Joint Commission sets new pain agenda
Joint Commission sets new pain agenda
Standards move pain management to center stage
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) in Oakbrook Terrace, IL, recently developed standards for the assessment and management of pain that were introduced into its 2000-2001 accreditation manuals along with examples of compliance. Beginning later this year, the Joint Commission will assess the ability of accredited organizations to comply with the new standards and put a plan in place for implementing and scoring for compliance of the pain standards beginning in 2001.
"The new JCAHO standards now require us to assess pain in every patient we care for," notes Carol P. Curtiss, RN, MSN, clinical nurse specialist consultant in Greenfield, MA. "This move has increased awareness in providers, patients and the public that pain is an important clinical problem that we must pay more attention to in every single patient we see."
"Unfortunately, the Joint Commission standards are only a beginning. As I travel the country, I find clinicians are very confused about pain guidelines and standards. The Joint Commission standards are a good first step to improving pain care in the United States," notes Mary Lou Perin, MEd, MSN, OCN, president of Pain Relief/USA in Middletown, MD, and coordinator of the Oklahoma Pain Project, one of the country’s largest pain management education efforts.
"They require organizations to have a continuous quality improvement process in place for pain management. They put organizations on notice that they will be accountable for controlling pain. Unfortunately, many organizations will be able to slide by with a minimal effort at pain management," Perin says.
The introduction of the standards late last year was the product of a two-year collaborative effort between the Joint Commission and the University of Wisconsin-Madison Medical School. Research clearly demonstrates that undertreatment of pain has serious effects that add to the escalating cost of health care, including slower recovery times and increased anxiety in patients and their families, says Donna L. Larkin, a media relations specialist for the Joint Commission.
A study conducted at the City of Hope National Medical Center in Duarte, CA, in the early 1990s found that hospital admissions for uncontrolled pain cost the hospital $5 million in one year. "The study revealed that uncontrolled pain is a very costly issue, especially under managed care contracts," says Betty R. Ferrell, RN, PhD, FAAN, research scientist for City of Hope. "After the study, the hospital implemented several efforts to improve pain management, and after a couple of years, we reevaluated and found we had reduced our costs for uncontrolled pain by $2 million annually."
That’s just the type of continuous quality improvement effort required by the Joint Com mission pain management standards. Under the new standards, health care organizations and health plans accredited by the Joint Commission are required to:
• recognize the right of patients to appropriate assessment and management of pain;
• assess the existence and, if pain does exist, the nature and intensity of pain in all patients;
• record the results of the assessment in a way that facilitates regular reassessment and follow-up;
• determine and assure staff competency in pain assessment and management and address pain assessment and management in the orientation of all new staff;
• establish policies and procedures that support the appropriate prescription or ordering of effective pain medications;
• educate patients and their families about effective pain management;
• address patient needs for symptom management in the discharge planning process.
Putting standards into practice
The Joint Commission sent copies of the proposed pain management standards to accredited health care organizations, professional associations, consumer groups, and purchasers of health care services in 1999. Overall, the proposed standards were well-received, with an average approval rating of 92%.
"The largest problem I find in most organizations trying to comply with the new JCAHO standards is that they aren’t clear how to demonstrate good pain management," notes Perin, who is helping health care organizations in Oklahoma develop the infrastructure necessary for pain management as part of the Oklahoma Pain Project. "The first step is to write a pain performance objective that is both reasonable and measurable."
In education seminars, for example, Perin asks attendees to compare the following two pain policies:
• Bring pain down to a level 4 or below within two hours.
• Bring pain under control within two weeks.
"The second policies has two big problems," she notes. "First, it sets no standard for measuring adequate pain control. Second, two weeks is too long to wait for pain relief."
She suggests organizations answer the following questions concerning systems issues that affect pain management as they develop pain policies:
• How hard is it to reach physicians for pain prescriptions?
• How long does it take for the pharmacy to fill pain prescriptions?
• Is it possible for the pharmacy to give pain prescriptions priority over other orders waiting to be filled?
• How can pain control be measured?
• What are our mechanisms for tracking pain?
• The JCAHO standards now require control of pain symptoms at time of discharge. What is a pain level that would prevent us from discharging a patient?
Of course, once an organization implements a pain policy that includes pain outcomes measures, it must perform chart audits as part of a continuous quality improvement program, notes Perin."You have to review charts to identify any incidences of pain levels which exceeded what you said was an acceptable level in your pain policy, and look for patterns that indicate areas needing improvement."
(For more information on the Joint Commission’s pain management standards, see the organization’s Web site at www.jcaho.org.)
Suggested reading
• Grant M, Ferrell BR, Rivera LM, Lee J. Unscheduled readmissions for uncontrolled symptoms. Nursing Clinics of North America 1995; 30:673-682.
• Ferrell BR, Jacox A, Miaskowski C, et al. Cancer Pain Guidelines: Now that we have them, what do we do? ONF 1994; 21:1,229-1,238.
• Ferrell BR, Griffith H. Cost issues related to pain management: Report from the Cancer Pain Panel of the Agency of Health Care Policy and Research. J Pain Symptom Manage 1994; 9:221-234.
• Ferrell BR. An institutional commitment to pain management. APS Bulletin April/May 1994:16-20.
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