1. Measure Target March, 2014 (Baseline) October, 2014 % change from baseline Number of physicians who prescribe pain med pre-op Source: Internal survey at 2 PP 045%18% 60% Number of physicians prescribing pain med day of surgery (DOS) Source: Manual count 100%54%82% 52% Standardize on the combination of pain meds prescribed DOS to be Tylenol and/or Motrin and Oxycodone (Eliminate Vicodin, Percocet) Source : M anual count/audit 100% compliance with standard 0% no standard 95% compliance 95% Standardize on the number of pain meds prescribed DOS ( Excludes complex cases) Source: Manual count/audit 100% compliance with standard 17%92% 441% Patient Pain Management Satisfaction rank score Source: Press Ganey, Day Surgery Pond Park, Ambulatory NA 98%96% -2% Clinical Integration IMPROVEMENT BULLETIN Reducing variation on opioid prescribing Sponsors: Mike Ayers, MD, Chief Joint Replacement; Owen McConville, MD, Chair, Orthopedics; Tim Quigley, RN, Chief Nursing Officer, South Shore Hospital Team: Michael Marchetti, MD; Angelica Duczankowski, PA-C; Bernie Hendriksen, PA-C; James Green; Lorraine Campbell, RN; Leslie Stenbeck, RN; Gerda Sullivan, RN; Ann Marie Materna, RN; Ellen Howard, RN; Quay Baker, RN; Edwina Brinkley, RN; Kim-Phung Lai, Rph; Richard Bello, MD Location: COSSM’s Ambulatory Surgery Center, 2 Pond Park, Hingham MA Background: There was significant variability among surgeons at 2 Pond Park regarding Post-Operative Pain Management. At times this led to complicated post operative instructions, occasionally confounding nursing staff, and impeding patient/family education. With a growing opioid drug problem on the south shore, concern was also expressed regarding the ultimate disposition of prescribed but unused narcotics. A Pain Management Committee was created to develop alternatives. Goals: Develop and implement standardized pain management guidelines segmented by procedure (e.g., knee arthroscopy, trigger finger release, ACL reconstruction) to achieve: 100% of pain meds prescribed on the day of surgery Standardize on: Types/combinations of pain meds Quantity of pain meds prescribed Materials and processes to inform patients and families on pain management Education for patient and families regarding safe disposal and use of narcotic medications Next Steps: Spread the standard across the Health System. METRICS/DATA Health Provider Services Organization Questions? Contact Lorraine Campbell at Lorraine_Campbell@sshosp.org See page 2 for information on the process improvements that were made.

2. Clinical Integration IMPROVEMENT BULLETIN The table below is a summary of the process improvements that were made. Click here to read the Patriot Ledger article related to this work.Click here ProblemSolutionsResultsNext Steps There was variability among Surgeons regarding when they prescribed pain medication (pre-op versus day of surgery). This often led to confounding nursing staff, and impeding patient/family education. Collected data from 2 Pond Park to assess variation Created Post-Operative Pain Management guidelines Post-Operative Pain Management guidelines developed: Reduced the number of pills prescribed pre-op to be 20 -60 procedure specific Standardized on prescribing day of surgery versus pre-op Continue to monitor and improve guidelines at 2 Pond Park Spread the guidelines across the SSH Health System There was variability among Surgeons regarding the quantity/types/combinations of pain medications prescribed sometimes confounding nursing staff and impeding patient/family education. Collected data from 2 Pond Park to assess variation Created Post-Operative Pain Management guidelines that limit types of opioids Post-Operative Pain Management guidelines developed: Establish DOS prescriptions should be a combination of Tylenol and/or Motrin and Oxycodone (Eliminated Vicodin and Percocet) Dilaudid if allergic Spread the guidelines across the SSH&EC Health System Some patients did not fully understand their pain management/medication plan. As a result there were numerous calls to the attending and/or on- call orthopedist. Developed patient and family education materials Ensured all staff was familiar with the materials and could share these at anytime with patients and families Encouraged physicians to start opioid/pain management education for patients in their office versus during pre-op or DOS Developed Opioid Education/Teaching leaflet being provided to every patient at discharge Safe Disposal of Medications flyer created and available in waiting room for families Work with staff to improve process for using the patient and family education materials Health Provider Services Organization Find more bulletins on the Clinical Improvement Corner on the Medical Staff website. Email us at: hpso@sshosp.org.For internal distribution only.hpso@sshosp.org Rev 2/15/15