Led Quality Improvement Research Articles

‘We listened and supported and depended on each other’: a qualitative study of how leadership influences implementation of QI interventions

BackgroundThere is growing recognition in the literature of the ‘Herculean’ efforts required to bring about change in healthcare processes and systems. Leadership is recognised as a critical lever for implementation...

Experiences of Newly Qualified Nurses' Engagement with Quality Improvement in Practice: A Qualitative Follow-Up Study.

Nurse education plays an essential role in preparing future nurses to engage with quality improvement (QI) initiatives in their organisations and improve patient care. However, frontline nurses continue to report that a lack of QI knowledge hinders their abilities to engage in improvement work. In the UK, student nurses are now trained in QI within their degree to enable them to contribute to improvements once qualified. This qualitative follow-up study investigated the sustainability of QI engagement in nurses who undertook QI training and a QI project during their degree and explored the factors influencing their engagement in QI once qualified. This paper followed the COREQ criteria to report upon 10 semi-structured interviews undertaken with registered nurses and focuses on their experiences of QI engagement post-registration. The data were investigated using an inductive thematic analysis and Nvivo 14. Five themes emerged: transition to a newly qualified nurse, QI knowledge decline, influencing factors (hierarchy, leadership, COVID-19 pandemic, data access and location), and skill transferability. This study showed that qualified nurses can sustain their QI knowledge and remain engaged with QI where they experience positive QI leadership and were exposed to ongoing QI activity in their preceptorship year. However, a lack of QI opportunities and a culture which does not consider QI a responsibility of new nurses is seen to hinder engagement. Educational institutions and practice partners require careful collaboration to assess and develop ongoing QI learning activities that support new nurses to engage in QI.

Implementation and improvement of a routine suicidal ideation screening process for an ambulatory, academic NCCN-designated center.

294 Background: From May – August 2021, outpatient suicidal ideation-related safety events nearly doubled from the three years prior at an academic NCCN center. This rise in events challenged staff and revealed improvement opportunities for suicide prevention, such as routine screening for suicidal ideation (SI) in the ambulatory setting. In addition, the COVID pandemic introduced an added layer of vulnerability to cancer patients, who are at an increased SI risk compared to the general population. Methods: From August 2021 - 2023, a multidisciplinary team developed and implemented a routine SI screening, intervention and escalation process that included a staff education program, a process-aligned EHR build, a metric dashboard, and a quality improvement-control plan. The vision was to identify all patients experiencing SI and support them with timely and compassionate care. A step-up metric target approach was used to set quarterly goals. The overarching goal was to screen at least 70% of eligible patients by the end of fiscal year 2024. The new process went live organization-wide on July 31, 2023. Following implementation, various improvement opportunities were identified with indicators including performance metrics, process audits, patient case reviews, and stakeholder feedback. Initial improvement efforts focused on clinics and sites that were screening < 25% between FY24 Q1 and Q2. Continued collaboration between Quality Improvement and clinic leaders revealed improvement opportunities in identifying eligible patients and staff screening practices. Impactful interventions addressed patient identification and staff coaching. Results: As a new process, the overall screening rate started at 0% and increased to 48% over FY24*. Conclusions: Overall, a new SI screening process was successfully implemented, and improved with diligent PDSA work, yet metric goals were not achieved. Many factors may have contributed to underperformance. Ongoing evaluation and collaboration with stakeholders are crucial for continued improvement. Beyond these efforts exists the social and cultural stigma of suicide, which may have limited the impact of improvement endeavors. Results may demonstrate further need for open and supportive discussion with staff, patients, and the larger healthcare community. Data time range: 7/31/23-5/21/24.* FY24 + Quarter Metric Goal Screening Rate Q1 40% 35.7% Q2 50% 34.5% Q3 60% 41.2% Q4 70% 47.8%

Is return on investment the appropriate tool for healthcare quality improvement governance?

PurposeIn this article, we outline our views on the appropriateness and utility of Return on Investment (ROI) for the evaluation of the value of healthcare quality improvement (QI) programmes.Design/methodology/approachOur recent research explored the ROI concept and became the genesis of our viewpoint. We reflect on our findings from an extensive research project on the concept of ROI, involving a multidisciplinary global systematic literature review, a qualitative and Delphi study with mental healthcare leaders from the United Kingdom National Health Service. Research participants included board members, clinical directors and QI leaders. Our findings led to our conclusions and interpretation of ROI against the broad QI governance. We discuss our views against the predominant governance frameworks and wider literature.FindingsROI is in-line with top-down control governance frameworks based in politics and economics. However, there is evidence that to be of better utility, a tool for the assessment of the value of QI benefits must include comprehensive benefits that reflect broad monetary and non-monetary benefits. This is in-line with bottom-up and collaborative governance approaches. ROI has several challenges that may limit it as a QI governance tool. This is supported by wider literature on ROI, QI as well as modern governance theories and models. As such, we question whether ROI is the appropriate tool for QI governance. A more pragmatic governance framework that accommodates various healthcare objectives is advised.Practical implicationsThis article highlights some of the challenges in adopting ROI as a QI governance tool. We signal a need for the exploration of a suitable QI governance approach. Particularly, are healthcare leaders to be perceived as “agents”, “stewards” or both. The evidence from our research and wider literature indicates that both are crucial. Better QI governance through an appropriate value assessment tool could improve clarity on QI value, and thus investment allocation decision-making. Constructive discussion about the utility and appropriateness of ROI in the evaluation of healthcare QI programmes may help safeguard investment in effective and efficient health systems.Originality/valueThe article raises awareness of QI governance and encourages discussions about the challenges of using ROI as a tool for healthcare QI governance.

Reviewing healthcare quality improvement initiatives: Best practices in management and leadership

This research paper explores best practices in management and leadership for healthcare quality improvement. Emphasizing the critical role of effective leadership, the study examines transformational leadership, interdisciplinary collaboration, and ethical considerations. Technological integration is identified as a critical enabler. Findings underscore the significance of patient-centric approaches and the need for enhanced training programs. Implications for healthcare practice and policy include prioritizing ongoing leadership education, integrating patient perspectives, and strategically investing in technology. The research highlights the interconnectedness of these elements in driving successful quality improvement initiatives. As healthcare systems strive for continuous enhancement, implementing these best practices promises to elevate patient outcomes, foster collaborative cultures, and contribute to the ongoing transformation of healthcare delivery. Keywords: Healthcare Quality Improvement, Leadership Best Practices, Transformational Leadership, Interdisciplinary Collaboration, Technological Integration.

Developing a Sustainable Quality Improvement Program in an Academic Center: The Experience of an Adolescent Unit.

Successful quality improvement (QI) efforts use a comprehensive, institutional QI framework and professional development, but literature describing implementing QI frameworks in Adolescent Medicine practices is sparse. We aimed to implement and increase the number of formally structured QI projects (primary aim) and the number of projects achieving a centerline (CL) shift (secondary aim) in our hospital's Adolescent Medicine Clinic. We used formal QI methodology to improve health outcomes by increasing the number of faculty with formalized QI education, creating interdisciplinary QI teams, and improving staff motivation. QI education was mandatory for Adolescent Medicine fellows and pediatric residents and encouraged for faculty and staff. The Divisional QI leadership team attended monthly meetings to review key driver diagrams, run and control charts, and receive intervention updates. All providers and staff received monthly updates, and the Hospital Quality and Safety Committee received biannual updates. We used run charts to share progress with primary and secondary aims. Since Q3 2014, the Adolescent Medicine team consistently achieved the primary aim of having 5 active projects in process, with 9 projects from Q1 2018-Q4 2020. For the secondary aim, a target of 50% of active QI projects attaining a sustained centerline shift was achieved in Q2 2018 and maintained in 16 of 20 quarters since. Clinicians can use QI methodology to improve health outcomes while facilitating professional development. For this initiative to succeed, institutional leadership must provide an infrastructure prioritizing meaningful QI involvement.

AB081. SOH24AB_239. A surgically led quality improvement initiative in surgical antibiotic prophylaxis (SAP): a one-year review of practice and change

AB081. SOH24AB_239. A surgically led quality improvement initiative in surgical antibiotic prophylaxis (SAP): a one-year review of practice and change

Physician insights on strategies for leading quality improvement

The Strategic Clinical Improvement Committee (SCIC) was established in 2015 to foster physician leadership in quality improvement (QI). In this study, we examined the experiences of physician committee members to determine leadership strategies perceived to support their involvement in QI.

Who are vaccine champions and what implementation strategies do they use to improve adolescent HPV vaccination? Findings from a national survey of primary care professionals

BackgroundImplementation science researchers often cite clinical champions as critical to overcoming organizational resistance and other barriers to the implementation of evidence-based health services, yet relatively little is known about who champions are or how they effect change. To inform future efforts to identify and engage champions to support HPV vaccination, we sought to describe the key characteristics and strategies of vaccine champions working in adolescent primary care.MethodsIn 2022, we conducted a national survey with a web-based panel of 2527 primary care professionals (PCPs) with a role in adolescent HPV vaccination (57% response rate). Our sample consisted of pediatricians (26%), family medicine physicians (22%), advanced practice providers (24%), and nursing staff (28%). Our survey assessed PCPs’ experience with vaccine champions, defined as health care professionals “known for helping their colleagues improve vaccination rates.”ResultsOverall, 85% of PCPs reported currently working with one or more vaccine champions. Among these 2144 PCPs, most identified the champion with whom they worked most closely as being a physician (40%) or nurse (40%). Almost all identified champions worked to improve vaccination rates for vaccines in general (45%) or HPV vaccine specifically (49%). PCPs commonly reported that champion implementation strategies included sharing information (79%), encouragement (62%), and vaccination data (59%) with colleagues, but less than half reported that champions led quality improvement projects (39%). Most PCPs perceived their closest champion as being moderately to extremely effective at improving vaccination rates (91%). PCPs who did versus did not work with champions more often recommended HPV vaccination at the earliest opportunity of ages 9–10 rather than later ages (44% vs. 33%, p < 0.001).ConclusionsFindings of our national study suggest that vaccine champions are common in adolescent primary care, but only a minority lead quality improvement projects. Interventionists seeking to identify champions to improve HPV vaccination rates can expect to find them among both physicians and nurses, but should be prepared to offer support to more fully engage them in implementing interventions.

O162: A Surgically Led Quality Improvement Initiative in Surgical Antibiotic Prophylaxis (SAP): A One-year Review of Practice and Change in an Irish Context

Abstract Introduction Amongst growing concerns of antimicrobial resistance, surgical site infection (SSI) remains one of the most common healthcare associated infections. Optimal use of Surgical Antibiotic Prophylaxis (SAP) is critical. Quality Improvement (QI) in this area is often led by pharmacists or infection specialists. Methods A two-year, surgically led QI initiative was established in two Irish hospitals in July 2022. Baseline level of compliance with local guidelines with regard four aspects of SAP (indication, agent, timing, and duration) was audited. Change interventions aimed at specific aspects of compliance were trialled. Interventions included; guideline education for prescribers, process changes (editing the sign in/time out sheet) and the application of prescribing nudges (antibiotic duration sticker in post-operative drug chart). Results A total of 620 patient records were audited over one year. Pre-intervention compliance with all four aspects of SAP was observed in only 72/303 patients (23.7%). Educational interventions with surgical prescribers led to improved compliance with agent choice (43.5% (71/165) to 65.3% (94/144)). Education of anaesthetists showed improved timing of administration with 10.8% (14/129) of SAP administered post-incision post-intervention compared to 18.9% (21/111) pre-intervention. Application of the SAP duration sticker showed an overall decrease in mean SAP duration from 70.4 hours to 28.2 hours in those patients requiring more than a single SAP dose. Overall compliance levels have improved, thus far, from 23.7% to 39.8%. Conclusion Increasing compliance with SAP guidance is a challenge. A multi-faceted, institution specific, surgically led approach grounded in QI methodology shows promise.

APP Lead Quality Improvement Initiative: Optimizing Referrals from Clinic to Transplant/Cell Therapy Coordination Team

APP Lead Quality Improvement Initiative: Optimizing Referrals from Clinic to Transplant/Cell Therapy Coordination Team

Review: Medical directors - Is there a need for reform?

Medical leadership remains integral to the health system amidst a growing burden of ill health and disease, rising patient expectations and medical and technological advancements. The study objectives were to (a) provide a perspective through a rapid review of medical director roles and responsibilities in public and private hospital settings across several Organisation for Economic Co-operation and Development (OECD) and Non-Organisation for Economic Co-operation and Development countries, and (b) provide recommendations on how health system performance could be strengthened. A rapid review of Medical Director job descriptions in public and private hospitals was carried out. Medical Directors are influential leaders in organisational decision-making and quality improvement; however, their role has shifted from clinical oversight to several managerial and leadership roles. We report some variation in their role and responsibilities, in the 'intensity of job requirements' and 'complexity of managing resources' dimensions. The changing expectations of medical directors and the variation in their roles and responsibiliteis may contribute to inefficiencies and misalignment within health systems. There may be a need to pursue reform to assure alignment with health system objectives, albeit reform may require different approaches to meet the needs of different health systems. Further research is needed to explore how reform of medical directors' roles and responsibilities can be quantified to demonstrate improvement within health systems.

Clinical Nurse Specialists Using Evidence-Based Practice to Prevent Falls

Abstract Purpose/Objectives The purpose of this quality improvement project was to reduce inpatient falls and falls with injury by implementing the Hester Davis Fall Program, a comprehensive, evidence-based prevention program, with the leadership of clinical nurse specialists. Description of the Project/Program The Plan-Do-Study-Act model was utilized to implement the program at 2 adult acute care facilities. Clinical nurse specialists collaborated with nurse managers to guide planning, implementation, and evaluation of patient outcomes. Routine meetings with Hester Davis sustainability coaches and access to data analytic dashboards provided visibility of audit data, allowing for the intentional selection of targeted strategies to improve risk assessment scoring and implementation of appropriate interventions. Outcome Although both facilities demonstrated overall favorable trends in fall rates, one facility demonstrated rates less than the National Database of Nursing Quality Indicators mean. In the 9 months following implementation, total falls for both facilities decreased from 744 to 692 for the same period in the previous year, resulting in estimated cost-savings of $202 176 to $491 400. Conclusion Clinical nurse specialists play a key role in the successful implementation of evidence-based programs. As organizations look to improve quality measures, it is vital that senior nurse leaders ensure the availability of appropriate resources including the identification of individuals with the appropriate skill set to lead quality improvement.

Costs and intermediate outcomes for the implementation of evidence-based practices of midwifery under a MIDWIZE framework in an urban health facility in Nairobi, Kenya

BackgroundThree evidence-based midwife-led care practices: dynamic birth positions (DBP), immediate skin-to-skin contact (SSC) with zero separation between mother and newborn, and delayed cord clamping (DCC), were implemented in four sub-Saharan African countries after an internet-based capacity building program for midwifery leadership in quality improvement (QI). Knowledge on costs of this QI initiative can inform resource mobilization for scale up and sustainability. MethodsWe estimated the costs and intermediate outcomes from the implementation of the three evidence-based practices under the midwife-led care (MIDWIZE) framework in a single facility in Kenya through a pre- and post-test implementation design. Daily observations for the level of practice on DBP, SSC and DCC was done at baseline for 1 week and continued during the 11 weeks of the training intervention. Three cost scenarios from the health facility perspective included: scenario 1; staff participation time costs ($515 USD), scenario 2; staff participation time costs plus hired trainer time costs, training material and logistical costs ($1318 USD) and scenario 3; staff participation time costs plus total program costs for the head trainer as the QI leader from the capacity building midwifery program ($8548 USD). ResultsAt baseline, the level of DBP and SSC practices per the guidelines was at 0 % while that of DCC was at 80 %. After 11 weeks, we observed an adoption of DBP practice of 36 % (N = 111 births), SSC practice of 79 % (N = 241 births), and no change in DCC practice. Major cost driver(s) were midwives’ participation time costs (56 %) for scenario 1 (collaborative), trainers’ material and logistic costs (55 %) in scenario 2(collaborative) and capacity building program costs for the trainer (QI lead) (94 %) in scenario 3 (programmatic). Costs per intermediate outcome were $2.3 USD per birth and $0.5 USD per birth adopting DBP and SSC respectively in Scenario 1; $6.0 USD per birth adopting DBP and $1.4 USD per birth adopting SSC in Scenario 2; $38.5 USD per birth adopting DBP and $8.8 USD per birth adopting SSC in scenario 3. The average hourly wage of the facility midwife was $4.7 USD. ConclusionImproving adoption of DBP and SSC practices can be done at reasonable facility costs under a collaborative MIDWIZE QI approach. In a programmatic approach, higher facility costs would be needed. This can inform resource mobilization for future QI in similar resource-constrained settings.

Comparing Cesarean Birth Utilization Between US Hospitals: A Demonstration of the Robson Ten-Group Classification System for Use in Quality Improvement and Benchmarking.

The World Health Organization-endorsed Robson Ten-Group Classification System (TGCS) is a standard reporting mechanism for cesarean birth, yet this approach is not widely adopted in the United States. To describe the application and utility of the TGCS to compare hospital-level cesarean births rates, for use in quality improvement and benchmarking. We conducted a descriptive, secondary data analysis of the Consortium on Safe Labor dataset using data from 228 438 women's births, from 2002 to 2008, in 12 sites across the United States. We stratified births into 10 mutually exclusive groups and calculated within-group proportions of group size and cesarean birth rates for between-hospital comparisons of cesarean birth, trial of labor after cesarean (TOLAC), and labor induction utilization. There is variation in use of cesarean birth, labor induction, and TOLAC across the 12 sites. The TGCS provides a method for between-hospital comparisons, particularly for revealing usage patterns of labor induction, TOLAC, and cesarean birth. Adoption of the TGCS in the United States would provide organizations and quality improvement leaders with an effective benchmarking tool to assist in reducing the use of cesarean birth and increasing the support of TOLAC.

Trainee Led Quality Improvement Addressing Lack of Transparency in Referral Processes for Psychiatric Reviews in the Maudsley Adolescent Mental Health Service

AimsThe Specialist Adolescent Mental Health Service at the Maudsley Hospital provides multi-disciplinary mental health care to adolescents in London. There is currently no policy by which non-medical members of the multi-disciplinary team can request a psychiatric review for their patients. Staff feedback revealed problems with the medical review referral process to be a lack of clarity on how to make referrals, and a lack of transparency (e.g. referral outcome, approximate waiting time).This projected aimed to improve the clarity of the process for requesting psychiatric reviews and to develop skills in leadership as a future child psychiatrist.MethodsWe designed and introduced a referral form and integrated waiting list. Next we developed a policy document for making referrals. Finally we modified the referral form so that when submitted, it automatically updated the integrated waiting list. At the outset and after each intervention we resurveyed the staff.ResultsAt the outset 71% of staff reported finding the process somewhat unclear, while 29% reported finding the referral process neither clear nor unclear. Following the final change 100% staff each reported finding the process very clear or somewhat clear.ConclusionThe changes we implemented resulted in a clearer and more transparent referral process for medical reviews. We anticipate that this improved staff satisfaction will equally translate into some benefits for patient care, such as more clarity around when a medical review can be expected and what it might entail.

Factors of a physician quality improvement leadership coalition that influence physician behaviour: a mixed methods study

BackgroundA coalition (Strategic Clinical Improvement Committee), with a mandate to promote physician quality improvement (QI) involvement, identified hospital laboratory test overuse as a priority. The coalition developed and supported the...

Improving the multidisciplinary Team Brief; a trainee led quality improvement project.

Background: The project was developed following the NatSSIPs2 consultation and recent publication to improve patient safety, team working, and efficiency.1 To meet the Team Brief standards and improve their quality we wanted to introduce a formalised approach at the Royal London Hospital. Methods: Quality improvement (QI) methodology was used to guide the project during the ‘CANDLE’ (Curriculum and Delivery Learning Event) regional QI training. A driver diagram was created and stakeholders analysed. The project began in September 2022 with the aim to implement the Team Brief standard by January 2023. Results: A snapshot audit and staff survey were performed in October 2022. Thirteen Team Briefs from a broad range of specialties were audited, and 27 staff members responded to the survey. The results of this were used to define the issues with team brief and to create a multidisciplinary team brief proforma. This was initially trialled over a 2-week period from 16 to 29 November. After the initial trial, the design was refined based on feedback. Well-being was included with individual and team ‘RAG’ (red, amber, green) ratings and inclusion of ‘Greatix’ QR code to encourage reporting of good feedback. Appropriateness of staffing was also recorded. The use of the new proforma was audited between 26 November 2022 and 20 January 2023. Usage was sporadic, only 38% of lists (183/480), except in the orthopaedic trauma theatres where uptake was much higher. The staff in these theatres were interviewed to ascertain why uptake was so good; it was because of nurse in charge adoption. The project was presented at local audit meetings, and a QI celebration event. This led to buy-in from the senior management team. The proforma was reintroduced in February 2023. The project became self-sustaining with recruitment of other members to the QI team and became imbedded in the local culture. Feedback from the most recent theatre audit meeting was excellent. From 20 February to 10 March 2023 the proforma was used in 79.3% (119/150) of main theatre lists. Conclusion: The multidisciplinary Team Brief project has introduced a proforma which has been adopted consistently in theatres and created a self-sustaining change. The proforma includes structured organisational information to improve patient safety and communication but also focusses on team working, psychological safety, and well-being. The CANDLE course for curriculum and delivery of QI supported trainee leadership, teamwork, and delivery of QI. 1.National Safety Standards for Perioperative Care 2. Centre for Perioperative Care. January 2023. Available from https://cpoc.org.uk/sites/cpoc/files/documents/2022-12/CPOC_NatSSIPs2_Summary_2023.pdf (accessed March 2023)

547 Volume-based Feeds: A Quality Improvement Project for Better Nutrition

Abstract Introduction Nutrition is a critical component to recovery in burn patients. Their heightened metabolic demand is well established. In our burn population, patients often received significantly less volume of feeds than they were prescribed, primarily due to stoppages for sedations and procedures. We, therefore, developed a quality improvement (QI) project to help improve the quantity of feeds received. Methods Under the direction of nursing QI leadership and our burn nutritionist, we established an outcome measure of increasing average feeds received from baseline 68% of those prescribed to greater than 75% of those prescribed. Using a process of iterative changes, we initially developed a calculator for volume-based feeds to make up the volume lost during times tube feeds were paused. Nursing staff gave feedback, and we ultimately used a chart for adjusted volumes based on the total 24 hour goal and number of hours remaining in which to make up the goal. On a bi-weekly basis, we examined the amount of tube feeds as a percent of total prescribed prior to and after the interventions. Results Early results have demonstrated improvements in the percent of tube feeds a burn patient is receiving. Prior to the interventions patients were receiving about 68% of the prescribed tube feeds and within 6 weeks of project initiation, patients were receiving 82% of the prescribed tube feeds (Figure 1). In addition, variability in feeds received decreased markedly, as have number of days above the target. Conclusions In conclusion, this has been an effective QI intervention as we surpassed our initial target within 6 weeks of initiation. Next steps are to consider increasing the target to 90% of prescribed feeds, as well as investigating adequacy of feeds using nitrogen balance in select patients. Future directions for this project include assessing outcome measures such as graft take and hospital length of stay. Applicability of Research to Practice Purpose is to share our methods in quality improvement to aid others efforts facing similar challenges in the care of the critically ill burn patient.

Real-World Observational Evaluation of Common Interventions to Reduce Emergency Department Prescribing of Opioid Medications.

Prior work on opioid prescribing has examined dosing defaults, interruptive alerts, or "harder" stops such as electronic prescribing of controlled substances (EPCS), which has become increasingly required by state policy. Given that real-world opioid stewardship policies are concurrent and overlapping, the authors examined the effect of such policies on emergency department (ED) opioid prescriptions. The researchers performed observational analysis of all ED visits discharged between December 17, 2016, and December 31, 2019, across seven EDs of a hospital system. Four interventions were examined in chronological order, with each successive intervention added on top of all previous interventions: 12-pill prescription default, EPCS, electronic health record (EHR) pop-up alert, and 8-pill prescription default. The primary outcome was opioid prescribing, which was described as number of opioid prescriptions per 100 discharged ED visits and modeled as a binary outcome for each visit. Secondary outcomes included prescription morphine milligram equivalents (MME) and non-opioid analgesia prescriptions. A total of 775,692 ED visits were included in the study. Compared to the preintervention period, cumulative reductions in opioid prescribing were seen with incremental interventions, including after adding a 12-pill default (odds ratio [OR] 0.88, 95% confidence interval [CI] 0.82-0.94), after adding EPCS (OR 0.7, 95% CI 0.63-0.77), after adding pop-up alerts (OR 0.67, 95% CI 0.63-0.71), and after adding an 8-pill default (OR 0.61, 95% CI 0.58-0.65). EHR-implemented solutions such as EPCS, pop-up alerts, and pill defaults had varying but significant effects on reducing ED opioid prescribing. Policy makers and quality improvement leaders might achieve sustainable improvements in opioid stewardship while balancing clinician alert fatigue through policy efforts promoting implementation of EPCS and default dispense quantities.