- Email: [email protected]
Designing an academic practice of pain medicine
Techniques in Regional Anesthesia and Pain Management (2010) 14, 149-153
Designing an academic practice of pain medicine Marc A. Huntoon, MD From the Department of Anesthesiology, College of Medicine, Mayo Clinic, Rochester, Minnesota. KEYWORDS: Medical education; Medical economics; Academic medical center
Designing an ideal academic practice of Pain Medicine is often challenging, as no formal specialty currently exists, and therefore the parent core disciplines (Anesthesiology, Physical Medicine and Rehabilitation, Neurology, Neurosurgery, or Psychiatry) exert significant influence over the potential directions the practice may take. This paper looks at developing mission statements, explores how to reach current and potential stakeholders, examines goals you should set and key performance indicators. It finishes by determining the idea practice set-up and then reviewing potential plans for implementation. © 2010 Elsevier Inc. All rights reserved.
Designing an ideal academic practice of Pain Medicine is often challenging, as no formal specialty currently exists, and therefore the parent core disciplines (Anesthesiology, Physical Medicine and Rehabilitation, Neurology, Neurosurgery, or Psychiatry) exert significant influence over the potential directions the practice may take. In some cases, new subspecialties, such as Palliative Care, may also compete for pain-related resources and promote alternative care pathways away from a unified practice model. Most pain practices tend to be dominated by one specialty (eg, Anesthesiology), which inherently fosters division and undermines collaboration. These divisions must be actively managed to promote cohesion, because if they are not appropriately managed, competitive forces may undermine the organizations ability to provide optimal pain care. For example, the Department of Orthopedic Surgery might hire a trained physiatrist interventionalist to do injections in the Spine Center that directly competes with the Pain Clinic. This situation would obviously hamper the ability to integrate all stakeholders in the future. Most universities have a pain clinic that evaluates patients with painful disorders and prescribes treatments that may be procedural Address reprint requests and correspondence: Marc A. Huntoon, MD, Department of Anesthesiology, College of Medicine, Mayo Clinic, Charlton-1 Anesthesiology, 200 1st Street SW, Rochester, MN 55905. E-mail address: [email protected].
1084-208X/$ -see front matter © 2010 Elsevier Inc. All rights reserved. doi:10.1053/j.trap.2010.08.001
(nerve blocks/epidural blocks), pharmacologic (opioids, antidepressants, anticonvulsants), physical (physical modalities, exercise), and cognitive behavioral (psychological counseling, group therapy, biofeedback). Many centers attempt to “bring the practitioners together” in some fashion, but few seamlessly integrate all the prime stakeholders in one unified, patient-centered, longitudinal care environment. Some of the Committee on the Accreditation of Rehabilitation Facilities-accredited facilities1 err on the side of cognitive behavioral/rehabilitative strategies, perhaps at the expense of procedures for relief of intensely painful chronic problems, whereas interventional clinics promote often endless interventions that do not address the biopsychosocial needs of this group of patients. Most patients, however, need a multimodal, multidisciplinary experience over time to manage their pain syndrome. This article is meant to stimulate development of a template for the type of pain center that fulfills the definition of an integrative pain medicine practice. Ideally, a balanced integrative approach that includes selected procedures, when indicated, is achieved.
Mission statements Whether coming in to a new university system or currently residing in an established practice, a review of the current mission statement is in order. The mission statement should be short (one sentence to a short paragraph), easy to remem-
150
Techniques in Regional Anesthesia and Pain Management, Vol 14, No 4, October 2010
Figure 1
The Pain Evaluation Center’s mission statement.
ber, and motivating to the stakeholders in the activity. It should clearly state the purpose for the program, its business, and core values. For example, “The three part mission of the Fictitious Medical College of Eastern Idaho Pain Center is to: (1) be the premier pain resource for the state, providing evidence-based, compassionate, patient-centered, and effective pain care to patients that restores their rela-
Figure 2
tional and functional autonomy and enhances well-being; (2) promote critical research to improve pain care; and (3) provide outstanding pain medicine education to our learners that instills them with values of leadership, mentorship, and intellectual curiosity.” For this mission statement, one can identify the needs being addressed; patients have pain that needs treatment and prevents them from being autonomous
Integrated Pain Medicine Committee.
Huntoon Table 1
Academic Pain Medicine Practice Design
151
Goals
1. Improve access for patients with predominantly pain diagnoses via a straightforward referral mechanism to one master intake center. 2. Eliminate duplication inherent in decentralized consultations. 3. Increase collaboration between consultants and among departments. 4. Provide expertise in the management of pain disorders. 5. Improve patient and referral source satisfaction. 6. Promote an interdisciplinary educational program. 7. Develop “best practice” clinical pathways. 8. Develop mentors for collaborative research in the field of Pain Medicine. 9. Promote collaboration with other “centers of excellence” 10. Enhance pain physician career satisfaction and retention.
and healthy, and learners need to be inspired to become more knowledgeable so they can take better care of patients and conduct research that solves problems. The means of addressing these needs can also be identified; the center provides patient-centered, compassionate, evidence-based care and provides mentorship to learners through education and research opportunities. Finally, the values of the organization are portrayed. The center believes in patient relational and functional autonomy and well-being and wants its learners to exemplify qualities, such as leadership, mentorship, and intellectual curiosity. Although it is desirable (when possible) to have a very concise, clear mission statement, this mission statement is perhaps too verbose. However, the very nature of academic medicine (education, research, and clinical care) makes writing a short mission statement a little harder than for private practices where clinical care is the sum of activity (Figure 1).
Reaching current and potential stakeholders If one is beginning to organize a new center, it will be important to include all stakeholders or potential stakeholders into some form of task force or committee. By making a few phone calls, or better yet, personal visits, one can determine who in the various groups has interest in being a part of an integrated effort. In some cases, key personnel may be wary of previous failures, or not desire to increase their current workload for another failed effort. Others may not view your leadership of the activity with “open arms.” The best way to win these people over is to include them, objectively listen to their concerns, and ultimately, to have patient-centered care at the heart of the plan. An example of a fictional integrated pain committee is shown in Figure 2. The leader of the committee should be the one with the vision and communication skills necessary to garner cooperation among the various specialties present. An integrated pain practice does not have to include every subspecialty listed below, but those practitioners with the skills and knowledge to manage pain will be most able to find the shortest route to optimal care (Table 1). After the committee has met, the leader should try to articulate specific goals that have been agreed upon by the
committee. The next step after goals are agreed upon is to derive a yardstick of sorts for what success looks like. These could be in the form of key success indicators (Table 2). A SWOT analysis (a business modeling strategy that lists strengths, weaknesses, opportunities, and threats) prior to development of a multidisciplinary pain evaluation center may be a helpful tool to promote awareness of potential opportunities and barriers to change. Most strengths will be obvious, but some may not. An integrated pain medicine committee should aid in identification of institutional areas of excellence that can be included. The committee can also help identify potential weaknesses and threats to success (Figure 3).
Personnel needs The personnel required to staff the pain center will depend on the model of care employed. Pain patients come from every area of medicine, and may have a wide range of potential issues to deal with. The unifying factor is that they all have pain. Thus, the primary intake center needs to have a leader (physician) who has expertise in evaluating pain patients. The physician leader should be a fellowshiptrained algologist, who might be from any of the core specialties. There could be more than one physician on a given day who needs to evaluate patients if a large referral volume is present. One could also employ physician extenders (physician assistants, nurse practitioners, or residents and fellows) depending on staffing and educational needs.
Practice set-up Fellows clinic. One attending physician is paired with two fellows. The fellows are first to evaluate the patients and do the body of the history, review of systems, and physical examination. The attending staff visits with the patient to confirm history, repeats pertinent examination as needed, and provides final recommendations. Attendings clinic. Each attending staff physician sees his/her own patients, possibly with a physician extender also in attendance. The physician extender may aid in pro-
152 Table 2
Techniques in Regional Anesthesia and Pain Management, Vol 14, No 4, October 2010 that the assessment is ready to be sent and billed at the conclusion of the visit. Blended model. In a blended model, one physician may be working either alone or with an extender while a teaching service physician is working with residents and/or fellows. Conversely, one physician may be working with both physician extenders and fellows at the same time. Many programs have a small number of trainees and may not be able to allow each staff physician to have help.
Key success indicators
Key success indicators for a Multidisciplinary Pain Evaluation Center could be measured in several ways: 1. The triage process should reduce duplication of consultations. 2. The triage process should streamline referral of patients to the correct physician expertise the first time, thus eliminating unnecessary evaluations. 3. The triage process should increase patient and referral source satisfaction. 4. The integrated process should promote improvement in patient outcomes and evidence-based practice as measured by key metrics. 5. Standardized curricula are developed as result of increased collaboration and physician interactions, improving the educational environment. 6. Centralized patient and physician resources provide a rich environment for collaborative research in pain medicine. 7. The Pain Evaluation Center is at minimum financially neutral or a net profit center while adding value to the care environment
Equipment
curing additional resources, such as drug information teaching tools, prescriptions, and follow-up appointments. The extender may also electronically populate care notes such
Figure 3
For physician offices, basic equipment, such as small spine models, reflex hammers, tuning forks, stethoscopes, and other small equipment, is all that is necessary. For procedure suites, vital signs monitors capable of monitoring pulse oximetry, blood pressure, and electrocardiogram are necessary for sedation cases. Fluoroscopy machines and monitors, ultrasound machines, radiofrequency lesion generators/ probes, fluoroscopy tables, infusion pumps, and other small equipment are necessary for most interventional practices. Many university programs may not have available space, or may have rules about which areas can use such equipment, sometimes becoming a barrier to effective practice. For example, multifunction imaging suites, such as flat detector
A SWOT analysis.
Huntoon
Academic Pain Medicine Practice Design
computed tomography suites with digital subtraction angiography, biplanar fluoroscopy, or 3D ultrasound may only be allowed in a radiology practice in some settings, thus limiting which specialists can be credentialed to do the procedures that require such equipment.2 Many universities also have capital equipment budgets, thus some pieces of equipment may require presentation to committees or budgetary authorities to be procured.
Room and physical needs As a rule of thumb, in an academic practice of pain medicine, each clinician evaluating patients should have a minimum of three to four examination rooms for optimal patient flow. For procedures, ideally these would be batched together on a given physician’s calendar in half-day or fullday blocks. This allows for the efficiency of doing several procedures in a row. Medical assistants can help prepare trays and clean rooms; fluoroscopy technical personnel can be available to assist as well. It is inherently inefficient to go back and forth from new evaluations and follow-ups to short and long procedures. In this type of model, each physician needs to have his/her own procedure room available at all times to make the model workable. Otherwise, physicians end up competing for fluoroscopy at similar times, whereas at other times, the machine is not in use.
Educational model Rotations Residents and fellows should have specific rotations that have well articulated structure, goals and objectives, evaluation metrics, and remediation pathways. These should be based on the Accreditation Council for Graduate Medical Education (ACGME) curriculum requirements. ACGME requirements have been peer-reviewed and instituted for all programs currently accredited.3 In the modern decade, the availability of web-based learning through lecture series, procedural videos, simulations centers, and anatomical skills laboratories may allow content to be available at convenient times for the learners. Other web-based content might include patient care help, such as opioids converter software, drug titration schedules, care pathways or algorithms, physical exercise templates, dictations templates, emergency procedure pathways, and many others.
Research/database In many university practices, it is increasingly necessary to track outcomes to prove the efficacy of specific practice paradigms and compare with other universities, such as the University Health System Consortium.4 These are wonderful benchmarking tools that encourage improvement. Data
153 may be entered by patients, in some cases, with handheld devices, and the data can then be manipulated and “mined” by researchers to decipher important care trends.
Implementation (roll-out schedule) An important part of any strategic plan is the implementation phase. Generally speaking, the new processes should be implemented in a controlled fashion, with only one “changed process” at a time. The name of the process is not important, but descriptors such as “pilot program” denote that something new is going on, and most people will generally try to be helpful, and perhaps be forgiving of problems that might come up. Referrers should be made aware of changes, and their input sought soon after initial implementation to assess for opportunities for improvement. The U.S. Army calls these “after action reviews.”5 If implementation is not done with a thoroughness in planning, care of the patient could be compromised. For example, the process of Intraspinal Drug Delivery System refill or medication change could have disastrous consequences if a dosing error is made and there are not fail-safe plans in effect. A patient could be sent home with far too much medication infusing and simply lapse into a drug-induced coma.6
Conclusions Developing a new academic practice within an established medical center can be a daunting task. Seemingly, the administrative, educational, research, and clinical missions may all need improvement. Prioritizing change is an important part of the challenge. Slow incremental work, harnessing the creative energies of core personnel, and working together in care teams (along with a little lucky break here and there) and unwavering support are critical to success.
Acknowledgments The author wishes to thank Mary M. Schrandt (MAOM) for her help with the SWOT analysis.
References 1. Available at: http://www.pain101.com/PainDoctors/DirectoryOfPain DoctorsCARFlist.aspx. Accessed August 23, 2010 2. Orth RC, Wallace MJ, Kuo MD: C-arm cone-beam CT: general principles and technical considerations for use in interventional radiology. J Vasc Interv Radiol 19:814-821, 2008 3. ACGME program requirements for graduate medical education in pain medicine (effective July 1, 2007). Available from: http://www.acgme. org/adspublic/. Accessed August 23, 2010 4. Available at: http://www.uhc.edu/. Accessed August 23, 2010 5. Available at: http://www.au.af.mil/au/awc/awcgate/army/tc_25-20/ chap1.htm. Accessed August 23, 2010 6. Coffey RJ, Owens ML, Broste SK, et al: Medical practice perspective: identification and mitigation of risk factors for mortality associated with intrathecal opioids for non-cancer pain. Pain Med 11:1001-1009, 2010
Designing an academic practice of pain medicine Marc A. Huntoon, MD From the Department of Anesthesiology, College of Medicine, Mayo Clinic, Rochester, Minnesota. KEYWORDS: Medical education; Medical economics; Academic medical center
Designing an ideal academic practice of Pain Medicine is often challenging, as no formal specialty currently exists, and therefore the parent core disciplines (Anesthesiology, Physical Medicine and Rehabilitation, Neurology, Neurosurgery, or Psychiatry) exert significant influence over the potential directions the practice may take. This paper looks at developing mission statements, explores how to reach current and potential stakeholders, examines goals you should set and key performance indicators. It finishes by determining the idea practice set-up and then reviewing potential plans for implementation. © 2010 Elsevier Inc. All rights reserved.
Designing an ideal academic practice of Pain Medicine is often challenging, as no formal specialty currently exists, and therefore the parent core disciplines (Anesthesiology, Physical Medicine and Rehabilitation, Neurology, Neurosurgery, or Psychiatry) exert significant influence over the potential directions the practice may take. In some cases, new subspecialties, such as Palliative Care, may also compete for pain-related resources and promote alternative care pathways away from a unified practice model. Most pain practices tend to be dominated by one specialty (eg, Anesthesiology), which inherently fosters division and undermines collaboration. These divisions must be actively managed to promote cohesion, because if they are not appropriately managed, competitive forces may undermine the organizations ability to provide optimal pain care. For example, the Department of Orthopedic Surgery might hire a trained physiatrist interventionalist to do injections in the Spine Center that directly competes with the Pain Clinic. This situation would obviously hamper the ability to integrate all stakeholders in the future. Most universities have a pain clinic that evaluates patients with painful disorders and prescribes treatments that may be procedural Address reprint requests and correspondence: Marc A. Huntoon, MD, Department of Anesthesiology, College of Medicine, Mayo Clinic, Charlton-1 Anesthesiology, 200 1st Street SW, Rochester, MN 55905. E-mail address: [email protected].
1084-208X/$ -see front matter © 2010 Elsevier Inc. All rights reserved. doi:10.1053/j.trap.2010.08.001
(nerve blocks/epidural blocks), pharmacologic (opioids, antidepressants, anticonvulsants), physical (physical modalities, exercise), and cognitive behavioral (psychological counseling, group therapy, biofeedback). Many centers attempt to “bring the practitioners together” in some fashion, but few seamlessly integrate all the prime stakeholders in one unified, patient-centered, longitudinal care environment. Some of the Committee on the Accreditation of Rehabilitation Facilities-accredited facilities1 err on the side of cognitive behavioral/rehabilitative strategies, perhaps at the expense of procedures for relief of intensely painful chronic problems, whereas interventional clinics promote often endless interventions that do not address the biopsychosocial needs of this group of patients. Most patients, however, need a multimodal, multidisciplinary experience over time to manage their pain syndrome. This article is meant to stimulate development of a template for the type of pain center that fulfills the definition of an integrative pain medicine practice. Ideally, a balanced integrative approach that includes selected procedures, when indicated, is achieved.
Mission statements Whether coming in to a new university system or currently residing in an established practice, a review of the current mission statement is in order. The mission statement should be short (one sentence to a short paragraph), easy to remem-
150
Techniques in Regional Anesthesia and Pain Management, Vol 14, No 4, October 2010
Figure 1
The Pain Evaluation Center’s mission statement.
ber, and motivating to the stakeholders in the activity. It should clearly state the purpose for the program, its business, and core values. For example, “The three part mission of the Fictitious Medical College of Eastern Idaho Pain Center is to: (1) be the premier pain resource for the state, providing evidence-based, compassionate, patient-centered, and effective pain care to patients that restores their rela-
Figure 2
tional and functional autonomy and enhances well-being; (2) promote critical research to improve pain care; and (3) provide outstanding pain medicine education to our learners that instills them with values of leadership, mentorship, and intellectual curiosity.” For this mission statement, one can identify the needs being addressed; patients have pain that needs treatment and prevents them from being autonomous
Integrated Pain Medicine Committee.
Huntoon Table 1
Academic Pain Medicine Practice Design
151
Goals
1. Improve access for patients with predominantly pain diagnoses via a straightforward referral mechanism to one master intake center. 2. Eliminate duplication inherent in decentralized consultations. 3. Increase collaboration between consultants and among departments. 4. Provide expertise in the management of pain disorders. 5. Improve patient and referral source satisfaction. 6. Promote an interdisciplinary educational program. 7. Develop “best practice” clinical pathways. 8. Develop mentors for collaborative research in the field of Pain Medicine. 9. Promote collaboration with other “centers of excellence” 10. Enhance pain physician career satisfaction and retention.
and healthy, and learners need to be inspired to become more knowledgeable so they can take better care of patients and conduct research that solves problems. The means of addressing these needs can also be identified; the center provides patient-centered, compassionate, evidence-based care and provides mentorship to learners through education and research opportunities. Finally, the values of the organization are portrayed. The center believes in patient relational and functional autonomy and well-being and wants its learners to exemplify qualities, such as leadership, mentorship, and intellectual curiosity. Although it is desirable (when possible) to have a very concise, clear mission statement, this mission statement is perhaps too verbose. However, the very nature of academic medicine (education, research, and clinical care) makes writing a short mission statement a little harder than for private practices where clinical care is the sum of activity (Figure 1).
Reaching current and potential stakeholders If one is beginning to organize a new center, it will be important to include all stakeholders or potential stakeholders into some form of task force or committee. By making a few phone calls, or better yet, personal visits, one can determine who in the various groups has interest in being a part of an integrated effort. In some cases, key personnel may be wary of previous failures, or not desire to increase their current workload for another failed effort. Others may not view your leadership of the activity with “open arms.” The best way to win these people over is to include them, objectively listen to their concerns, and ultimately, to have patient-centered care at the heart of the plan. An example of a fictional integrated pain committee is shown in Figure 2. The leader of the committee should be the one with the vision and communication skills necessary to garner cooperation among the various specialties present. An integrated pain practice does not have to include every subspecialty listed below, but those practitioners with the skills and knowledge to manage pain will be most able to find the shortest route to optimal care (Table 1). After the committee has met, the leader should try to articulate specific goals that have been agreed upon by the
committee. The next step after goals are agreed upon is to derive a yardstick of sorts for what success looks like. These could be in the form of key success indicators (Table 2). A SWOT analysis (a business modeling strategy that lists strengths, weaknesses, opportunities, and threats) prior to development of a multidisciplinary pain evaluation center may be a helpful tool to promote awareness of potential opportunities and barriers to change. Most strengths will be obvious, but some may not. An integrated pain medicine committee should aid in identification of institutional areas of excellence that can be included. The committee can also help identify potential weaknesses and threats to success (Figure 3).
Personnel needs The personnel required to staff the pain center will depend on the model of care employed. Pain patients come from every area of medicine, and may have a wide range of potential issues to deal with. The unifying factor is that they all have pain. Thus, the primary intake center needs to have a leader (physician) who has expertise in evaluating pain patients. The physician leader should be a fellowshiptrained algologist, who might be from any of the core specialties. There could be more than one physician on a given day who needs to evaluate patients if a large referral volume is present. One could also employ physician extenders (physician assistants, nurse practitioners, or residents and fellows) depending on staffing and educational needs.
Practice set-up Fellows clinic. One attending physician is paired with two fellows. The fellows are first to evaluate the patients and do the body of the history, review of systems, and physical examination. The attending staff visits with the patient to confirm history, repeats pertinent examination as needed, and provides final recommendations. Attendings clinic. Each attending staff physician sees his/her own patients, possibly with a physician extender also in attendance. The physician extender may aid in pro-
152 Table 2
Techniques in Regional Anesthesia and Pain Management, Vol 14, No 4, October 2010 that the assessment is ready to be sent and billed at the conclusion of the visit. Blended model. In a blended model, one physician may be working either alone or with an extender while a teaching service physician is working with residents and/or fellows. Conversely, one physician may be working with both physician extenders and fellows at the same time. Many programs have a small number of trainees and may not be able to allow each staff physician to have help.
Key success indicators
Key success indicators for a Multidisciplinary Pain Evaluation Center could be measured in several ways: 1. The triage process should reduce duplication of consultations. 2. The triage process should streamline referral of patients to the correct physician expertise the first time, thus eliminating unnecessary evaluations. 3. The triage process should increase patient and referral source satisfaction. 4. The integrated process should promote improvement in patient outcomes and evidence-based practice as measured by key metrics. 5. Standardized curricula are developed as result of increased collaboration and physician interactions, improving the educational environment. 6. Centralized patient and physician resources provide a rich environment for collaborative research in pain medicine. 7. The Pain Evaluation Center is at minimum financially neutral or a net profit center while adding value to the care environment
Equipment
curing additional resources, such as drug information teaching tools, prescriptions, and follow-up appointments. The extender may also electronically populate care notes such
Figure 3
For physician offices, basic equipment, such as small spine models, reflex hammers, tuning forks, stethoscopes, and other small equipment, is all that is necessary. For procedure suites, vital signs monitors capable of monitoring pulse oximetry, blood pressure, and electrocardiogram are necessary for sedation cases. Fluoroscopy machines and monitors, ultrasound machines, radiofrequency lesion generators/ probes, fluoroscopy tables, infusion pumps, and other small equipment are necessary for most interventional practices. Many university programs may not have available space, or may have rules about which areas can use such equipment, sometimes becoming a barrier to effective practice. For example, multifunction imaging suites, such as flat detector
A SWOT analysis.
Huntoon
Academic Pain Medicine Practice Design
computed tomography suites with digital subtraction angiography, biplanar fluoroscopy, or 3D ultrasound may only be allowed in a radiology practice in some settings, thus limiting which specialists can be credentialed to do the procedures that require such equipment.2 Many universities also have capital equipment budgets, thus some pieces of equipment may require presentation to committees or budgetary authorities to be procured.
Room and physical needs As a rule of thumb, in an academic practice of pain medicine, each clinician evaluating patients should have a minimum of three to four examination rooms for optimal patient flow. For procedures, ideally these would be batched together on a given physician’s calendar in half-day or fullday blocks. This allows for the efficiency of doing several procedures in a row. Medical assistants can help prepare trays and clean rooms; fluoroscopy technical personnel can be available to assist as well. It is inherently inefficient to go back and forth from new evaluations and follow-ups to short and long procedures. In this type of model, each physician needs to have his/her own procedure room available at all times to make the model workable. Otherwise, physicians end up competing for fluoroscopy at similar times, whereas at other times, the machine is not in use.
Educational model Rotations Residents and fellows should have specific rotations that have well articulated structure, goals and objectives, evaluation metrics, and remediation pathways. These should be based on the Accreditation Council for Graduate Medical Education (ACGME) curriculum requirements. ACGME requirements have been peer-reviewed and instituted for all programs currently accredited.3 In the modern decade, the availability of web-based learning through lecture series, procedural videos, simulations centers, and anatomical skills laboratories may allow content to be available at convenient times for the learners. Other web-based content might include patient care help, such as opioids converter software, drug titration schedules, care pathways or algorithms, physical exercise templates, dictations templates, emergency procedure pathways, and many others.
Research/database In many university practices, it is increasingly necessary to track outcomes to prove the efficacy of specific practice paradigms and compare with other universities, such as the University Health System Consortium.4 These are wonderful benchmarking tools that encourage improvement. Data
153 may be entered by patients, in some cases, with handheld devices, and the data can then be manipulated and “mined” by researchers to decipher important care trends.
Implementation (roll-out schedule) An important part of any strategic plan is the implementation phase. Generally speaking, the new processes should be implemented in a controlled fashion, with only one “changed process” at a time. The name of the process is not important, but descriptors such as “pilot program” denote that something new is going on, and most people will generally try to be helpful, and perhaps be forgiving of problems that might come up. Referrers should be made aware of changes, and their input sought soon after initial implementation to assess for opportunities for improvement. The U.S. Army calls these “after action reviews.”5 If implementation is not done with a thoroughness in planning, care of the patient could be compromised. For example, the process of Intraspinal Drug Delivery System refill or medication change could have disastrous consequences if a dosing error is made and there are not fail-safe plans in effect. A patient could be sent home with far too much medication infusing and simply lapse into a drug-induced coma.6
Conclusions Developing a new academic practice within an established medical center can be a daunting task. Seemingly, the administrative, educational, research, and clinical missions may all need improvement. Prioritizing change is an important part of the challenge. Slow incremental work, harnessing the creative energies of core personnel, and working together in care teams (along with a little lucky break here and there) and unwavering support are critical to success.
Acknowledgments The author wishes to thank Mary M. Schrandt (MAOM) for her help with the SWOT analysis.
References 1. Available at: http://www.pain101.com/PainDoctors/DirectoryOfPain DoctorsCARFlist.aspx. Accessed August 23, 2010 2. Orth RC, Wallace MJ, Kuo MD: C-arm cone-beam CT: general principles and technical considerations for use in interventional radiology. J Vasc Interv Radiol 19:814-821, 2008 3. ACGME program requirements for graduate medical education in pain medicine (effective July 1, 2007). Available from: http://www.acgme. org/adspublic/. Accessed August 23, 2010 4. Available at: http://www.uhc.edu/. Accessed August 23, 2010 5. Available at: http://www.au.af.mil/au/awc/awcgate/army/tc_25-20/ chap1.htm. Accessed August 23, 2010 6. Coffey RJ, Owens ML, Broste SK, et al: Medical practice perspective: identification and mitigation of risk factors for mortality associated with intrathecal opioids for non-cancer pain. Pain Med 11:1001-1009, 2010