 2016

Hi Mark - I was lucky enough to be coached by Dr. Jack Billi, here at the University of Michigan. He was an outstanding mentor! I found that his guidance really helped me hone in on a process that we could actually change instead of trying to take on the whole "epidemic" at once.



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Mark Graban December 15, 2016

Thanks... I was hoping the answer was Dr. Billi :-)



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Brian Cole December 15, 2016

Great work and great article Ryan!  I like how you used the 5 Why's within your article to further define the root cause.  It is also great to see that the result of your efforts have significantly reduced the number of pills that fall into inappropriate hands.  Thank you for sharing your story!



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Jeanne Kin December 15, 2016

Great work Ryan! Look forward to hearing the next chapter in the story.



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Tara Moler December 16, 2016

Ryan - GREAT consise and interesting example of how the A3 tool can be used effectively...even by someone new to it (with some coaching)!



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Andrew Bishop December 16, 2016

Ryan,
Outstanding work! Thanks for posting this for a whole list of reasons, among them:
- The topic is obviously of high importance and timeliness.
- The document itself will be a useful as a teaching tool. We teach the A3 process/ A3 thinking in our health system and I've found that healthcare professionals are much more comfortable with examples from their own sphere (vs. manufacturing, e.g.), and preferably from someone outside our system (she who travels furthest has the most expertise!)

Go Blue!

 



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Stephanie M Dougherty December 17, 2016

Outstanding achievement?? I would love to bring your design to our organization, full credits to you, of course. Please email me with your process. So glad you published your work- just fab.

Blessings??

Stephanie D



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Shon Dwyer December 18, 2016

Ryan,

Thank you for using Lean to help us improve the care to patients at UMHS and across the State of Michigan.  Your work is invaluable!



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Michael Higgins December 19, 2016

We looked at the same problem through a slightly different approach where I work. Our approach implemented multi-modal pain management to eliminate opioid prescribing from the beginning of the process. This work focused on elective orthopedic procedures like hip & knee replacement. NSAIDs like ibuprofen were started before surgery, as were drugs like Lyrica, to begin pain management immediately prior to surgery. This approach was continued after surgery and throughout recovery. This approach allowed us to reduce the use of Patient Controlled Analgesia pumps (patient controlled delivery systems for opioids while in the hospital) by 95% for this group of patients. This has sustained for over 6 months, so far.



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Mike Conroy December 23, 2016

Ryan,

Great work!

Can you also share the actual guidelines you developed?  I realize they don't automatically translate across practice settings, but I'd like to be able to start the work with our surgeons by saying that coming to agreement is possible!

Mike Conroy



Reply »

Ryan Howard December 23, 2016

Hi Mike,

Thanks for the kind words! Feel free to send me an email at rhow@med.umich.edu and I'd be happy to share and discuss our guidelines.

 

Ryan



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