Non-Pharmacologic Pain Management PI PDSA form

Non-Pharmacologic Pain Management Performance Improvement

The Illinois Academy of Family Physicians (IAFP) oversees and manages the Non-Pharmacologic Pain Management Education Performance Improvement project. This initiative aligns with the American Board of Family Medicine (ABFM) Performance Improvement standards and fulfills Meaningful Participation requirements.

To receive completion credit and for IAFP to report your participation to the ABFM, you must answer all questions in the project.

CME Credit: The AAFP has reviewed Non-Pharmacologic Pain Management for Family Physicians Performance Improvement and deemed it acceptable for up to 20.00 Performance Improvement AAFP Prescribed credit(s). Term of Approval is from 03/20/2026 to 03/19/2028. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

ABFM Approval:This activity has been approved by the American Board of Family Medicine (ABFM) for Family Medicine Certification credit. Term of approval is for 02/17/2026 to 03/19/2028

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn twenty (20) Performance Improvement points in the American Board of Family Medicine (ABFM) Family Medicine Certification program.

Questions? Please contact Kate Valentine at kvalentine@iafp.com

Please complete and submit this form when your project is finished. This form cannot save your progress.

If you need to track your work over time, download and use the fillable PDF or the Word document.

For additional guidance on this PSDA cycle, including the sample AIM and learning objectives, please refer to the PI website.

Name *

Enter your name exactly as it is within the ABFM Physician Portfolio

ABFM Board ID *

ABFM Board IDs are 6 digits and being with a 1 or zero

AAFP Member #*

Needed to submit CME Credits to the AAFP

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email Address*

example@example.com

Start Date of Participation*

Date

End Date of Participation*

Date

Each individual physician must truthfully respond to the following questions:*

I was engaged in planning and executing the project.I was involved in the changes implemented during this project.I regularly reviewed data in keeping with the project's measurement plan.I participated in team meetings for the project.

Describe your individual involvement in the project:*

PLAN

Implement a structured, evidence-based pain management protocol that includes:

Assessment and Documentation

Use a functional assessment tool such as the PEG Scale or Oswestry Disability Index.
Document patient‑identified functional goals.

Safety and Monitoring

Ensure an opioid treatment agreement is signed and on file for all patients receiving chronic opioid therapy.
Review the state Prescription Drug Monitoring Program (PDMP) at each prescribing encounter.

Nonpharmacologic Interventions Incorporate at least one nonpharmacologic treatment option, such as:

Physical therapy or movement‑based programs.
Cognitive‑behavioral therapy or mindfulness‑based strategies.
Lifestyle counseling focused on sleep, activity, ergonomics, and nutrition.
Stress management education
Behavioral health referral as appropriate.

AIM - What is the goal of this project? The aim of this Performance Improvement activity is to improve chronic pain management by improving functional outcomes, increasing use of nonpharmacologic interventions, and reducing opioid reliance among patients with chronic non-cancer pain within 90 days *

Note: Physicians may adjust or narrow the AIM to fit their practice needs, provided the revised AIM remains within the scope of improving function, increasing use of nonpharmacologic treatments, and supporting safe opioid practices for patients with chronic non‑cancer pain

Objectives - What quality gap is the project addressing, and what are its primary objectives? Example: 1. Enhance safe opioid prescribing practices (dose, duration, monitoring). 2. Increase use of nonpharmacologic pain management interventions. 3. Improve documentation of functional goals and pain assessments 4. Increase patient engagement in self‑management strategies.*

Plan - Which measures will you use? What changes or improvements will you test? How does this plan align with practice goals?*

These measures should align with the aim statement and indicate whether the implemented changes are leading to improvements.

Stakeholder Engagement - Who are the key stakeholders, and how were they involved in developing this plan? How will their feedback be incorporated?

Anticipated Challenges - What potential barriers or challenges might arise during implementation? How will these challenges be addressed?

Team - Who is involved in the plan, and what are their roles?*

Improvement Results – What are the baseline and follow-up percentages or numbers that reflect performance on the stated measures?.*

Measures of success - How will you know the change is an improvement?

DO

Example:

During the 90‑day project period, clinicians will:

Identify all patients receiving chronic opioid therapy for ≥3 months.
Review and update individualized pain management plans.
Educate patients on nonopioid and nonpharmacologic treatment options.
Set or revise functional goals using a simple SMART framework (e.g., walk 10 minutes 5 days/week, practice relaxation 3 times/week).
Ensure all opioid agreements are completed and documented.
Adjust opioid prescriptions to the lowest effective dose and document functional improvement goals.
Initiate nonpharmacologic referrals or provide direct interventions as appropriate.

Interventions Implemented - Describe actions taken during the 90-day period.*

Patient/Participant Involvement - How were patients informed or educated?*

Observations - What happened during implementation? How were the implemented changes documented or tracked?*

STUDY

Example:

Evaluate the following measures to assess improvement:

Changes in patient pain and functional scores using validated tools (PEG or Oswestry).
Number or percentage of patients participating in nonpharmacologic interventions.
Opioid prescribing patterns including MME per day, duration, and whether tapering was initiated when appropriate.
Adherence and documentation of opioid treatment agreements.

Physicians will analyze whether the interventions improved patient function, reduced opioid reliance, or increased patient engagement in self‑management activities.

Results - Compare the outcomes to the measures of success. Pain/functional score changes: intervention participation: Opioid prescribing changes (MME/day): Opioid agreement completion:*

Analysis of Variance - Were there any unexpected outcomes, both positive and negative? How did these outcomes compare to the expected results?*

Impact on Equity - Did the interventions affect different groups of participants differently? How were equity considerations addressed?

Data - Attach de-identified aggregate results data

Lessons Learned - What insights or reflections were gained from the implementation process?*

ACT

Based on findings from the Study phase, physicians will:

Identify barriers limiting improvement (access issues, workflow challenges, patient engagement).
Adjust clinic workflows (for example, adding EHR templates or reminders).
Strengthen collaboration with physical therapy, behavioral health, or pain specialists.
Enhance patient education materials and revisit goal‑setting as needed.
Sustain successful changes by embedding new workflows or templates into the EHR.

Next Steps - What actions will be taken based on the findings and lessons learned? How can the approach be adjusted for better outcomes next time?*

Example: Adopt: Fully implement the change. Adapt: Make modifications and test again. Abandon: Discontinue the change

Sustainability - What steps will ensure the improvements are maintained over time? Are there plans for ongoing monitoring?

Scalability - Can this approach be expanded to other groups, settings, or regions? What adjustments would be necessary for broader implementation?

Feedback Incorporation - How will lessons learned be shared with the team or stakeholders? How will feedback inform future PDSA cycles?

Notes:

Optional information: Attach any additional files or references relevant to the project.

Outcomes: 20% of patients with chronic pain participate in at least one nonpharmacologic intervention. ≥15% improvement in functional or pain‑interference scores using a validated tool. ≥10% percent reduction in average daily MME among chronic opioid users. 100% documentation of opioid agreements.*

ATTESTATION

Required by the ABFM

Each individual physician must truthfully respond to the following questions.

I was engaged in planning and executing the project*

YesNo

I was involved in the changes implemented during the project.*

YesNo

I regularly reviewed data in keeping with the project’s measurement plan*

YesNo

I participated in team meetings for the project*

YesNo

Describe your individual involvement in the project, including lessons learned: