spilled medication

Data-Driven Opioid Guardianship: A Health Care System’s Blueprint for Change

Drug overdose is the leading cause of death in the United States and opioid addiction is driving this epidemic. In 2016, over 214 million prescriptions were written for opioids. On average, 115 Americans die every day after overdosing on opioids. Deaths from prescription opioids have more than quadrupled since 1999. The U.S. Department of Health and Human Services declared opioid abuse a nationwide public health emergency in 2017. 

Methodist Health System implemented an Opioid Guardianship program, a large-scale project spanning across the health system, focused on adhering to all opioid-related regulatory requirements and reducing unnecessary opioid prescription and usage.

“Methodist health system has been committed to reducing unnecessary opioid prescribing by developing expertise and a data infrastructure to support surveillance and identification of potential vulnerabilities for patients. Through this data-driven process, issues have been mitigated to improve patient safety and shared throughout the system. Partnering with providers, patients and families has been an integral part in reducing unnecessary opioid prescriptions and advocating for non-narcotic modalities when appropriate,” stated Dr. Ann Polich; Vice President of Quality, Safety and Population Health.

The team established the following project goals:

Project Goals

  • Create a roadmap for Opioid Guardianship across Methodist health system
  • Adhere to all related regulatory requirements
  • Reduce unnecessary narcotics prescribing and usage

The metrics being measured are opioid prescribing at discharge – Morphine Milligram Equivalent (MMI) as well as total opioid pills prescribed.

The Players

Task Force Teams are listed below; for a list of the action items within each Task Force can be found on the blueprint, housed on the Nebraska Hospital Association Web site.

A cross-functional steering committee provides oversight and prioritization to efforts across the health system. Quarterly Steering Committee meetings provide a platform for all task force teams to report on progress and increase collaboration and minimize duplicated efforts. A dedicated project manager was assigned to oversee the Opioid Guardianship program as well as help guide and prioritize the efforts of each of the six Task Force teams.

  1. Pharmacy Task Force
  2. Clinical Task Force
  3. Hospital Enhanced Recovery Task Force
  4. Nursing/Joint Commission Task Force
  5. Community Task Force
  6. Data Task Force

“I commend the Methodist Health System for identifying a need and creating the Opioid Guardianship Team. We all must work together to help combat the issue of opioid misuse,” shared Tammy Wagner, RN, LSSGB, CADDCT, CDP; Great Plains QIN Quality Improvement Advisor.

Instituting a healthcare system-wide Opioid Guardianship Program requires leadership support, strong project management and continuous improvement expertise. Creating an opioid database/dashboard ensures a data-driven approach to institute change by identifying and reducing unnecessary prescribing and adhering to state and national regulatory requirements.

“Our team has taken a system-wide approach using data to drive our decisions and improvements. The successes have been greatly attributed to our multi-disciplinary teamwork, dedication to improvement and collaboration with community partners,” added Kelsey Haswell, MBA, SSBB; Lean Improvement Specialist.

Learn more by accessing the Nebraska Methodist Health System Blueprint for Opioid Guardianship via the Nebraska Hospital Association Web site.

Great Plains has been assisting health systems across Nebraska identify potential opioid issues in the community with the opioid prescribing report for prescribers, counties, health systems and communities. The GPQIN website has a wealth of information for your organization or health system to begin your opioid stewardship/guardianship teams. Additional resources are included below.


On August 22, 2019 at Noon (CT), the Nebraska Coalition for Patient Safety is hosting a WebEx on the timely topic of antibiotic stewardship and pain management; focusing on implementation, policies and prescribing practices. The invitation to attend is open to all healthcare professionals. Learn more.

Maps – Opioid Prescribing Rates by County
KS Opioid Prescribing Rates by County
ND Opioid Prescribing Rates by County
NE Opioid Prescribing Rates by County
SD Opioid Prescribing Rates by County

Additional Resources
Prescription Pain Pad
Pain Management Pocket Guide