Implementing the JCAHO Pain Management Standards

Subash  B.  Duggirala, MD, MPH, FAAFP

      The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) approved new pain assessment and management standards in the summer of 1999.  The standards will be scored for compliance beginning in 2001.

      The mission of the Joint Commission is to continually improve the safety and quality of patient care by providing accreditation, education, and consultation services. JCAHO has comprehensive quality review programs for hospitals, health plans, home care agencies, behavioral healthcare settings, long‑term care facilities, ambulatory care clinics, and others, such as laboratories that may not provide direct patient care. Many organizations use their  JCAHO accreditation to obtain Medicare certification through a process known as "deemed status."

      Similar reliance for licensure purposes exists for hospitals and other types of provider organizations. Since the  JCAHO accredits 80% of US hospitals comprising 98% of the hospital beds, the new standards have put pain on hospitals' radar screens. However, the Joint Commission only mandates what must be done or improved, not  how to do it.

     Development of the pain assessment and management standards was driven by the reality that the under-treatment of pain despite of years of emphasis and effective therapies.  Pain is a major public health problem in the United States. Studies carried out over the last 25 years have documented the under-treatment of both acute and chronic pain[2‑4] .  Unrelieved pain carries profound physiological and psychological consequences that result in significant costs to patients, families, the healthcare system, and to society as a whole.

      Under-treatment persists despite the availability of drugs and other therapies to effectively manage pain. Unfortunately, a variety of barriers impede the application of appropriate treatments which results in patients   suffering needlessly[5,6].   Healthcare professionals may lack the knowledge and skills to manage pain appropriately,  and patients and families often hold misconceptions that interfere with appropriate pain management[7].

      Many have argued that if clinicians would only be educated, pain management practice would improve. Although critical, education alone rarely changes practice[8,9].  Changes must be made in organizational processes to support  changes in the clinical environment. One must address the systemic factors, which may be the most challenging   impediments to effective pain management:

 

•                      The fact that pain management has low priority;

•                      The failure to routinely assess and document pain;

•                      The lack of access to practical treatment protocols;

•                      The lack of accountability for poor pain management;

•                      The lack of continuity of care; and

•                      The fragmentation of care.

 The healthcare  organizations  can  effectively  implement  the  JCAHO  standards through a “Ten Steps process for Compliance.   The steps are:

 

1.                    Recognize patients' rights to pain control

2.                    Screen for pain

3.                    Perform a complete assessment when pain is present

4.                    Record the assessment in a way that facilitates regular reassessment  and

                  follow‑up

5.                    Set a standard for monitoring and intervention

6.                    Educate providers and assure staff competency

7.                    Establish policies that support appropriate prescription or ordering of pain

                  medicines

8.                    Educate patients and families

9.                    Include patient needs for symptom control in discharge planning

10.                 Collect data to monitor the effectiveness and appropriateness of pain

                 management

  "The medical staff should assume a leadership role in the improvement of clinical processes that are dependent primarily on individuals with clinical privileges, such as surgery, physical examinations, and prescribing of medication(MS.8 through MS.8.4)."

 The intent of these standards is to change the thought process and the culture of the organization , and encourage the organization to interweaven the standards of pain management into the fabric of the organization. The expectation of these standards is to incorporate the basic principles of pain assessment  and treatment into the patterns of daily practice, including documentation systems; policies and procedures; standards of practice, orientation and continuing education programs; and quality improvement programs.

 Process  for implementing the Standards:

 The healthcare organizations should make the quality pain management as an institutional priority. It can be achieved through the utilization of the following elements critical in their quality patient care process.

1.                   Develop an interdisciplinary workgroup (pain committee/team), with core

                 members from nursing, medicine,  pharmacy, and administration

2.                    Analyze current pain management practices in your care setting; establish a

                 database by carrying out an  institutional needs assessment, surveys of staff

                 and/or patients, and/or auditing medical record

3.                    Articulate and implement a standard of practice; attack 1 problem at a time,

                 (focus on pain assessment first)

4.                    Establish accountability for pain management

5.                    Provide clinicians with information about pharmacologic and

                 non-pharmacologic interventions to facilitate order writing, interpretation, and

                 implementation

6.                    Promise patients a quick response to their report of pain.

7.                    Provide education for staff

8.                    Continually evaluate and work to improve the quality of pain management

 

  Improvement in Hospitals:

 There is  evidence of significant performance improvement in practice settings at which pain teams used the JCAHO pain standards to set goals.

      For example, Standard TX.3.3 requires that procedures "support safe medication ordering." One hospital had  reported 3 normeperidine seizures in the previous year. They found that meperidine was the pain drug of choice  among 92% of the surgeons at their institution, it was the preferred opioid for patient controlled analgesia (PCA), and it was the most‑used opioid in high‑risk patients. Multiple guidelines state that meperidine use should be  restricted to short procedures.[2,3,11]

      The pain team instituted a process to reduce the use of meperidine because it is not a safe drug for routine analgesia. They convened monthly meetings of their interdisciplinary team to set an action plan; gained representation on the Pharmacy and Therapeutics Committee; revised their preprinted analgesic orders; sent form letters to all surgeons who were frequent users of meperidine; and also implemented a variety of educational interventions.

      If surgeons continued frequent use of meperidine even after receipt of 3 letters, they were asked to meet with the  Medical Director who recommended more appropriate, alternative analgesics. One year after the team set its  goal, meperidine use was limited to the GI lab and for treatment of shivering; morphine and hydromorphone were the primary drugs used for IV PCA, and 89% of patients with sickle cell disease were switched to oral controlled‑release opioids. The team is now working to develop a pain resource nurse program, to establish an interdisciplinary pain consultation program, and to address circumcision pain.

 Improvements in  Ambulatory Surgical Centers:

      In another example, an ambulatory surgery center found that the primary postoperative route of opioid administration was by intramuscular (IM) injection; 79% of patients were discharged with pain ratings higher than  4 (on a scale of 0‑10); and 64% of patients reported pain ratings higher than 4 at the time of the next day  follow‑up phone call. The pain team used the new standard that states that patients are to be monitored during the  postprocedure period (Standard TX. 5.4). to reduce the use of the IM route and help patients achieve a  discharge pain rating below 5.

      Their pain team met twice monthly and, with the help of a pain consultant, established an action plan: