April 30, 2020

Taking the Pain out of Implementing Changes in Practice

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Taking the Pain out of Implementing Changes in Practice

Timothy J. Atkinson, Pharm.D., BCPS, CPE

Clinical Pharmacy Specialist, Pain Management, Director, PGY2 Pain Management and Palliative Care Residency, VA Tennessee Valley Healthcare System, Murfreesboro, Tennessee

Timothy J. Atkinson is Clinical Pharmacy Specialist in Pain Management at the VA Tennessee Valley Healthcare System (TVHS) in Murfreesboro, Tennessee, where he specializes in complex and high risk pain medication management through direct patient care and electronic consult services within the regional referral pain clinic. He also is Director of the ASHP-accredited PGY2 Pain Management and Palliative Care Residency program at TVHS and represents pain management on the national VA Residency Advisory Board. 

Dr. Atkinson earned a Doctor of Pharmacy degree at Lake Erie College of Osteopathic Medicine School of Pharmacy in Erie, Pennsylvania. His residency training was at the Department of Veterans Affairs—PGY1 pharmacy residency at VA Western New York Healthcare system in Buffalo and PGY2 residency in pain management and palliative care pharmacy at Albany Stratton Veterans Affairs Medical Center in Albany, New York. He is a certified pain educator and board certified pharmacotherapy specialist.

Dr. Atkinson is a strong advocate for expansion of clinical pharmacy led pain medication management. His research interests include opioid equivalencies, serum level monitoring, pain management in specialty disease states, and the elderly. In 2019, he won the VA Clinical Pharmacy Practice Office’s Mental Health/Pain Strong Practice competition, and he was TVHS PGY1 preceptor of the year in 2018.


Which of these will be your first priority when planning to improve your clinical practice related to pain management and safe use of opioids?

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Many of you have likely identified changes that could be made to your practice to improve pain management and the safe use of opioid analgesics but have experienced roadblocks to process improvement. How do you achieve meaningful practice changes when you encounter these barriers?

Let me outline four basic strategies that I have found effective to expand my pain practice, whether that be starting new pain clinics, expanding practice into new areas or settings in primary care, or justifying new hires, and to obtain funding and lead expansion of my health system’s PGY2 pain management and palliative care training programs. These strategies have broad applicability beyond any one specialty, and while the strategies may seem simple or just common sense, there is a substantial difference between “simple” and “easy.” There are numerous barriers to implementing changes in practice but I have included those I believe are most common.

Barrier: Personal performance
Strategy: Be a teammate first, expert second

Performance is often the first major hurdle to making practice changes. After all, no matter how good your ideas may be, people have to believe in you as much as the idea itself. As a newly minted pain pharmacist, I found establishing myself in practice more difficult than anticipated. Challenges with daily workload, new team members, and unclear expectations slowed my progress. For me, once I changed my mindset to one of service, things quickly improved.

I suggest studying your practice workflow and its place in the department and health system (i.e., the big picture). This takes a great deal of honest self-awareness. See your practice through the eyes of your supervisor and/or team to determine how you can best serve them. Be willing to examine every aspect of what you do and its alignment with the big picture because those things are immediately within your control. My team very quickly realized that my strength was working with difficult patients, and they would be more productive if they referred these patients to me. Take ownership of everything in your practice area and be committed to improving it.1

Focus on accuracy first, then efficiency until your day-to-day responsibilities become easy. A high performer dedicated to practice excellence is who people want to support with new ideas. There is no substitute for performance.

Barrier: Lack of experience
Strategy: Experience…get some!

Having a vision is not enough. Sharing your vision effectively involves providing objective proof that the practice change you seek is necessary. If you do it well enough, others, including leadership, will champion the initiative and assist in pushing it through the approval process.

My initial request to start a pain residency was denied, but I was passionate about training and believed the way we trained pain specialists needed to change. How could I convince others or help them see my vision? First, I created a needs assessment, which involves collecting background information and summarizing evidence for the desired practice change. For me this involved surveying existing PGY2 pain management and palliative care programs to determine where they concentrated their training. I wanted to highlight gaps in practice and consequences of not taking action. Next, I wrote a review article that incorporated those results and demonstrated inadequacies of the current structure for training new pain pharmacists in chronic pain and substance abuse, which was the focus of the current opioid crisis.2 I presented the article to key decision makers, asking them to consider allowing me to start a residency program.

Another more common path for implementing a desired practice change is to leverage existing resources to pilot the change in a quality improvement study. This allows you to refine the workflow, collect data, and present real outcomes to key decision makers. As pharmacists, we practice evidence-based medicine, and effecting change without the ability to show outcomes is rarely successful.

I was successful at not only justifying starting my own residency training program in pain management but also in changing the focus for pain management expansion.2 Showing evidence for the potential success of your proposed change will also benefit from the increased exposure and scrutiny of a larger audience. Pay attention, and you will see that this process often leads to the creation of new positions and/or services.

Barrier: Difficult team or service member
Strategy: Focus on team building and providing service

Sooner or later you will work with a team member or clinician with some authority over you who is difficult and perhaps even hostile at times. It is also quite possible that you may need this individual’s support to implement any practice changes. While solid performance is key and outcomes are helpful at making changes, the most effective path forward is team building through service. In other words, find a way to make this team member’s job easier and demonstrate a willingness to perform additional work if necessary. This should not be interpreted as a recommendation to perform menial tasks. You have to be careful how you implement this strategy, or you can permanently find yourself with additional long-term responsibilities. Instead, what I do is make myself available, regardless of workload, to assist them with difficult patients who may require more time and/or monitoring, which decreases their frustration and increases my value to the team. It is remarkable how easily these relationships can change just by a simple expression of support and willingness to provide assistance.

There is an old saying, “people don’t care how much you know until they know how much you care,” or in this case, your ideas for practice change will sound like additional work until difficult relationships become supportive. A highly functioning team will always make you look good.

Barrier: Leadership
Strategy: Align your vision with leadership

Effecting change is often viewed as making others see and adopt your vision for how things should be. Talk to your leadership about their current priorities and even volunteer to assist with projects important to them when they do not benefit you. These conversations lead to valuable information about leadership’s concerns and vision for the best path forward. For example, if a hospital pharmacy supervisor does not have enough staff pharmacists to complete basic functions and fulfill pharmacy’s overall mission, then your request for an additional pain specialist will likely be ignored no matter your past performance or how well you documented the potential impact of the expanded pain team on improved patient care.

The creation of primary care-based pain clinics and new positions for pain specialists at my facility began with conversations with leadership about where they believed we needed pain support. I volunteered to pilot a clinic one day a week in primary care and formed relationships with primary care providers who were ecstatic for the help. Word spread quickly, and soon other clinics in our health system wanted access to these same resources, which resulted in new positions at several clinics.
To be successful, your proposed practice change needs to align with pharmacy leadership’s vision and demonstrate its potential to free up resources, promote efficiency, decrease costs, or elevate the standing of pharmacy service to facility leadership.


Advocating for improved patient care is one of the most important functions of pharmacists on healthcare teams. Thoughtfully consider your own barriers to improving patient care and reflect on the simple but effective strategies discussed here to determine where your efforts are best spent to overcome them.

More Information


  1. Willink J, Babin L. Extreme ownership: how U.S. Navy SEALs lead and win. 2nd ed. New York: St. Martin’s Press; 2017.
  2. Atkinson TJ, Gulum AH, Forkum WG. The future of pain pharmacy: driven by need. Integr Pharm Res Pract. 2016; 5:33-42.