Stage 3: Monitor & Sustain – Six Building Blocks

Implementation Guide

This is the closing out stage in which the quality improvement lead helps prepare the site to sustain the work done to improve opioid management. During this stage, the quality improvement lead uses the Monitor and Sustain Guide to lead the Opioid Improvement Team in reviewing baseline goals, celebrating successes, and making plans to move forward independently and sustain the work.

Open the Monitor & Sustain Guide to begin work toward achieving the following milestones.

This is a starting list of activities for ongoing work after the facilitation support ends, which you can adapt to your needs.

Building Block Activities
Leadership & consensus Continue to protect time for improvement team to meet and work Continue to engage leadership, staff, and clinicians by regularly sharing data and stories Assess adequacy of resources needed to support opioid management processes and identify additional resources if needed Obtain feedback from staff and clinicians and adjust as necessary Identify reluctant clinicians and staff and identify strategies to improve engagement Stay up to date with guidelines (Medicaid, CDC, state, etc.)
Policies, patient agreements, & workflows Revisit and revise policies, patient agreements, and workflows, as needed based on experiences and new evidence
Tracking & monitoring patient care Adjust and iterate best possible tracking & monitoring approaches
Planned, patient-centered visits Offer educational opportunities in opioid management, empathic communication, and patient involvement Integrate opioid management processes into standard trainings, including onboarding new employees When workflows need development or updating, involve those who will do the work and do small cycle tests of change before implementing changes across the organization
Caring for patients with complex needs Ensure clear referral pathways for OUD and mental/behavioral health patient resources and close the loop on referrals If not already in place, consider providing opioid use disorder treatment within the clinic
Measuring success Produce provider-specific reports on performance measures and discuss during medical staff meetings Regularly review performance measure data at the level of the clinic during all staff meetings and other opportunities Identify additional opportunities for improvement and implement small cycle tests of change

Building Block Activities

Leadership & consensus

Continue to protect time for improvement team to meet and work
Continue to engage leadership, staff, and clinicians by regularly sharing data and stories
Assess adequacy of resources needed to support opioid management processes and identify additional resources if needed
Obtain feedback from staff and clinicians and adjust as necessary
Identify reluctant clinicians and staff and identify strategies to improve engagement
Stay up to date with guidelines (Medicaid, CDC, state, etc.)

Policies, patient agreements, & workflows

Revisit and revise policies, patient agreements, and workflows, as needed based on experiences and new evidence

Tracking & monitoring patient care

Adjust and iterate best possible tracking & monitoring approaches

Planned, patient-centered visits

Offer educational opportunities in opioid management, empathic communication, and patient involvement
Integrate opioid management processes into standard trainings, including onboarding new employees
When workflows need development or updating, involve those who will do the work and do small cycle tests of change before implementing changes across the organization

Caring for patients with complex needs

Ensure clear referral pathways for OUD and mental/behavioral health patient resources and close the loop on referrals
If not already in place, consider providing opioid use disorder treatment within the clinic

Measuring success

Produce provider-specific reports on performance measures and discuss during medical staff meetings
Regularly review performance measure data at the level of the clinic during all staff meetings and other opportunities
Identify additional opportunities for improvement and implement small cycle tests of change