Pain management is high priority for surveyors
Common set of measures developed by 3 groups
As three of the nation’s leading health care organizations develop a common set of evidence-based measures for evaluating the appropriateness and effectiveness of pain management, the first year under the Joint Commission on Accreditation of Healthcare Organizations’ pain standards indicates that documentation can be the weak point for many otherwise good programs.
The two-year project to develop evidence-based measures is sponsored by the American Medical Association (AMA) in Chicago, the Joint Commission, and the National Committee for Quality Assurance (NCQA). (For more on the measures, see "Groups team up to develop evidence-based measures," in this issue.) The new measures are intended to help you determine how well you are managing patients’ pain, an important issue now that it is clear the new pain management standards are a big priority for Joint Commission surveyors.
Those who have been surveyed recently say that surveyors may smile nicely and nod while you explain how much you’ve improved your pain management over the past year, but the only thing that matters is what you can show them on paper.
The Joint Commission started enforcing its new pain standard Jan. 1, 2001, and the first year shows that surveyors are taking them seriously. The standards require that all health care providers assess patients for pain regularly and then effectively manage their pain. In addition, RI.1.2.8 requires that providers educate all relevant professionals in pain assessment and management; educate patients and families regarding their roles in managing pain, as well as the potential limitations and side effects of pain treatments; and communicate to patients and families that pain management is an important part of care.
As simple as that may sound, actually complying with the standard can be difficult. Those who have been surveyed recently say documentation can be a weakness even in a good pain program. Carol Curtiss, RN, MSN, a clinical nurse specialist consultant in Greenfield, MA, helps quality professionals prepare for Joint Commission surveys, and she tells Hospital Peer Review that the pain standards have been a big focus for the past year and that will continue in 2002.
"There’s no doubt this is a standard they’re taking very seriously and, because it is relatively new, the surveyors want to see what you’re doing," she says. "For many hospitals, this is something new to them and they really have a lot of work to do to comply with the standard, so surveyors want to see what you’re doing."
Curtiss says her clients across the country are reporting that the Joint Commission surveyors seem to be asking the same questions about the pain standard. The surveyors want to know how you assess a patient’s pain, what you do in response, what you do if your first efforts don’t work, and how pain management is improving at the facility. Surveyors also are concerned with whether you routinely assess pain — for all patients and at regular intervals — as required by the standard. The makeup of your pain committee also is important, Curtiss says.
"They will want to see that you have an interdisciplinary team in place," she says. "The standard specifically says you need a multidisciplinary team with representatives from all clinical areas, not just doctors or oncology nurses."
Because the standard is only a year old, Curtiss says surveyors may understand if you still have work to do. But if that is the case, she says, you must show that you have made great improvements and have plans for continuing. Including a pain management indicator in your quality improvement program can be a good step: One option is to monitor the responses when patients are screened for pain.
The patient’s initial response on admission should remain level over time, but a decrease in subsequent responses can show that the pain management program is effective and improving.
Joint Commission surveyors expect to see evidence that your pain management program is effective, says Susie McBeth, MT, MPH, project director for standards development at the Joint Commission. Section PI.3.1 of the Joint Commission’s pain standards says, "The organization collects data to monitor its performance." Every organization must choose which processes and outcomes are important to monitor, based on its mission and the scope of care and services it provides, McBeth explains. Some hospitals choose to monitor effectiveness by adding pain-related questions to their patient satisfaction surveys.
"There are different ways to approach it. We’re not looking for one specific way," she says. "It depends on your priorities as an organization. You could do it during the treatment, on an ongoing basis, by asking if the patient’s pain is relieved or tolerable. But most organizations find that it’s easier to collect the data at the end."
Even more important than monitoring the effectiveness is what you do with the results, McBeth says. Unless your monitoring reveals that your program is 100% effective, your records should indicate that you’ve acted on the shortcomings revealed in the results.
"The surveyor will look to see if you analyzed the data, instead of just making it part of the chart or filing it away," she says. "Are the outcomes they wanted being met? If the monitoring reveals that those goals aren’t being met, like if it points out that clinicians aren’t competent in pain assessment or they don’t have current pain management materials to use, the next question is, what are you doing about that?"
Usually, the surveyor will ask what the organization is doing in terms of performance improvement (PI), why that PI was chosen, how you approached it, what the goals were, and whether there is continuing measurement.
Document everything you do to control pain
One provider found that even though it was far from a novice with pain management, it didn’t have what the Joint Commission surveyor wanted to see. The University of California-Davis Medical Center in Sacramento has been a leader in pain management since 1992, winning accolades for its progressive approach at a time when most providers were just waking up to the idea. But when the Joint Commission surveyor visited in April 2001, there was a surprise waiting for Sharon Melberg, RN, MPA, assistant director of the hospital and clinics’ nursing services, and co-chair of the hospital’s pain management task force.
With the triennial survey approaching, Melberg started putting out newsletters in November 1999 that reminded staff of some of the issues likely to be of concern to the Joint Commission surveyor. The pain standards were a primary focus because she thought the Joint Commission would check for compliance with the new rule.
Melberg says the survey experience confirmed her suspicions that pain would be a big concern for the surveyors. She estimates that about 20% of the surveyors’ time was spent looking for evidence of pain management compliance. "They were looking at it every time they checked a patient chart or talked to staff about procedures. They definitely were looking at pain management much more this year than they ever have before."
At the end of the three-day inspection, the hospital fared well overall and received good scores for the pain program as well. But the surveyors determined that UC-Davis was deficient in its documentation for pain management. The surveyors found some patient records in which nurses had not completely filled out pain assessments, or pain scores were not charted with the vital signs. Those problems resulted in a Type I recommendation. Melberg says she’d like to think that the surveyors just happened to pull up the one inadequate chart on a unit, but she realizes that the survey revealed a gap in the pain program.
Melberg says that she suspects the failing was in documentation, not the actual pain management provided at the hospital. But still, that came as a surprise, since the hospital had revamped its already good pain management program in response to the new Joint Commission standards.
In particular, the hospital added a section on the admission form to assess both acute and chronic pain. All patients were asked when the pain was worst and least, to provide highest and lowest pain scores, and what made the pain worse or better. When the Type I recommendation showed there still was a problem, Melberg and her staff reviewed the deficient charts and talked to staff about why they had not been filled out properly.
The problem became apparent: The charts were poorly designed. For instance, on the admission assessment, a question asked the patient what level of pain would be acceptable. That question is useful for chronic pain patients because they often will accept some level of pain in return for consciousness, mobility, ability to work, or other issues. For acute pain patients, however, staff often assumed the question was inappropriate because no level of pain would be acceptable. That meant that nurses caring for chronic pain patients routinely filled out that section of the admission form, but nurses caring for acute pain patients, such as those recovering from surgery, often left it blank. And everyone knows that Joint Commission surveyors don’t like blank spaces.
Melberg put out a directive to staff that they should never leave the question blank. Always put "zero" or "N/A," she told them. The hospital also reprinted the forms to include an instruction stating that all questions must be answered and no blanks are acceptable.
The pain management committee also incorporated pain management documentation into the hospital’s performance improvement monitoring and measure compliance every six months. Pain documentation was included in staff meetings and inservices for several months, and an ongoing review of sample charts indicates that the documentation has been improved significantly, Melberg says.
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