The Role of Human Resource Managers on Employee Motivation to Avoid Labor Market Competition in Amazon

Running head: Improving Quality and Performance for Primary Care Pain Management

Improving Primary Care Pain Management at Portland Adventist Hospital

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Table of Contents

Executive Summary…………………………………………………………………… 3

Introduction…………………………………………………………………………… 4

Organizational Background……….…………………………………………………… 5

Statement of Problem………………………………………………………………… 5

Purpose of Research………………………………………………………………….. 6

Research Questions…………………………………………………………………… 6

Research Methodology ……………………………………………………………… 6

Method 1: Personal Observation ……..……………………………………………… 6

Method 2: Review of Literature……………..……………………………………… 11

Method 3: Interview…………..……..……………………………………………… 14

Method 4: Models of Analysis…………….………………………………………… 18

Model 1: Ishikawa’s Fishbone Diagram …………………………………… 19

Model 2: Lewin’s Force Field Analysis ……………………………………… 22

Model 3: Peter Drucker’s Management by Objectives Model ……………… 25

Model 4: Kaizen 5S Framework Workplace Organization………………… .. 28

Summary of Findings………………………………………………………………… 31

Recommendations…………………………………………………………………….. 32

References ……………………………………………………………………………. 35

Executive Summary

Problem

  • There is a clear epidemic of overdose deaths from opioid pain medications in the State of Oregon. Although data indicates that Oregon is moving in the right direction, there is further change required.
  • Currently, our physicians lack support and educational training for practicing proper opioid medication management for patients suffering from chronic pain.

Causes

  • Dependence on Opioid pain medication is widely considered a chronic disease. This is in large part due to a healthcare culture change. In the 1990s and 2000s, a higher emphasis was on the treatment of pain, resulting in a widespread belief that individuals with pain less likely to abuse opioid medications. As a result, rates of opioid addiction and misuse increased as well as death rates associated with opioid medications.
  • Today, our PCPs are not equipped with the resources to be effective in managing patients using opioid pain medications.

Recommendations

  • Scheduling longer chronic pain follow up consultations.
  • Implement a clinic wide risk assessment tool usage.
  • Implement a standardized UDS screening table for Providers.
  • Increased MA participation.
  • Hold Opioid Medication training for the Providers.
  • Management must conduct a strategic control system for further assessment and evaluation.

Introduction

Primary care is generally recognized as a unique specialty requiring unique skills. Primary care is an essential health care practice rooted in practical, scientifically sound and socially acceptable methods. Primary care is first-contact, continual, comprehensive, and coordinated care provided to populations undifferentiated by gender, disease, or illness (Bali, R. K., & Dwivedi, A. N. 2010).

It appears extremely difficult for Primary Care Providers (PCPs) to adequately manage Opioid Pain Medication Monitoring (OPMM) for their patients. This inadequacy or lack of quality stems from the inability for the PCP to have referral leverage, changing guidelines, and the disorganized and chaotic aspect of opioid pain prescriptions in the Primary Care Setting.

Americans suffering from chronic pain, require safe and effective pain management. Additionally, the CDC designates opioids as a viable source for managing some types of pain in the short term, not allotting for long term use patients. When a patient is on long-term or monthly basis use of Opioid Pain Medications, they must complete a MEDICATION AGREEMENT, signed by the patient and the physician. Additionally, the CDC Guidelines require Urine Drug Sampling (UDS). The UDSs are used by the providers to evaluate if the patients are taking other illicit drugs or not taking the medication at all. Currently, the standard is, if the patient fails a drug test 3 times, they can no longer receive prescriptions for opioids from the clinic.

The State of Oregon has a Prescription Drug Monitoring Program (PDMP) is a tool to help healthcare providers provide better care in managing prescriptions. This program compiles data for dispensing Schedule II, III, and IV controlled substances for Oregon residents. Currently, all of the PCPs are required to review this data every instance a Schedule II, III, and IV class medication is prescribed.

Although there are strategies such as MEDICATION AGREEMENTS, UDSs, and PDMP forms, there continues to be a gap in how to use these tools effectively. It is well known that the PCPs of Portland Adventist Health are unable to adhere to the organization’s objectives and goals as it pertains to providing optimal opioid medication management in the Primary Care Setting.

Organizational Background

Portland Adventist Hospital and Oregon Health Science University (OHSU) finalized an agreement which integrates their clinical activities and services in the Metropolitan health system. Mitch Wasden, Ed.D., executive vice president and chief executive officer of OHSU Healthcare indicated the mission of this partnership as follows:

“We are excited to provide an integrated delivery system that will improve access, create better outcomes, and control costs by coordinating care for patients across a spectrum of their health needs.”

This is the value that associates with the OHSU and Portland Adventist must adhere to. A significant percentage of patients, predominantly in the Primary Care setting, need sufficient pain medication monitoring. However, PCPs are burdened with implications surrounding pain management such as understanding the guidelines, the subjectiveness of pain, and continuous time consuming monitoring leading to worse outcomes for patients.

Statement of Problem

Physicians appear to be unable to appropriately manage patients using opioid pain medication in the Primary Care Setting. as evidenced by the lack of opioid medication education (to or for whom) and systematic protocol.

Purpose of Research

Thus, this research intends to: (The purpose of this research is to:

  • Identify the most common internal factors that cause Primary Care Physicians to be ineffective in managing chronic pain patients.
  • Determine the external factors associated with the insufficient management by Primary Care Physicians of chronic pain patients.
  • What can be done to improve the management of chronic pain by Primary Care Physicians in the Primary Care Setting?

Research Questions

  1. In what way are Adventist Health Primary Care Physicians ineffective in Opioid Pain Management?
  2. What are the factors that cause Adventist Health Primary Care Physicians to be ineffective in Opioid Pain Management?
  3. What can be done to improve Opioid Pain Management in the Primary Care Setting at Adventist Hospital?

Research Methodology

The research methodology for this research project utilizes: a personal observation, personal interview, literature review, and the use of theoretical models to support research (separate Section)

Personal Observation

Findings:

In my experience, I worked as a medical scribe for several Primary Care settings in the Portland Adventist System. During this role, I was exposed to every aspect of how a Primary Care Physician (PCP) assesses, diagnose and ultimately treat or manage their patients. As I began to learn about how to practice medicine, it became clear through hundreds of patient visits that there are many deviations from an ideal state in the Primary Care Setting. Namely, the management of Opioid medication was exceedingly difficult for all of the PCPs I observed.

Research Question 1: In what way are Adventist Health Primary Care Physicians ineffective in Opioid Pain Management?

Primary Care is essential in the sense that PCPS manage the entire patient as a whole, from their mental state, comorbidities, and managing blood sugars among many other conditions and diseases. These physicians screen for cancer and mitigate the health of thousands individuals ranging from all ages and walks of life. They are currently insufficient in managing patients using opioid pain medications because these medicines are highly regulated and pain is only truly subjective. Therefore, they will frequently have to make tough decisions for patients in regards to what dose and how many tablets on a monthly basis.

The current role of Adventist PCPs is to focus on the patient’s well-being, body, mind and spirit, not just one time but all the time. The current system for patients to obtain opioid pain management is cumbersome and the time required to operate in the current system constraints PCPs.

Additionally, they operate in a high stressed environment: with speed and efficiency being paramount for the success of meeting wait-time benchmarks and providing optimal patient care.

With the role as a PCP, the physician must balance between many different areas of treatment. Long term chronic pain patients typically have a plethora of other morbidities such as diabetes, cardiovascular diseases, obesity as well as many others. These are examples of the many issues that PCPs must address in an office visit.

Research Question 2: What are the factors that cause Adventist Health Primary Care Physicians to be ineffective in Opioid Pain Management?

Primary Care Physicians are burdened with extreme volumes of patients, additionally, they have to manage an array of diseases and conditions chronic and acute ranging from diabetes, hypertension, COPD, and other serious health concerns.

This burden can be mitigated with the leverage of referrals to specialists. For example, if a PCP finds that a patient has a positive Mcmurray and Drawer (knee test) then, they can make a referral to an orthopedist for further evaluation and assessment. Or, if a PCP has a patient who has neurological concern, they can make a referral to a neurologist for further consultation and evaluation.

However, currently, the PCPs at Portland Adventist Health are unable to make a referral to pain specialists for two key reasons: 1. Many are at capacity and are not accepting new patients. 2. Many of the patients that have been using Opioid pain medications are also in need of adequate mental health intervention, another specialty that has very limited access for PCPs to make a referral.

This is an extreme issue, because PCPs, when they are not able to optimal serve the patient, they ought to be able to make a referral to a specialist that can further treat, but in the case of patients using opioid pain medications, they do not have access to this luxury of making a referral to either mental health specialists or pain specialists.

Most concerning, was the obvious lack of opioid management education for the providers, very few having training in this medication prescribing.

Research Question 3. What can be done to improve Opioid Pain Management in the Primary Care Setting at Adventist Hospital?

The current system in place for patients to continue getting prescriptions for opioid pain medications is difficult and convoluted. Essentially, the protocol on opioid pain management in the state of Oregon changes constantly, and the physicians have no support in getting up to date protocols. It should not rest solely on the physician to adequately manage patients using Opioid pain medications, the current system is not conducive for adequate management.

Therefore, Incorporating Medical Assistants, Front office, and Management intervention to assist the PCPs is required, reducing the load on the PCP.

Primary Care Physicians lack additional training and education in regards to prescribing Opioid pain medications. Often either prescribing too many tablets, or at too high of doses. Thus, implementing a training regimen can allow the PCPs to conduct better medication regimens for their patients.

Method 1: Reasons for ineffective management of OPM in the Primary Care Setting

Review of Literature:

Primary Care Physicians are sometimes insufficient in their ability to manage patients using Opioid Pain Medications. Various contributions to this problem, exemplified in the following literature review.

  1. The use of opioid medication for chronic pain has increased dramatically during the last 20 years. Much of the burden of monitoring these patients is falling on primary care physicians (PCPs), who do not have the time or resources to handle what is entailed in a best-practice approach (McCann KS, et. al. 2018). More than 60 million patient visits for chronic pain occur annually in the United States consuming resources and time (Morteza Khodaee, et. al. 2019). Chronic pain is a costly condition requiring interdisciplinary action and treatment.
  2. Our current physicians approach opioid pain management differently. Currently, our physicians are struggling with rapidly changing guidelines regarding pain medication management. Many of the current PCPS were trained in medicine prior to or during the late 90’s. In December 1995, OxyContin was approved by the FDA allowing for dosing every 12 hours instead of every 4-6 hours. Slowly, reports of overdose and death from prescription drug products drive further guidelines in the early 2000s. And since the opioid epidemic, an immense pressure has been placed on Primary Care Providers to manage complex patients and their pain in a structured fashion.
  3. Opiates is no longer considered to be the best strategy for long-term management of chronic pain as it has been shown that (1) Opioid use tends to reduce function, (2) Opioids are often not effective for long-term pain treatment. (3) Response to pain and opioids is highly variable (Mehl-Madrona, L., et al. 2016). This creates an issue, physicians at one time were encouraged to prescribe pain medications, this resulted in a philosophy of medical practice that adheres to loss of opioid prescriptions. Essentially, patients who are at a high risk, tend to become dependent on these medications.
  4. With opioid pain medications being highly addictive, physicians are met with patients that have been taking opiods for many years, this dynamic can lead to tough and stressful conversations and termination of further opioid prescription refills if a pain contract is breached.
  5. The role of opioids in managing chronic pain has evolved in light of the opioid misuse epidemic and new evidence regarding risks and benefits of long-term opioid therapy. With mounting national guidelines and local regulations, providers need interventions to standardize and improve safe, responsible prescribing Eeghen, C. V., et al. 2020).
  6. Pain specialist intervention often requires a referral through Primary Care intervention. However, the current Adventist Pain Specialty interdisciplinary clinics are not accepting new patients. Our Providers are disadvantaged by limited access to pain medicine specialists, and inadequate pain medicine training and support (Doorenbos, et. al. 2017). Hospitals have many specialty clinics that deal with specific aspects of a patient. Examples include, Urology, Cardiology, Gastroenterology, Rheumatology, and many more. However, the Primary Care Physicians of Portland Adventist do not have this resource for more optimal OPMM.
  7. Physicians were significantly more likely to prescribe opioids as the workday progressed and as appointments started later than scheduled. According to (Neprash HT, Barnett ML.2019), among 678,319 primary care appointments (642,262 patients; 392,422 [61.1%] women) with 5603 primary care physicians, the likelihood that an appointment resulted in an opioid prescription increased by 33% as the workday progressed. Primary Care physicians are swamped, with added time pressure this may be leading to insufficient management of treatment.
  8. Due to the lack of training and education for improved opioid medication management, physicians have been shown to view training as essential. Additionally, Primary Care Physicians have been shown to admit that their medical training in opioid medication therapy is lacking (Craig E. Keller et al. 2012).

Findings:

Research Question 1: In what way are Adventist Health Primary Care Physicians ineffective in Opioid Pain Management?

  • Changing Guidelines
  • Lack of assistance from ancillary staff or management.
  • Lack of pain medicine referral leverage
  • Lack of proper opioid prescription training
  • Literature overwhelmingly substantiates my personal observation regarding in what way PCPs are ineffective in managing patients using Opioid Pain Medications.

Research Question 2: What are the factors that cause Adventist Health Primary Care Physicians to be ineffective in Opioid Pain Management?

  • Opioid Narcotics no longer best strategy for long term pain management.
  • Opioid attachment or addiction
  • Opioid misuses and overdoses
  • Stressful environment
  • Large volume of workload

Research Question 3. What can be done to improve Opioid Pain Management in the Primary Care Setting at Adventist Hospital?

There are several methods that can be used to mitigate the current issue.

  1. Increased coordination, PCPs simply cannot bear the workload of all the steps required for we can utilize ancillary staff and management to assist them. Much like a medical scribe can empirically enhance PCPs performance, we can use Medical Assistants to further review Urinary Drug Screens, PDMPs, and Review in detail the MEDICATION AGREEMENT prior to the PCP starting the visit.
  2. Implement standardized screening questionnaires that must be completed and recorded into EMR:
    1. Mood Disorder: Hamilton D Scale, GAD-7 scale prior to obtaining prescription.
    2. Opioid Risk Assessment Tool
    3. Subjective Pain Tool
  3. Guidelines Change frequently, leaving the PCPs often not adhering to the standard because simply they are unaware of a change. This is highly problematic and can lead to very serious legal implications and can even cause a PCP to lose their medical license.
    1. Implementing a standardized Clinic policy in regards to Urinary Drug screens being every 6 months regardless of scheduled class of drugs.
    2. This will allow PCPs to more easily adhere to UDS required by Oregon Department of Health and CDC Guidelines.
    3. Having management play a role in effectively informing and educating PCPs and Staff regarding new or recently changed guidelines.
  4. Educational Training for Providers
    1. Use Community Provider Training Program to better educate PCPs regarding the issue of Opioids in the State of Oregon.

Method 2: Interview (Clinic Manager at Gresham Troutdale Primary Care)

An informal phone interview with Connie on October 20th, 2020, she is a Primary Clinic Manager for the clinic that I was previously employed. She indicated similar issues described in the literature review and my personal observation.

Research Question 1: In what way are Adventist Health Primary Care Physicians ineffective in Opioid Pain Management?

  • With the CDC changing guidelines constantly, it burdens the PCPs because instead of understanding guidelines and best practice for other pertinent diseases and conditions, they have to spend time working around new Opioid Prescription Protocol.
    • For many years PCPs could prescribe Benzodiazepines and Sleep Aids such as Ambien in tandem with Opioid pain medications.
    • This is no longer the case.
  • Primary Care approach to patients is variable. She noted that many physicians practice opioid medication monitoring differently. If a PCP is on vacation, for instance, a different physician may provide different amounts of medication.
    • Often she fields questions from angry patients regarding this matter. She reported instances of patients being dissatisfied with their treatment of pain.
    • Consequently a particular patient will be addressed by two different PCPs for opioid pain medication management, thus, they are susceptible to receiving inconsistent treatment.
  • MEDICATION AGREEMENT BREACH: When a medication contract is breached, the PCP has to discontinue prescriptions. There are times that patients will become confrontational and this leads to increased stress for the staff and Providers. This results in tough conversations with chronic pain patients. After patients are denied medications that they are seeking, typically they will move on to the next Primary Care Provider and the Drug seeking continues in a cyclical fashion.

Research Question 2: What are the factors that cause Adventist Health Primary Care Physicians to be ineffective in Opioid Pain Management?

  • First, she described the issue of the opioid pandemic. Frequently, there are patients that simply are attached to opioid pain medication due to long term loose restrictions in the late 1990s and early 2000s.
  • She also indicated that some providers are more lenient with medication contracts, some are strict. Overall, there is extreme variation across providers as to their approach with managing patients opioid pain therapy. Currently, there is no centralized standard for the clinic that all the providers adhere to or refer to. Some PCPs will not prescribe as many tablets as other PCPs, resulting in patients essentially receiving inadequate amounts or excess amounts of narcotics.
  • Lack of Education and Training: Uncertainty on guidelines regarding UDS assessment: The Providers often confuse when the UDS shall be conducted, often asking “Is it every 3 months or every 6 months, is it yearly?” Essentially, there is a lack of education as to guidelines put forth by CDC and Oregon Department of Health.
  • Pain management clinics do not want to manage Opioids, they want to take patient’s for which they can have alternative therapies and procedures such as cortisone injections. Many times, the pain specialists will be making referrals to mental health specialists as many of the Opioid Pain Medication using patients are more so in need of mental health intervention to mitigate their addiction to narcotics.
    • Both of these careers are at a limited resource.
  1. Pain Specialists
  2. Counselors
    1. Counselors are essential, because many of the patients using long term opioid pain medication require mental health intervention. Yet, PCPs have limited access to sending their patients to a consultation.

Additionally, she will have to navigate patients seeking a pain specialty referral as currently Adventist Pain Specialists are not accepting new patients. Thus, the PCPs are left with the difficult task of drug monitoring, without assistance from a more comprehensive specialty.

Research Question 3. What can be done to improve Opioid Pain Management in the Primary Care Setting at Adventist Hospital?

  • For long term opioid pain medication prescriptions, patients are required to sign a Medication Agreement. These Medication Agreements are very extensive and often there is not enough time for a physician to review in detail this contract, simply it is too long to keep up with the pace of the day. This is a severe issue, because many patients glance through the agreement and do not completely understand all the agreements they are signing for.
  • Uncertainty of when to conduct a UDS: Patient’s are required to have a consistent UDS prior to continuation of long-term opioid refills.
    • Patients all use Opioid Pain medications differently, sometimes patients will have an inconsistent test although they are using the medication “as needed” (PRN).
    • If the test results are inconsistent, the PCP has to address this breach in the patient’s contract which can lead to difficult conversions burdening the PCP.
    • UDS Requirements often change and for Opioid Medications, long term use patients currently have to have a consistent drug screen every 6 months, but this could change at any given point in time.
  • Implementing a more supportive role from management, being more engaged and increased intervention for monitoring, and making adjustments. Underpinning a more interactive management entails gathering information about regulations and policy and communicating this information to the providers.

Models of Analysis

Models of Analysis used in this applied research case study include:

  1. Ishikawa’s Fishbone Analysis
  2. Lewin’s Force Field Analysis
  3. Peter Drucker’s Management by Objectives
  4. Kaizen 5S Framework Workplace Organization

Model 1: Ishikawa Diagram

Review of Model

I need the research paper in this layout. Include diagrams and analysis like you did before but add it to this. Use diagrams to help with solutions and identify the problem. For example, the  Lewin's 1

This is a Fishbone Diagram associated with the barriers to adequate Opioid Medication Management, used with permission from the University of Wisconsin Board of Regents.

Review of Literature

The first step in quality improvement is to brainstorm the perceived causes of problems. The first Model to be implemented is the Ishikawa Diagram. This is a cause and effect diagram; an effect is defined as a desirable or undesirable situation, condition, or event. (LONGEST).

The Ishikawa or Cause and Effect Diagram is a graphical technique that is used to identify and arrange causes of an event or problem or outcome. The assumption required by this model is that a problem is composed of sub causes. Distinguishing subcauses are a useful first step in mitigating this problem.

The Fishbone Diagram is the first step used to address the problem statement: “Physicians appear to be unable to appropriately manage patients using opioid pain medication in the Primary Care Setting. as evidenced by the lack of opioid medication education and systematic protocol.”

The Fishbone Diagram exposes the various driving factors that contribute to the ineffectiveness of opioid pain management in the Primary Care Setting. Ensuring that adequate documentation of key drivers can allow for closer monitoring of patients using opioid pain medications (Longest, B. B. (2014).

Findings:

Research Question 1: How are Adventist Health Primary Care Physicians ineffective in Opioid Pain Management?

Currently, the physicians have not undergone any opioid management training. Additionally, there is inconsistency among the providers in regards to pain assessment and management practices. PCPs are burdened with the duty of compiling all relevant screening data such as MEDICATION AGREEMENTS, PDMPs, UDS, and subjective pain questionnaires. Furthermore, there is no clear accountability from management to be alleviating this issue.

Research Question 2: Why are Adventist Health Primary Care Physicians ineffective in Opioid Pain Management?

My personal observation indicated that the PCPs are burnt out in regards to management of opioid pain medications. Currently, the Medical Assistants do not assist the PCP in printing PDMP reports, reviewing recent UDSs, and do not assist in going through MEDICATION AGREEMENTS. Simply, the PCPs do not have assistance in operating quality opioid pain management practices.

Furthermore, the PCPs cannot refer their patients to chronic pain clinics. Leaving them to manage complex patients for which they are not adequately trained to manage. Additionally, there is a high volume of patients receiving opioid pain medications. Thus, there is a high volume of work in order to achieve proper medication management.

Research Question 3. What can be done to improve Opioid Pain Management in the Primary Care Setting at Adventist Hospital?

After scribing in the Primary Care Clinic for a number of months, it was obvious that there was no clinic wide system that PCPs followed. They all performed opioid pain management their own way often having gaps in their practice. Thus, there needed to be a systematic approach that all the providers adhered to, this would eliminate gaps in risk screening, proper UDS ordering, and an overall increased efficiency. Using a systematic approach would simplify this complex issue, reducing the burden for PCPs when prescribing opioids.

Model 2: Kurt Lewin’s Force Field Analysis

Review of Model: (Flesh out this Model for analysis)

I need the research paper in this layout. Include diagrams and analysis like you did before but add it to this. Use diagrams to help with solutions and identify the problem. For example, the  Lewin's 2

Review of Literature

The implementation of changes in medical facilities is not an easy task. Usually smaller amounts of employees desire change or willing to partake in change processes.

According to Kurt Lewin, a problem is held in balance by the interaction of two forces, driving forces and restraining forces. Promotion of change is indicated through driving forces and those attempting to continue with the status quo are represented through the resisting forces (Longest, B. B. 2014).

This dynamic balance allows the visualization of an equilibrium of forces working in opposing directions. In order for change to occur, the driving forces must exceed the restraining forces, thusly, shifting the equilibrium. Examples of these forces include persons, habits, customs, and attitudes (Crittendon, R. et al. 2020).

The Force Field Analysis is used to identify factors that can support or hinder a potential solution. Working with this model, we can identify the factors that are likely to support change, distinguished as driving forces. Additionally, using this model can identify barriers that hinder change, referred to as restraining forces. A valuable result after applying this model is determining if the driving forces are weaker, stronger, or equal to the restraining factors. Clear understanding of this dynamic leads to development of effective strategies that lead to an effective improvement effort.

Findings:

Research Question 1: How are Adventist Health Primary Care Physicians ineffective in Opioid Pain Management?

Findings:

PCPs tend to be very ritualistic in their practice of medicine, often being resistant to change. Associated with this resistance is adjusting to new regulations and systems, staff typically will not be keen to implement new standards. It is clear that Medical Assistants will have further roles, thus, resulting in a larger workload lending itself to resisting. Alternatively, the PCPs, with more assistance, drive them to new change.

Research Question 2: Why are Adventist Health Primary Care Physicians ineffective in Opioid Pain Management?

Currently, PCPs are met with too many restraining forces, inhibiting them from optimal prescribing of opioid pain medications. A driving force is identified, as patient visits for opioid pain monitoring can exceed allotted visit time, this results in increased wait times leading to stress for the staff, providers, and patients. Additionally, physicians are not adequately trained in opioid medication treatments, resulting in likelihood of prescription misuse.

Research Question 3. What can be done to improve Opioid Pain Management in the Primary Care Setting at Adventist Hospital?

When implementing a change process, it is important to minimize the restraining forces while attempting to increase the driving forces. Although training can be a burden, it is obvious that the PCPs desire to have a better system in place to better manage patients using opioid pain medications. Thus, by ensuring and emphasizing that training will lead to better more efficient management must be communicated with the staff.

Health organizations, nonetheless, must adapt to external, and changing conditions, which employees must cope with. By promoting trust and being flexible with staff can lead to decreasing the resistance forces to change and promoting the driving forces.

Model 3: Peter Drucker’s Management by Objectives

Review of Model:

I need the research paper in this layout. Include diagrams and analysis like you did before but add it to this. Use diagrams to help with solutions and identify the problem. For example, the  Lewin's 3

Review of Literature:

The management of objectives relies on defining objectives respective to each employee and to compare and direct their performance against the objectives which have been set. This Model can be used to increase the performance of the organization by matching organizational goals with the objectives of the subordinates throughout the organization. This management by objectives model requires continual tracking of the processes and providing feedback to reach the objectives.

The management by objectives model also has an associated acronym which allows for checking the validity of the objectives as follows: SMART

  • Specific
  • Measurable
  • Achievable
  • Realistic
  • Time-related

Findings:

Research Question 1: How are Adventist Health Primary Care Physicians ineffective in Opioid Pain Management?

Currently, PCPs do not have guidance in regards to properly adhere to Regulations and Policies associated with the treatment of opioid pain medications. They rely on themselves to research guidelines and often misunderstand or misinterpret the proper guidelines and regulations. For instance, some of the PCPs improperly prescribe Benzodiazepines in tandem with opioid pain medications, which is not within guidelines of CDC prescription standards. Essentially, there is a knowledge deficit as to what is acceptable prescribing practices. Ultimately PCPs lack assistive support from management in regards to information resources behind what is acceptable prescribing protocols.

Research Question 2: Why are Adventist Health Primary Care Physicians ineffective in Opioid Pain Management?

Pulling from my personal observation, it is clear that PCPs are not actively reviewing results from their treatments. Time is of the essence in the Primary Care Setting, and currently, there is not a review protocol allowing and emphasizing PCPs to review if their current practicing of opioid pain medication therapy is effective. Furthermore, management has not jointly intervened or worked alongside the PCPs to provide support and assistance with this difficult issue.

Research Question 3. What can be done to improve Opioid Pain Management in the Primary Care Setting at Adventist Hospital?

  • Increased management intervention and support. Management must start to be more interactive in regards to implementing an opioid management improvement process while maintaining effective communication.
  • The increased management must work in tandem with PCPs, MAs, and staff and provide them the necessary flexibility associated with this effort.
  • Using the Drucker’s SMART, and emphasize the importance of making appropriate adjustments pertaining to improved opioid medication management across the clinic.
  • Review and discuss the results of changed process and to make necessary improvements and adjustments when necessary.

Model 4: The Kaizen Model

Review of Model:

I need the research paper in this layout. Include diagrams and analysis like you did before but add it to this. Use diagrams to help with solutions and identify the problem. For example, the  Lewin's 4

Review of Literature:

It is obvious that we cannot employ a speedy and quick model to this issue, optimizing Opioid medication monitoring in the Primary Care setting will have to be slow and gradual with constant monitoring through management.

The Kaizen Model is a concept of gradual, continual change. Kaizen is a structured, iterative and participatory approach for making continual improvement. This approach, one of the main reasons for engaging employees in continual improvement is the assumption that the people closest to the work process are best suited to quickly identify areas in need of improvement and, consequently, implement action plans (Ulrica von Thiele Schwarz, K. et. al. 2017).

The Kaizen model is ideal because it is a structured iterative and participatory approach for making continual improvements. Additionally, this approach converges employee engagement, in the case of this research, allowing the PCPs to be directly integrated with changes. One of the main reasons the Kaizen Model engages employees in the continual improvement is the assumption that the people closest to the work process are best suited to quickly identify areas in need of improvement and consequently, implement action plans (Alhassan RK, et al. 2015).

Findings:

Research Question 1: How are Adventist Health Primary Care Physicians ineffective in Opioid Pain Management?

Currently there is no standardization of opioid treatment for the PCPs to follow. Often, they will rely on estimation and do not adhere to a set process for prescribing opioids. This leads them to have extreme variation in their treatment doses and tapering regimens. Mamy of the physicians are using outdated or insufficient risk assessment tools to identify comorbidities associated with patients to receive opioid medications.

Research Question 2: Why are Adventist Health Primary Care Physicians ineffective in Opioid Pain Management?

Additionally, there is no team coordination in the opioid prescribing process, this leads to complete disorganization of data associated with prescribing opioid pain medications. Currently, there is lack of teamwork in regards to Opioid Pain Medication Management, much of the burden of properly managing, reviewing UDS tests, current guidelines, PDMPs, and subjective pain levels that can be distributed to other team members of the PCPs IE: Medical Assistants having a new role of accurately reviewing recent UDSs, PDMPs, Subjective Pain questionnaires, Medication Agreements.

Research Question 3. What can be done to improve Opioid Pain Management in the Primary Care Setting at Adventist Hospital?

There are 5 foundational elements of the Kaizen Model that can be applied nicely with the Primary Care Setting we are addressing:

There are currently PCP meetings with clinic managers and senior management on the first Tuesday of every month. Therefore, this is a perfect opportunity to further strategize and implement adjustments when undergoing a change process. This promotes sorting out information that is relevant, straightening out current perceptions, sweeping out unnecessary resources, and standardizing the direction in which best promotes adequate opioid pain medication management in the Primary Care setting. Ultimately, if used effectively, PCPs self discipline will improve as they will ideally experience alleviation from the current issue of the difficult opioid prescription process.

Summary of Findings

This research project was based on a personal observation, informal interview, literature review, and 4 theoretical models of analysis. The models included in this research emphasized determining the internal and external factors that cause PCPs to be ineffective in managing chronic pain patients using opioid therapy. This research attempts to identify how the PCPs insufficiency can be improved. The following findings attempt to identify key contributors to the isse by addressing the following research questions: (1) In what way are Adventist Health Primary Care Physicians ineffective in Opioid Pain Management? (2) What are the factors that cause Adventist Health Primary Care Physicians to be ineffective in Opioid Pain Management? (3) What can be done to improve Opioid Pain Management in the Primary Care Setting at Adventist Hospital?

Ineffective opioid medication by PCPs was attributed to the following:

  • There has been a shift in healthcare, a movement to reduce the amount of opioid medication prescriptions. Opioid pain medications are no longer considered the best strategy for managing chronic pain. However, there continues to be a high volume of patients using opioid pain medications resulting in PCPs having to manage a high volume of narcotic prescriptions.
  • With this shift, has resulted in rapidly changing guidelines and policy regarding the prescription of opioid pain medications. This has resulted in PCPs to be confused or uninformed of proper opioid prescribing practices.
  • Opioid pain prescriptions are highly addictive leading to patients developing complex pain syndromes and resistance to tapering off regimens, complicating quality pain management.
  • There is no referral leverage for pain specialty clinic intervention, thus, PCPs are burdened with managing complex chronic pain patients with lacking proper and adequate training.
  • There is a lack of protocol for PCPs to follow to help PCPs simplify obtaining UDSs, MEDICATION AGREEMENTS, reviewing PDMPS, and pain and psychological risk assessment tool capabilities.
  • There is a lack of assistance for PCPs from the Medical Assistants and management.

Recommendations

  1. Scheduling longer chronic pain follow up consultations.
    1. This would alleviate the stress associated with these types of patient office visits. Additionally, more time can be used for completing risk assessment tools, more comprehensive physical examinations, and reviewing lengthy MEDICATION AGREEMENTS.
  2. Implement a clinic wide risk assessment tool usage.
    1. Hamilton D Scale: is an effective psychosocial risk assessment tool to evaluate the mental health of patients using opioid pain medications as they are at a higher risk for mental health conditions.
    2. Standard use of Opioid Risk Assessment Tool (ORT) for every patient prescribed opioid pain medications for prolonged non acute periods of time.
  3. Implement a standardized UDS screening table provided to providers to have at their desk and rooms.
    1. This table would be updated whenever there is a policy change regarding the months between opioid prescription medications.
    2. Physicians would then have appropriate and accurate knowledge of when they need to order repeat UDS tests.
    3. Management would monitor any changes and inform and change the tables when indicated.
  4. Increased MA participation.
    1. MAs will be required to print out the PDMPs for patients using opioid pain medications and give it to the provider after rooming the patient. This takes the burden off of the physicians to search and take time for reviewing this important tool.
    2. MAs when rooming a patient at a MEDICATION AGREEMENT signing visit must review the MEDICATION AGREEMENT. This will reinforce the MEDICATION AGREEMENT for the patient and improve efficiency as this is a lengthy process for the PCPs.
    3. MAs will Chart Review and review recent UDS and inform the PCP if there is a breach in the UDS test. This will decrease PCPs from neglecting to review UDSs and consequently provide a patient opioids after an inconsistent test.
  5. Hold Opioid Medication training for the Providers.
    1. The Oregon Pain Guidance is a joint coalition of 70 individuals working as prescribing healthcare providers, behavioral health clinicians, and administrators.
    2. This group has developed a website that includes all information pertinent to the appropriate prescription practices for providers to adhere to.
    3. PCPs within this clinic will undergo the video training regarding Risk assessment tools, UDSs, PDMPs, MEDICATION AGREEMENTS, and other relevant informational resources.
    4. Management must be flexible and accommodating for the training to be achieved.
  6. Additionally and most importantly, management must conduct a strategic control system to achieve the successful implementation of the strategic adjustments by detecting discrepancies between desired and actual performance.
    1. Facilitate coordination in the organization and systems.
    2. Motivate effort toward achievement of objective.
    3. Provide an early decision system to warn that the assumption and conditions underlying strategies are wrong or have changed.
    4. Provide a means through which strategic managers can intervene to correct an ineffective or inappropriate strategy.

Based on findings; this is what I recommend in regards to the research questions. As we do this, we are carrying out the organization’s goal of providing optimal healthcare services for our deserving patients.

These recommendations serve as a framework that promotes continuous evaluation and adaptation of the program to meet the needs of the clinical system. Once the goals of continual compliance workflow improvements are achieved, this clinic can achieve supporting the lead role of managing chronic pain, the Providers. Moving forward, this clinic has a framework in the attempt to improve opioid-prescribing best practices for patients.

References

Bali, R. K., & Dwivedi, A. N. (2010). Healthcare knowledge management: Issues, advances, and successes. Springer.

Berry PH, Dahl JL. The new JCAHO pain standards: implications for pain management nurses. Pain Manag Nurs. 2000 Mar;1(1):3-12. doi: 10.1053/jpmn.2000.5833. PMID: 11706454.

Craig E. Keller BS, Lisham Ashrafioun MA, Anne M. Neumann PhD, Justin Van Klein BS, Chester H. Fox MD & Richard D. Blondell MD (2012) Practices, Perceptions, and Concerns of Primary Care Physicians About Opioid Dependence Associated with the Treatment of Chronic Pain, Substance Abuse, 33:2, 103-113, DOI: 10.1080/08897077.2011.630944

Crittendon DR, Cunningham A, Payton C, et al. Organizational Readiness to Change: Quality Improvement in Family Medicine Residency. PRiMER. 2020;4:14. https://doi.org/10.22454/PRiMER.2020.441200

Doorenbos, A., Eaton, L., Theodore, B., Sullivan, M., Robinson, J., Rapp, S., & Tauben, D. (2017). (372) TelePain: Improving primary care pain management. The Journal of Pain, 18(4). doi:10.1016/j.jpain.2017.02.346

Eeghen, C. V., Kennedy, A. G., Pasanen, M. E., & Maclean, C. D. (2020). A New Quality Improvement Toolkit to Improve Opioid Prescribing in Primary Care. The Journal of the American Board of Family Medicine, 33(1), 17-26. doi:10.3122/jabfm.2019.01.190238

Hurstak, E., Chao, M. T., Leonoudakis-Watts, K., Pace, J., Walcer, B., & Wismer, B. (2019). Design, Implementation, and Evaluation of an Integrative Pain Management Program in a Primary Care Safety-Net Clinic. The Journal of Alternative and Complementary Medicine, 25(S1). doi:10.1089/acm.2018.0398

Longest, B. B. (2014). Managing health services organizations and systems. Health Professions Press.

McCann KS, Barker S, Cousins R, Franks A, McDaniel C, Petrany S, Riley E. Structured Management of Chronic Nonmalignant Pain with Opioids in a Rural Primary Care Office. J Am Board Fam Med. 2018 Jan-Feb;31(1):57-63. doi: 10.3122/jabfm.2018.01.170163. PMID: 29330240.

Mehl-Madrona, L., Mainguy, B., & Plummer, J. (2016). Integration of Complementary and Alternative Medicine Therapies into Primary-Care Pain Management for Opiate Reduction in a Rural Setting [Abstract]. The Journal of Alternative and Complementary Medicine, 22(8), 621-626. doi:10.1089/acm.2015.0212

Morteza Khodaee, M., December;65(12):E1-E6, J., & Author: Doug Campos-Outcalt, M. (2019, January 18). A look at the burden of opioid management in primary care. Retrieved October 17, 2020, from https://www.mdedge.com/familymedicine/article/118896/pain/look-burden-opioid-management-primary-care

Opioid Timeline. Retrieved October 18, 2020, from https://www.fda.gov/drugs/information-drug-class/timeline-selected-fda-activities-and-significant-events-addressing-opioid-misuse-and-abuse

Neprash HT, Barnett ML. Association of Primary Care Clinic Appointment Time With Opioid Prescribing. JAMA Network Open. 2019;2(8):e1910373. doi:10.1001/jamanetworkopen.2019.10373

Ulrica von Thiele Schwarz, K. (n.d.). Using kaizen to improve employee well-being: Results from two organizational intervention studies – Ulrica von Thiele Schwarz, Karina M Nielsen, Terese Stenfors-Hayes, Henna Hasson, 2017. Retrieved November 06, 2020, from https://journals.sagepub.com/doi/10.1177/0018726716677071

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