Improving The Quality of Pain Management Through Measurement and Action

Improving the Quality of
Pain Management
Through Measurement and Action
NATIONAL
PHARMACEUTICAL
COUNCIL, INC
This monograph was developed by JCAHO as part of a collaborative project with NPC.
March 2003
Joint Commission Mission Statement:
To continuously improve the safety and quality of care provided to the public through the provision of health care accreditation and
related services that support performance improvement in health care organizations.
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@ 2003 by the Joint Commission on Accreditation of Healthcare Organizations
For information about the Joint Commission on Accreditation of Healthcare Organizations, please visit www.jcaho.org. For information
about Joint Commission Resources, please visit www.jcrinc.com.
DISCLAIMER: This monograph was developed by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) for
which it is solely responsible. Another monograph titled “Pain: Current Understanding of Assessment, Management, and Treatments”
was developed by the National Pharmaceutical Council (NPC) for which it is solely responsible. The two monographs were produced
under a collaborative project between JCAHO and NPC and are jointly distributed. The goal of the collaborative project is to improve
the quality of pain management in health care organizations.
This monograph is designed for informational purposes only and is not intended as a substitute for medical or professional advice.
Readers are urged to consult a qualified health care professional before making decisions on any specific matter, particularly if it
involves clinical practice. The inclusion of any reference in this monograph should not be construed as an endorsement of any of the
treatments, programs or other information discussed therein. JCAHO has worked to ensure that this monograph contains useful infor-
mation, but this monograph is not intended as a comprehensive source of all relevant information. In addition, because the information
contained herein is derived from many sources, JCAHO cannot guarantee that the information is completely accurate or error free.
JCAHO is not responsible for any claims or losses arising from the use of, or from any errors or omissions in, this monograph.
Editorial Advisory Board
Patricia Berry, PhD, APRN, BC, CHPN Christine Miaskowski, RN, PhD, FAAN
Assistant Professor Professor and Chair
College of Nursing Department of Physiological Nursing
University of Utah University of California
Salt Lake City, UT San Francisco, CA
June L. Dahl, PhD Mark Stillman, MD

Professor of Pharmacology Section Head
University of Wisconsin Medical School Section of Headache and Pain
Madison, WI Department of Neurology
Cleveland Clinic Foundation
Cleveland, OH
Marilee Ivers Donovan, PhD, RN
Clinical Nurse Specialist/Manager Karen L. Syrjala, PhD
Kaiser Permanente Northwest Associate Professor
Chronic Pain Management Clinic Psychiatry and Behavioral Sciences
Portland, OR University of Washington-School of Medicine
Associate Member
Fred Hutchinson Cancer Research Center
Perry G. Fine, MD Seattle, WA
Associate Medical Director
Pain Management Center
Professor of Anesthesiology
University of Utah
Salt Lake City, UT
Joint Commission Project Team

Vice President, Division of Research Research Assistant
Jerod M. Loeb, PhD Kristine M. Donofrio
Project Director Editorial Consultant

Barbara I. Braun, PhD Lindsay Edmunds, PhD
Project Coordinator
Annette Riehle, MSN
Table of Contents
Section I: Introduction................................................................................................1
Section II: Getting Started on Measurement to Improve Pain Management ..................2
A. Measurement Is Key to Improvement............................................................................2
1. Internal Uses for Pain Management Performance Measurement..............................2
2. External Uses for Pain Management Performance Measurement .............................2
3. Addressing Concerns Related to Measuring Performance ........................................2
B. Using Criteria for Effective Measurement......................................................................3
1. Overview of Criteria...................................................................................................3
2. Criteria Similarities and Differences ..........................................................................4
3. Mandated Criteria ....................................................................................................10
Section III: Understanding Organizational Improvement in Pain Management ...........14
A. Viewing the Organization as a System.........................................................................14
B. Understanding Pain Management................................................................................14
C. Institutionalizing Pain Management............................................................................15
D. Understanding Current Pain Management Practices in Your Organization...............16
E. Understanding Quality Improvement Principles .........................................................17
1. The Cycle for Improving Performance ....................................................................17
2. Repeating the Cycle at Different Phases of the Project ..........................................17
3. Integrating With Internal Quality Improvement Activities ...................................20
Section IV: Designing Your Pain Management Improvement Initiative.......................21
A. Establishing the Project Team......................................................................................21
B. Selecting Objectives and Target Goals.........................................................................21
C. Establishing the Scope of Measurement ......................................................................22
D. Identifying Resources and Project Timeline ................................................................24
Section V: Measuring What You Need to Know ........................................................25
A. Consider Your Measurement Approach.......................................................................25
1. Data Quality .............................................................................................................25
2. Data Quantity ...........................................................................................................27
B. Collecting Data With Established Assessment Instruments........................................28
1. Pain-Specific Instruments.........................................................................................28
2. Choosing Pain Instruments ......................................................................................28
C. Selecting a Measurement Approach ............................................................................31
1. Conduct An Organizational Self-assessment...........................................................31
2. Review Medical Records ..........................................................................................32
3. Test Knowledge and Attitudes .................................................................................33
4. Directly Observe the Care........................................................................................33
5. Conduct a Point Prevalence Study ..........................................................................35
6. Assess Patient Status and Outcome Over Time ......................................................36
7. Collect Indicator Data..............................................................................................38
8. Utilize an Externally Developed Performance Measurement System .....................44
Improving the Quality of Pain Management Through Measurement and Action

ii
Table of Contents
Section VI: Assessing and Analyzing Your Processes and Results ..............................50
A. Using Quality Improvement Tools...............................................................................50
B. Analysis of Data ............................................................................................................50
C. Interpretation of the Results of Data Analysis ............................................................53
D. Display of Data and Results..........................................................................................54
E. Dissemination of Information .......................................................................................55
Section VII: Improving Your Performance ................................................................56
A. Designing a Pain Improvement Intervention ..............................................................56
B. Testing and Implementing a Pain Improvement Intervention ....................................57
C. Monitoring for Success .................................................................................................57
D. Sustaining Change........................................................................................................58
Section VIII: Understanding Factors That Affect Organizational Improvement .........59
A. Factors That Influence Change ...................................................................................59
1. Patient Factors ..........................................................................................................59
2. Clinician Factors.......................................................................................................60
3. Organization Factors.................................................................................................61
4. External Factors ........................................................................................................62
B. Improving Pain Management Through the Principles of Total
Quality Management ....................................................................................................63
Section IX: Examples of Organizations Implementing Pain Management–
Related Measurement and Improvement Initiatives ....................................................66
A. Overview.......................................................................................................................66
B. Educational Effectiveness in a Home Health Agency: Visiting Nurse
Association & Hospice of Western New England, Inc................................................67
1. Special Challenges....................................................................................................67
2. Choosing a Methodology .........................................................................................67
3. Assembling a Team...................................................................................................67
4. Identifying the Problem............................................................................................68
5. Implementing Interventions.....................................................................................69
6. Analyzing Processes and Results Leads to Redesign ................................................70
7. Sharing the Success and Sustaining Change ...........................................................70
C. Creative Improvement in a Rural Hospital: Memorial Hospital of
Sheridan County...........................................................................................................72
1. Doing Some Homework ...........................................................................................72
2. Establishing a Team ..................................................................................................72
3. Implementing Improvements ...................................................................................73
4. Collaborating for Improvement................................................................................75
5. Integrating Nonpharmacologic Approaches ............................................................76
6. Sustaining Change....................................................................................................76
Joint Commission on Accreditation of Healthcare Organizations

iii
Table of Contents
D. Integrating Pain Management Improvement Activities in an

Academic Medical Center: University of Iowa Hospitals and Clinics .......................77
1. History of Pain Management Activities at UIHC...................................................77
2. Forming a Standing Committee...............................................................................78
3. Establishing an Action Plan.....................................................................................80
4. Fulfilling the Charge: The Assessment and Documentation Work Group.............80
5. Complementing Centralized Pain Improvement Activities: A
Division-level Initiative to Manage Circumcision Pain..........................................81
E. Improving Care Across Hundreds of Facilities: The Veterans
Health Administration’s National Pain Management Strategy...................................84
1. Organizing the National Initiative...........................................................................85
2. National Goals and Objectives ................................................................................85
3. Implementing Multiple Interventions......................................................................85
4. Evaluating Effectiveness Through System-wide Measurement ...............................86
5. VHA-IHI Collaborative ...........................................................................................87
6. Implementing the IHI Initiative in Two New England Hospitals...........................88
7. Operational Strategies ..............................................................................................89
8. Sharing Success and Next Steps ..............................................................................90
9. Summary: Key Lessons..............................................................................................91
Appendix A: A Selection of Resources Related to Pain Management and
Improvement ..................................................................................................................93
Appendix B: A Plan-Do-Check-Act Worksheet..............................................................96
References ..........................................................................................................................99
List of Tables, Figures, Text Boxes, and Appendices
TABLES
Table 1. Pain Management Guidelines ...............................................................................5
Table 2. Consensus and Position Statements ...................................................................12
Table 3. Examples of Tasks Associated with Each Stage of the
Improvement Cycle ............................................................................................19
Table 4. Examples of Roles and Behaviors of Pain Project Team Members ....................23
Table 5. Scientific Review Criteria for Health Status Instruments..................................29
Table 6. Examples of Unidimensional and Multidimensional Pain-
Specific Instruments ............................................................................................30
Table 7. Examples of Indicator Development for Pain Management .............................39
Table 8. Desirable Attributes of Measures ........................................................................45
Table 9. Comparing Process and Outcome Indicators......................................................47
Table 10. Quality Improvement Tools: Definition And Use............................................51
Table 11. Visiting Nurse Association & Hospice Of Western New
England Pain Performance Improvement Time Line .......................................68
Table 12. Memorial Hospital of Sheridan County Pain Management
Improvement Initiative .....................................................................................74

iv
Table of Contents
Table 13. Examples of Departmental Pain Improvement Activities:

University of Iowa ............................................................................................78
Table 14. Examples of Pain Management Interventions for Circumcision:
University of Iowa Hospitals and Clinics (UIHC) ..........................................83
Table 15. Attributes of a Successful Pain Management Program:
VHA-IHI Collaborative Planning Group.........................................................88
FIGURES
Figure 1. Dynamics of Systems Thinking in Relation to the
Health Care Organization ..................................................................................15
Figure 2. The PDSA Cycle................................................................................................18
Figure 3. Cycle for Improving Performance .....................................................................19
Figure 4. Selection Grid: Improvement Tools ..................................................................52
Figure 5. [cartoon]..............................................................................................................54
Figure 6. Using Appropriate Scales on Graphs.................................................................55
Figure 7. Examples of Factors Affecting Pain Management
Improvement Initiatives.....................................................................................60
Figure 8. Second Pain Management Newsletter Distributed by the Visiting
Nurse Association & Hospice Of Western New England................................71
Figure 9. Mean Score on Staff Pain Management Knowledge Survey:
Visiting Nurse Association & Hospice of Western
New England, Inc. .............................................................................................72
Figure 10. Baseline and Post (6 Months) Indicator Data: Memorial
Hospital of Sheridan County Clinical Indicators............................................76
Figure 11. Quality and Performance Improvement Program Framework
Illustrating the Reporting Lines for Communication: University
of Iowa Hospitals and Clinics ..........................................................................79
Figure 12. Mean Number of Times Pain Intensity Is Documented
Every 24 Hours: Department of Nursing Services and
Patient Care Intensive Care Units, University of Iowa
Hospitals and Clinics .......................................................................................82
Figure 13. Percentage of Records With Documented Pain Scores Within
the Last Year: Veterans Health Administration, National
External Peer Review Program .......................................................................87
Figure 14. Performance on Two Indicators Within 6 Weeks of Initiation
of the Veterans Health Administration/Institute for Healthcare
Improvement Pain Management Collaborative at the Togus, Maine,
and Providence, Rhode Island, Veterans Affairs Medical Centers .................91
TEXT BOXES
Overview of Joint Commission on Accreditation of Healthcare
Organizations Standards Related to Pain Management.................................................4
American Pain Society Quality Improvement Guidelines for
the Treatment of Acute and Cancer Pain ....................................................................10

v
Table of Contents
Comparing Criteria: Guidelines, Standards, Consensus Statements ...............................11

Eight Steps to Develop an Institutional Pain Management Program ..............................16
Getting Physicians Involved in the Quality Improvement Process .................................22
Common Characteristics of Successful Quality Improvement Teams .............................23
Examples of Approaches to Assesing Data Quality..........................................................26
Examples of Approaches for Selecting Samples ...............................................................27
Organizational Example: Conduct Organizational Self-assessment .................................32
Organizational Example: Review Medical Records ..........................................................33
Organizational Example: Test Knowledge and Attitudes .................................................34
Organizational Example: Directly Observe the Care .......................................................35
Organizational Example: Conduct a Point Prevalence Study ..........................................36
Organizational Example: Assess Patient Status and Outcome Over Time ......................37
Organizational Example: Collect Indicator Data .............................................................48
Organizational Example: Utilize an Externally Developed Performance
Measurement System.....................................................................................................49
Ten Key Lessons From the National Demonstration Project on
Quality Improvement....................................................................................................53
The 14 Points of Total Quality Management Applied to Improving Pain
Management..................................................................................................................63
No Pain, Big Gain Kick-off Activities in February 2001 .................................................75
APPENDICES
Appendix A. A Selection of Resources Related to Pain Management and
Improvement .................................................................................................................93
Appendix B. A Plan-Do-Check-Act Worksheet..............................................................96
Acknowledgements
The Joint Commission project team gratefully acknowledges the important contribution of the staff at the health
care organizations who shared their valuable time and experience in improving pain management with this proj-
ect. In particular, we would like to thank Micki Bonnette, RN.C, CHPN, Memorial Hospital of Sheridan
County, Sheridan, WY; Janet I. Moss, MS, RN, CPAN, Advocate Christ Medical Center, Oak Lawn, IL; Lyn
Sullivan Lee, RN, BSN, Swedish Medical Center, Seattle, WA; Lynnette Kenne, RN, MSN, Mercy Medical
Center-North Iowa, Mason City, IA; Marguerite Jackson, RN, PhD, FAAN, and Wendy Hansbrough, RN, BSN,
UCSD Medical Center, San Diego, CA; Marilee Ivers Donovan, PhD, RN, Kaiser Permanente Northwest,
Portland, OR; Terri Savino, RN C, BSN, Middlesex Hospital, Middletown, CT; Tim Ashley, Crouse Hospital,
Syracuse, NY; Marita Titler, PhD, RN; and Janet Geyer, RN, MSN, University of Iowa Hospitals and Clinics,
Iowa City, IA; Carol Rodrigues, RN, MS, CHPN, VNA and Hospice of Western New England, Inc., Springfield,
MA; and Robert Kerns, PhD, VA Connecticut Healthcare System, West Haven, CT. We also appreciate the
assistance of others too numerous to mention at these organizations who facilitated and supplemented interviews
or in-person visits with members of the project team.
We wish to thank the members of the Editorial Advisory Panel who provided outstanding advice and feedback
throughout the project, as did others who reviewed materials and advised us on content. Last, but certainly not
least, we are grateful to our colleagues at NPC, who made this project possible through the support of an unre-
stricted educational grant. They were a pleasure to work with and helped advance the monograph from concep-
tion to completion.

vi
Section I: Introduction
SECTION I: ■
implemented improvement initiatives.
References and other sources for more
detailed information on selected topics.
This monograph is written for clinicians,
Introduction pain management teams, quality improve-
ment professionals, researchers, and others
Despite ongoing, significant advances in involved in pain management performance
treatment options, studies indicate that pain assessment, improvement, education, and
continues to be poorly managed and under- policy making. It is intended for use in con-
treated.1-6 The increase in clinical informa- junction with the companion monograph
tion related to pain management, as well as Pain: Current Understanding of Assessment,
recent high-profile press coverage of individ- Management, and Treatments,9 which focuses
ual cases of undertreatment,7 has resulted in on the etiology, physiology, and clinical
heightened awareness among health care treatment of pain.
professionals and the public that this critical Because of the broad intended audience,
issue must be addressed. some readers may find aspects of the mono-
At the most fundamental level, improving graph too technical while others may find it
pain management is simply the right thing to overly simplistic. Similarly, some sections
do. As a tangible expression of compassion, (e.g., organization examples or measurement
it is a cornerstone of health care’s humanitar- approaches) may be of greater interest to
ian mission. Yet it is just as important from a some readers than others, depending on one’s
clinical standpoint, because unrelieved pain care setting, role, and experience in pain
has been associated with undesirable out- management improvement activities.
comes such as delays in postoperative recov- Nevertheless, we hope that readers will find
ery and development of chronic pain condi- much of the material relevant and helpful in
tions.8,9(p14, Table 5) In addition, effective treat- their efforts to measure and improve pain
ment of pain is necessary to respond to management processes and patient outcomes.
patients’ increasing expectations for health Given the primary focus of this mono-
care and new standards or requirements such graph on measuring and improving perform-
as those set by accrediting bodies, insurers, ance, certain aspects of pain management are
government regulatory bodies, and other not addressed.
constituent groups. In fact, Congress ■ This monograph does not review or cri-
declared the decade beginning on January 1, tique recommendations for treatments,
2001, as the Decade of Pain Control and though reference material on clinical
Research.10 practice guidelines is provided.
The key to judging the success of improve- ■ This monograph covers subjects that are
ment efforts in an organization is measure- integral to evaluating pain management
ment, because accurate data underpin all programs. Readers interested in material
aspects of the change and improvement that focuses specifically on establishing
process. This monograph is designed to help and implementing new pain manage-
health care organizations implement the per- ment programs should consult the refer-
formance measurement processes they need ences cited in Section III.C
to achieve their goal of improving pain man- (Institutionalizing Pain Management).
agement. This monograph takes a practical ■ Individuals and organizations seeking
approach to provide: information on compliance with require-
■ An overview of methods for measuring ments for certification and accreditation
performance and principles of organiza- programs mentioned in this monograph
tional improvement applied to pain should request specifications and educa-
management. tional materials from the appropriate
■ Examples of organizational use of per- sponsoring agency (see references listed
formance measurement methods and in Appendix A).

1
Section II: Getting Started on Measurement to Improve Pain Management
SECTION II: ■ Identification of knowledge, attitudes,

and competencies of clinicians.
■ Identification of educational needs, indi-
vidual preferences, beliefs, and expecta-
Getting Started tions about pain management among
patients and their family caregivers.
on Measurement ■ Dispelling false beliefs about pain and its
to Improve Pain ■
treatment such as fear of addiction.
Prioritization when multiple improve-
Management ment opportunities exist.
■ Provision of objective data in order to
gain support from organizational leader-
ship and buy-in from clinicians for
improvement activities.
A. Measurement Is
Key to Improvement 2. External Uses for Pain
Evaluating improvement in pain manage- Management Performance
ment performance depends on measurement. Measurement
By its nature, measurement is comparative Examples of external uses for measuring
and used to establish relationships based on performance include:
common units of analysis.11 For example, ■ Comparison of performance on pain
during the start-up phase of an improvement management processes and outcomes
initiative, measurement allows staff to estab- with those of other organizations.
lish the baseline performance of a process or ■ Compliance with performance data
activity, to assess current practice, and to demands from external sources such as
identify opportunities for improvement. payers, accreditors, and government reg-
Then, over time, continued measurement ulatory bodies.
enables them to compare current perform- ■ Establishment of national, regional, or
ance against baseline data to evaluate the other benchmarks.
success of their interventions. ■ Validation and refinement of criteria
Two important reasons to measure per- such as guidelines, standards, and care
formance in health care organizations are to recommendations. Evaluation of the
assess change for quality improvement pur- effect of these criteria on areas such as
poses within an organization (internal) and patient outcomes, costs, and provider
to compare quality of care between different behavior.
entities (external).12 ■ Collection of research data to validate
treatment efficacy, evaluate assessment
1. Internal Uses for Pain Management instruments, or establish evidence-based
Performance Measurement practice.
Examples of internal uses for performance
measurement in pain management include: 3. Addressing Concerns Related to
■ Measurement of direct and indirect Measuring Performance
changes in pain management processes Although most health care professionals
and patient outcomes in response to would agree that performance measurement
quality improvement interventions. is valuable and necessary for effective quality
■ Assessment of compliance with selected improvement, it is often met with resistance
guidelines and evidence-based practices and apprehension. Lack of familiarity with
in order to eliminate non-evidence– data analysis methods and tools (e.g., statisti-
based approaches to pain management cal process control) can lead to concerns
grounded in habit, opinion, and biases. about the ability to understand and commu-

2
nicate findings. Prior negative experiences enhance effectiveness by:

can give rise to perceptions that performance ■ Viewing measurement as part of an
measurement is not valuable or valid.11 ongoing process rather than as an end
These include judgments based on insuffi- point.
cient sample size, poorly tested measures ■ Exercising care in choosing what to
(e.g., measures that do not have an estab- measure.
lished link to patient outcomes or measures ■ Keeping in mind that measurement is
not adequately adjusted for differences in most valuable when it is conducted with
severity of illness among different patient rigorous attention to quality, analyzed
populations), and disclosure of misleading with accuracy, and applied in a timely
data. manner.
At the organizational level, performance As Donald Berwick, MD, a widely recog-
measurement may be perceived as requiring nized leader in the quality improvement
too much dedicated staff time and resources field, has said “measurement without change
relative to the expected benefit. is waste, while change without measurement
Overcoming these challenges requires is foolhardy.”14 Keeping this in mind, organi-
early communication and ongoing education zations can avoid the pitfall of “measurement
throughout the organization to ensure every- for measurement’s sake” as well as the nega-
one understands the purpose of data collective effects on morale and costs that can
tion, the measurement methods used, and result when data are collected but not used.11
the ultimate project goals. In general it is By recognizing and attending to common
best to prepare special communications for concerns surrounding performance measure-
management, department heads, and other ment and use of data, organizations can over-
influential groups to address specific con- come resistance.
cerns and solicit buy-in.
It is important to choose measurement
objectives carefully and consider the impact
on related processes of care. It has been B. Using Criteria for Effective
observed that measurement may have the Measurement
unintended result of allocating resources,
effort, and attention to targeted areas, possi-
1. Overview of Criteria
bly to the detriment of other functions.12,13
Therefore, careful planning and attention to When evaluating pain management activi-
institutional priorities is important to ensure ties, it is important to refer to credible, evi-
resources are wisely distributed. dence-based sources for identifying measure-
Adopting a systems-level approach to per- ment objectives and establishing perform-
formance measurement and improvement ance expectations. Examples of possible
can help overcome the concern that data sources include clinical practice guidelines,
will be used to single out individuals for criti- standards, consensus statements, and position
cism. Those charged with implementing such papers. For the purposes of this monograph,
activities must assess data quality and relia- all of these items will be referred to as
bility and use sound analysis and interpreta- criteria, which are defined as a means for
tion techniques to ensure data are translated judging or a standard, a rule, or a principle
into information that is fully substantiated against which something may be measured.16
and can be readily understood. More infor- a. Guidelines
mation about this issue is provided in Guidelines are systematically developed
Section VI (Assessing and Analyzing Your statements to assist practitioner and patient
Processes and Results). decisions about appropriate health care for
Whether launching new pain management specific clinical circumstances.15 Guidelines
improvement activities or maintaining estab- are often a mechanism by which treatment
lished improvements, organizations can recommendations are communicated. Pain

3
management–related guidelines have been

developed for different patient populations Overview of Joint Commission on
(pediatric, adult, geriatric), types of pain Accreditation of Healthcare
(chronic or acute), and conditions or proce- Organizations Standards Related to
dures (e.g., low back pain, postoperative Pain Management
pain, cancer pain). One source of informa-
tion on current guidelines related to pain ■ Recognize the right of patients to
management is the National Guideline appropriate assessment and manage-
Clearinghouse Web site (www.guideline. ment of pain.
gov). Examples of pain management guide- ■ Screen for the presence and assess
lines are included in Table 1. the nature and intensity of pain in all
b. Standard patients.
A standard is 1) a criterion established by ■ Record the results of the assessment
authority or general consent as a rule for the in a way that facilitates regular
measure of quality, value, or extent; or 2) for reassessment and follow-up.
purposes of accreditation, a statement that ■ Determine and ensure staff compe-
defines the performance expectations, struc- tency in pain assessment and man-
tures, or processes that must be substantially agement (i.e., provide education),
in place in an organization to enhance the and address pain assessment and
management in the orientation of all
quality of care.16 (Note: this definition is dis-
new clinical staff.
tinct from the use of “standard” in a “stan-
■ Establish policies and procedures that
dard of care,” which may be used in a legal
support the appropriate prescribing or
context or a “standard of practice” estab-
ordering of pain medications.
lished by an organization). Standards typical-
■ Ensure that pain does not interfere
ly are used by accrediting bodies such as the
with a patient’s participation in reha-
Joint Commission on Accreditation of
bilitation.
Healthcare Organizations (JCAHO) and
■ Educate patients and their families
The Rehabilitation Accreditation
about the importance of effective
Commission (CARF) to evaluate health care
pain management.
organizations and programs. An example of
■ Address patient needs for symptom
standards related to pain management from
management in the discharge plan-
JCAHO is included in the box at right.
ning process.
c. Consensus statements and ■ Incorporate pain management into
position papers performance activities (i.e., establish
Consensus statements and position papers a means of collecting data to monitor
are expressions of opinion or positions on the appropriateness and effectiveness
health care issues generally prepared by pro- of pain management).
fessional societies, academies, and organiza-
tions and generated through a structured Adapted from reference 17.
process involving expert consensus, available
scientific evidence, and prevailing opinion. Quality Improvement Guidelines for the
Table 2 provides a sample of consensus state- Treatment of Acute and Cancer Pain (see
ments and position papers that may provide box on page 10).18
additional resources for examining pain man-
agement practice in an organization, devel- 2. Criteria Similarities and Differences
oping improvement interventions, and creat-
ing an organization-wide program. One con- Often, these terms (standards, guidelines,
sensus statement of special relevance for pain and consensus statements) are used inter-
management improvement is the American changeably throughout the literature and
Pain Society Quality of Care Committee’s (continued on page 10)
4
Table 1. Pain Management Guidelines
Date of
Guideline Title Release/Update Developer Focus/Application Contact Information
Acute Pain Release date: 1992 U.S. Department of Acute pain associat- AHRQ
Management: Health and Human ed with operations, Clearinghouse;
Operative or Medical Services medical procedures, 800-368-9295
Procedures and Agency for Health or trauma; includes www.ahrq.gov;
Trauma AHCPR Care Policy and all age groups from Agency for
Publication No. 92- Research (AHCPR) neonates to the Healthcare Research
0032 now known as elderly and Quality; 2101
Agency for East Jefferson Street,
Healthcare Research Suite 501; Rockville,
and Quality (AHRQ) MD 20852
Acute Pain Release date: 1993 U.S. Department of The Quick AHRQ
Management in Health and Human Reference Guide Clearinghouse
Adults: Operative Services Agency for includes excerpts 800-368-9295
Procedures. Quick Health Care Policy from the guideline, www.ahrq.gov;
Reference Guide for and Research Acute Pain Agency for
Clinicians AHCPR (AHCPR) now Management: Healthcare Research
Publication No. 92- known as Agency Operative or and Quality 2101
0019 for Healthcare Medical Procedures East Jefferson Street,
Research and and Trauma; the Suite 501 Rockville,
Quality (AHRQ) excerpts are MD 20852
designed to provide
clinicians with some
suggestions for prac-
tical and flexible
approaches to acute
pain assessment and
management
Acute Pain Release date:1992 U.S. Department of The Quick AHRQ

Management in Health and Human Reference Guide Clearinghouse;
Infants, Children, and Services Agency for includes excerpts 800-368-9295;
Adolescents: Health Care Policy from the guideline, www.ahrq.gov;
Operative and and Research Acute Pain Agency for
Medical Procedures. (AHCPR) now Management: Healthcare Research
Quick Reference known as Agency Operative or and Quality; 2101
Guide for Clinicians for Healthcare Medical Procedures East Jefferson Street,
AHCPR Publication Research and and Trauma Suite 501; Rockville,
No. 92-0020 In: J Pain Quality (AHRQ) MD 20852
Symptom Manage.
1992;7:229-242
Practice Guidelines Release date: April American Society of Perioperative pain American Society of
for Acute Pain 1995 Anesthesiologists management Anesthesiologists;
Management in the 520 North
Perioperative Setting Northwest Highway;
Park Ridge IL
60068-2573;
E-mail: publica-
tions@asahq.org

5
Table 1. Pain Management Guidelines (continued)
Date of
Guidelines for the Release date: American Academy Care of the pediatric American Academy
pediatric perioperative February 1999 of Pediatrics patient in the peri- of Pediatrics; P.O.
anesthesia environ- operative anesthesia Box 747; Elk Grove,
ment environment IL 60009-0747;
www.aap.org
Clinical Practice Release date: March U.S. Department of AHRQ

Guideline: 1994 Health and Human Clearinghouse;
Management of Revision In Press – Services Agency for 800-368-9295;
Cancer Pain AHCPR The American Pain Health Care Policy www.ahrq.gov;
Publication No. 95- Society: Expected and Research Agency for
0592 Spring 2003 (AHCPR) now Healthcare Research
known as Agency and Quality; 2101
for Healthcare East Jefferson Street,
Research and Suite 501; Rockville,
Quality (AHRQ) MD 20852
NCCN Practice Revision date: June National Recommendations National

Guidelines for Cancer 2000 Comprehensive for standardized Comprehensive
Pain Cancer Network assessment and Cancer Network;
(NCCN) treatment of cancer 50 Huntington Pike,
pain Suite 200;
Rockledge, PA
19046;
215-728-4788;
www.nccn.org
Cancer Pain Treatment Release date: American Cancer A source of cancer American Cancer
Guidelines for Patients January 2001 Society (ACS) pain treatment infor- Society;
AND National mation for patients 800-ACS-2345;
Comprehensive based on the NCCN www.cancer.org OR
Cancer Network treatment guidelines National
(NCCN) Comprehensive
Cancer Network;
800-909-NCCN;
www.nccn.org
Cancer Pain Relief Release date: World Health Consensus guide- WHO Distribution
and Palliative Care in December 1998 Organization in col- lines on the man- and Sales Office;
Children laboration with the agement of pain in 1211 Geneva
International children with cancer Switzerland; Phone:
Association for the 41-22-791-24-76;
Study of Pain Fax: 41-22-791-48-
57;
E-mail:
publications@
who.ch
Practice Guidelines Release date: 1996 American Society of Evaluation and American Society of
for Cancer Pain Anesthesiologists assessment of the Anesthesiologists;
Management (ASA) patient with cancer 520 North
pain Northwest Hwy;
Park Ridge, IL
60068-2573;
E-mail:
publications@asahq.
org

6
Date of
Cancer Pain Relief Release date: 1986 World Health Management of WHO Distribution
Organization cancer pain and Sales Office;
1211 Geneva
Switzerland; Phone:
41-22-791-24-76;
Fax: 41-22-791-48-
57;
E-mail:
publications@
who.ch
Migraine Headache Release date: 2001 U.S. Headache Diagnosis, treat- American Academy
Treatment Guidelines Consortium ment, and preven- of Neurology; 1080
tion of migraine Montreal Avenue;
headache St. Paul, MN 55116;
651-695-1940;
www.aan.com
Practice Guidelines Release date: 1997 American Society of Management of American Society of
for Chronic Pain Anesthesiologists chronic pain and Anesthesiologists;
Management pain-related prob- 520 North
lems Northwest Hwy;
Park Ridge, IL
60068-2573; E-mail:
publications@asahq.
org
Guideline for the Release date: August American Pain Guideline to aid American Pain
Management of Acute 1999 Society physicians, nurses, Society; 4700 W.
and Chronic Pain in pharmacists, and Lake Ave; Glenview,
Sickle-Cell Disease other health care IL 60025;
professionals in Phone: 847-375-
managing acute and 4715;
chronic pain associ- Fax: 847-375-4777;
ated with sickle-cell www.ampainsoc.org
disease

7
Date of
Acute Pain Release date: 1997 University of Iowa Acute pain manage- University of Iowa
Management (in the Revision date: April Gerontological ment in the elderly Gerontological
elderly) 1999 Nursing patient Nursing
Interventions Interventions
Research Center Research Center,
Research
Dissemination
Core, 4118
Westlawn, Iowa
City, IA 52242-1100
www.nursing.uiowa.
edu/gnirc
Model Guidelines for Release date: May The Federation of Evaluating the use of Federation of State
the Use of Controlled 1998 State Medical controlled sub- Medical Boards of
Substances for the Boards of the United stances for pain con- the United States,
Treatment of Pain States Inc. trol Inc.; Federation
Place; 400 Fuller
Wiser Road, Suite
300; Euless, TX
76039-3855;
Phone: 817-868-
4000;
Fax: 817-868-4099;
www.fsmb.org
Clinical Practice Release date: 1999 American Medical Addressing chronic American Medical
Guideline: Chronic Directors pain in the long- Directors
Pain Management in Association term care setting Association; 10480
the Long-Term Care Little Patuxent
Setting Parkway, Suite 760;
Columbia, MD
21044;
Phone: 800-876-
2632;
Fax: 410-740-4572;
www.amda.com
Principles of Analgesic Release date: 1999 The American Pain Principles and American Pain
Use in the Treatment Society recommendations Society; 4700 W.
of Acute Pain and related to analgesic Lake Ave; Glenview,
Cancer Pain therapy IL 60025;
Phone: 847-375-
4715;
Fax: 847-375-4777;
www.ampainsoc.org
Treatment of Release date: 2000 The American Management of non- American Academy
Nonmalignant Academy of Family malignant chronic of Family Physicians;
Chronic Pain Physicians pain 11400 Tomahawk
Creek Parkway;
Leawood, KS
66211-2672;
913-906-6000;
www.aafp.org

8
Date of
Guideline for the Release date: 2002 The American Pain Pain management American Pain
Management of Pain Society for juveniles with Society; 4700 W.
in Osteoarthritis, osteoarthritis, Lake Ave.;
Rheumatoid Arthritis rheumatoid arthritis, Glenview, IL 60025;
and Juvenile Chronic and juvenile chronic www.ampainsoc.org;
Arthritis arthritis Phone:
847-375-4715;
Fax: 847-375-4777
Management of Low Release date: May Veterans Health Management of low Department of
Back Pain or Sciatica 1999 Administration and back pain in the Defense
in the Primary Care Department of ambulatory care Department of
Setting Defense setting for patients Veterans Affairs
older than 17 years Veterans Health
of age Administration
(VHA)
Office of Quality
and Performance
(1OQ); 810 Vermont
Ave, NW;
Washington, DC
20420
Acute Low Back Release date: 1994 U.S. Department of Management of low AHRQ
Problems in Adults Health and Human back pain-adults Clearinghouse;
AHCPR Publication Services Agency for 800-368-9295;
No. 95-0642 Health Care Policy www.ahrq.gov;
and Research Agency for
(AHCPR) now Healthcare Research
known as Agency and Quality; 2101
for Healthcare East Jefferson Street,
Research and Suite 501; Rockville,
Quality (AHRQ) MD 20852
The Management of Release date: 2002 American Geriatric Management of per- American Geriatrics
Persistent Pain in Society (AGS) sistent pain in older Society; The Empire
Older Persons adults State Building; 350
Fifth Avenue, Suite
801; New York, NY
10118;
212-308-1414;
www.
americangeriatrics.
org

9
to the recommendation that, as a general

American Pain Society Quality rule, guidelines should be reassessed for valid-
Improvement Guidelines for the ity every 3 years.19
Treatment of Acute and Cancer Pain
3. Mandated Criteria
■ Recognize and treat pain promptly. Another important set of criteria consists
■ Chart and display patient’s self- of those mandated by federal, state and local
report of pain. statute or regulation. All health care profes-
■ Commit to continuous improve- sionals and organizations need to be aware of
ment of one or several outcome the statutes and regulations applicable to
variables. their practice. Though a detailed discussion
■ Document outcomes based on is beyond the scope of this monograph, due
data and provide prompt feedback. in part to the complexity and changing
■ Make information about analgesics nature of such criteria, an introduction with
readily available. references is provided.
■ Promise patients attentive analgesic a. Statute
care. A statute is a law created by a legislative
■ Define explicit policies for use of body at the federal, state, county, or city
advanced analgesic technologies. level. Commonly called a law or an act, a
■ Examine the process and outcomes of single statute may consist of just one legisla-
pain management with the goal of tive act or a collection of acts.20 Examples
continuous improvement. include the Pain Patient’s Bill of Rights
(California, 1997) and the Intractable Pain
(18) Source: JAMA, 1995; 274:1874-1880. Used with
permission
Act (West Virginia, 1998).
b. Regulation
across the health care field by entities rang- A regulation is an official rule or order
ing from government agencies to accrediting issued by agencies of the executive branch of
organizations to professional societies to legal government. Regulations have the force of
experts. Although similarities exist among law and are intended to implement a specific
them, there also are some distinct differences statute, often to direct the conduct of those
that should be kept in mind to prevent con- regulated by a particular agency.20 An exam-
fusion over terminology (see box on pg. 11). ple is the 1999 pain management regulation
Although criteria can be highly beneficial provided by the Washington Medical
for assessing and improving organizational Quality Assurance Commission.
performance and quality of care, health care Detailed information on state statutes and
organizations must ensure that the sources regulations addressing multiple aspects of
are credible, evidence-based where applica- pain management is available from the Web
ble, scientifically sound, and accepted by cli- site for the Pain and Policies Study Group,
nicians. As options for managing pain con- University of Wisconsin Comprehensive
tinue to evolve, it is important to consider Cancer Center, which is a World Health
the extent to which information in the crite- Organization collaborating center for policy
ria reflect the current state of knowledge. and communication in cancer care
Some criteria are subject to established (www.medsch.wisc.edu/painpolicy/). The
cycles of review and revision, while others Pain and Policy Studies Group publishes an
are not. For example, a recent study designed annual review of state pain policies on its
to assess the current validity of 17 guidelines Web site; this review summarizes and com-
developed by the Agency for Healthcare ments on each new or amended state statute,
Research and Quality (AHRQ) (including regulation, and medical board policy affect-
the landmark 1992 postoperative pain guide- ing pain management. The complete cita-
lines) and to use this information to estimate tion, full text, and Internet citation also are
how quickly guidelines become obsolete, led provided for each pain-related policy.

10
Comparing Criteria: Guidelines, Standards and Consensus Statements
Similarities Differences
■ They are useful for establishing ■ The intended audience can vary
expected or desired levels of per- widely. For example, guidelines are

formance that are credible, evi- often written for clinicians who
dence-based, and recognized by deliver care, while standards often
professionals. are written for a broader audience
■ Scientific evidence and/or expert such as a department or organiza-
consensus are used in develop- tion.
ment. ■ The intended purpose can vary.
■ They can be multidisciplinary in For example, standards of all types

scope and focus. are frequently seen as authoritative
■ Usually compliance is considered statements, expectations, or
voluntary rather than mandated by requirements and are used at the
law. level of assessment for organiza-
■ They are useful for improving con- tions or programs. Guidelines, on
sistency and reducing variation in the other hand, generally are
care processes and for evaluating viewed as strategies for clinical
links between processes of care and decision-making, and hence are
outcome quality management. more flexible. They also are used
■ They can serve to educate clini- to develop protocols allowing for
cians, organizations, and others in clinically justifiable deviations in
the health care community regard- treating individual patients or for
ing advances in the field and sub- alleviating specific conditions or
sequent care recommendations. symptoms.
■ The degree of clinical certainty
can vary across and even within

each criterion category based on
the developmental approach used
and the availability of documented
scientific evidence.

11
Table 2. Consensus and Position Statements
Date of
Title Release Developer Focus/Application Contact Information
Quality Improvement 1995 American Pain Improving treatment American Pain Society
Guidelines for the Treatment Society Quality of for patients with 4700 W. Lake Ave;
of Acute Pain and Cancer Care Committee acute pain and can- Glenview, IL 60025-1485;
Pain cer pain. www.ampainsoc.org
The Use of Opioids for the 1996 American Academy The management of American Pain Society;
Treatment of Chronic Pain: of Pain Medicine chronic pain 4700 W. Lake Ave;
A Consensus Statement and American Pain Glenview, IL 60025-1485;
From American Academy of Society www.ampainsoc.org; or
Pain Medicine and American Academy of Pain
American Pain Society Medicine; 4700 W. Lake
Ave; Glenview, IL
60025-1485;
www.painmed.org
Treatment of Pain at the End 1997 American Pain The management of American Pain Society;
of Life: A Position Statement Society pain at the end of 4700 W. Lake Ave;
from the American Pain life Glenview, IL 60025-1485;
Society www.ampainsoc.org
Pediatric Chronic Pain: 2001 American Pain The special needs in American Pain Society;
Position Statement Society pediatric chronic 4700 W. Lake Ave.;
pain assessment, Glenview, IL 60025-1485;
treatment, research, www.ampainsoc.org
and education
Pain Assessment and 2000 American Pain Assist managed care American Pain Society;
Treatment in the Managed Society organizations 4700 W. Lake Ave;
Care Environment: A (MCOs) in advanc- Glenview, IL 60025-1485;
Position Statement from the ing the quality of www.ampainsoc.org
American Pain Society pain management
services and the
patient satisfaction
and clinical out-
comes for people
receiving care
through these
organizations
Oncology Nursing Society 2000 Oncology Nursing Pain management in Oncology Nursing Society;
Position on Cancer Pain Society (ONS) patients with cancer 501 Holiday Drive;
Management Pittsburgh, PA 15220;
www.ons.org
The Assessment and 2001 American Pain Pediatric acute pain American Pain Society;
Management of Acute Pain Society; AND 4700 W. Lake Ave.;
in Infants, Children, and American Academy Glenview, IL 60025-1485;
Adolescents of Pediatrics www.ampainsoc.org or
American Academy of
Pediatrics; 141 Northwest
Point Blvd.; P.O. Box 927;
Elk Grove Village, IL
60009-0927;
www.aap.org

12
Table 2. Consensus and Position Statements (continued)
Date of
Title Release Developer Focus/Application Contact Information
Circumcision Policy March American Academy A policy statement American Academy of

Statement 1999 of Pediatrics on neonatal circum- Pediatrics; 141 Northwest
cision of the male Point Blvd.; P.O. Box 927;
infant Elk Grove Village, IL
60009-0927;
www.aap.org
Prevention and February American Academy A policy statement American Academy of

Management of Pain and 2000 of Pediatrics and regarding the recog- Pediatrics; 141 Northwest
Stress in the Neonate Canadian Pediatric nition and manage- Point Blvd; P.O. Box 927;
Society ment of pain in Elk Grove Village, IL
neonates (preterm to 60009-0927;
1 month of age) www.aap.org
Symptom Management: July State of the Science Assessment by expert State of the Science
Pain, Depression, and 2002 Conference panel of medical Statements; NIH Consensus
Fatigue (draft statement) Statement, Expert knowledge at the Development Program;
Panel time the statement www.consensus.nih.gov
was written regard-
ing symptom man-
agement in cancer
Definitions Related to the 2001 The Liaison Definitions of addic- American Academy of Pain
Use of Opioids for the Committee on Pain tion, tolerance and Medicine; 4700 W. Lake
Treatment of Pain, A and Addiction. The physical depend- Avenue; Glenview, IL
Consensus Document committee is a col- ence 60025-1485;
laborative effort of www.painmed.org or
the American American Pain Society;
Academy of Pain 4700 W. Lake Avenue;
Medicine, American Glenview, IL 60025-1485;
Pain Society & www.ampainsoc.org or
American Society of American Society of
Addiction Medicine Addiction Medicine; 4601
North Park Avenue; Arcade
101; Chevy Chase, MD
20615;
www.asam.org
Clinical Policy: Critical 2000 American College of Evaluation and man- American College of
Issues for the Initial Emergency agement of patients Emergency Physicians;
Evaluation and Management Physicians presenting with a Customer Service Dept.;
of Patients Presenting With a chief complaint of P.O. Box 619911; Dallas,
Chief Complaint of nontraumatic acute TX 75261-9911;
Nontraumatic Acute abdominal pain. www.acep.org;
Abdominal Pain 800-798-1822;
Ann Emerg Med. October
2000;36:406-415

13
Section III: Understanding Organizational Improvement In Pain Management
SECTION III: ■ Inputs—including patients, clinicians,

technology, equipment, pharmacologic
and nonpharmacologic therapies.
■ Throughputs—care processes.
Understanding ■ Outputs—including patient satisfaction,
pain experience, outcomes (e.g., morbidity,
Organizational length of stay), changes in clinician
Improvement In Pain behavior, and healthcare utilization (e.g.,
emergency room visits, rehospitalization).
Management Improvement efforts will produce the
greatest effect when inputs and throughputs
are simultaneously addressed by altering how
these elements interact to change outputs.29
As Donald Berwick, MD, has said, “Every
A. Viewing the Organization system is perfectly designed to achieve exact-
as a System ly the results it achieves” (cited in reference
Recent trends in health care performance 29, p. 6). Poorly designed systems often lead
assessment indicate organizations are moving to inefficiency and inadequate quality of
toward systems techniques and approaches care. Understanding and simplifying the
that originated in industrial improvement steps of a process can yield substantial
models. A system is a group of interacting, improvements in performance.
interrelated, or interdependent elements or
processes that form a collective entity and
share a common goal.21 Taking a systems
approach means emphasizing the organiza- B. Understanding Pain
tion as a whole, focusing on the interconnec- Management
tivity of processes and underlying structures, As with any clinical performance evalua-
recognizing relationships and interactions tion, it is essential to obtain and review the
across the organization, and identifying root latest information available before proceed-
causes of problems. Figure 1 illustrates how ing. The rapidly expanding body of evi-
an organization’s culture and leadership are dence-based findings related to pain manage-
influenced by patients (customers), staff ment makes it imperative to conduct such a
(people), strategies, and processes. review before implementing quality improve-
Similarly, improving pain management ment activities. Resources include criteria
performance requires “systems thinking,” (guidelines, consensus statements, and stan-
much like that used for identifying opportu- dards), journal articles, texts, Web sites, and
nities to improve the medication use other publications. McCaffery and Pasero27
process.23,24 The use of a systems approach suggest that pain management reference
when designing or redesigning processes materials, including books, journals, and
requires one to consider ways to overcome videos, be used to create an institutional
potential process or task design failures in library. Sources useful in identifying refer-
such areas as equipment, organizational and ence materials include: City of Hope
environmental factors, psychological precur- Pain/Palliative Care Resource Center Web
sors, as well as team building and training.25 site (www:cityofhope.org/prc) and
Experts consistently emphasize the need for Department of Pain Medicine and Palliative
a system-wide, collaborative, and interdisci- Care at Beth Israel Medical Center Web site
plinary approach to pain management.17,26-28 (www.stoppain.org). In addition, confer-
Strategies for improving pain management ences, professional society meetings, research
can be viewed in relation to a system com- symposia, and educational seminars are often
posed of: great sources of new or “cutting edge” infor-

14
Figure 1. Dynamics of Systems Thinking in Relation to the Health Care

Organization
• Create a shared strategic • Identify key strategic work

vision for the organization Strategy processes
• Develop a deployment plan to • Align all organizational work
translate the strategic plan into with strategic vision
action • Design an ongoing process for
• Identify critical success factors • Align culture with systematic review
strategic vision • Measure and monitor results
• Identify core • Communicate strategy • Identify critical
processes “strategic”
• Redesign key customers
processes • Identify
• Continuously Culture customer
improve
Process Leadership
Customer delight factors
processes • Create the
• Measure and organizational
monitor results • Train for leadership in capability and
rapidly changing infrastructure to
environment continuously
• Identify corporate and • Measure and monitor gather
individual competencies results “actionable”
necessary to achieve the customer data
strategic vision • Design and align reward and use them to
• Identify current competency and recognition systems drive process
levels People with organizational goals improvement
• Design and employ plans to and desired competencies and design
“close gaps” • Measure and monitor • Measure and
results monitor results
(22) This figure illustrates how an organization’s strategies, patients, staff, and processes affect its culture and leaders.
Reprinted with permission from Labovitz G, Rosansky V. The Power of Alignment: How Great Companies Stay Centered
and Accomplish Extraordinary Things. Copyright © 1997 John Wiley & Sons, Inc. This material is used by permission of
John Wiley & Sons, Inc.
mation. They also provide the opportunity sional and scientific meetings. These activi-
for staff to gain new skills, network with ties are critical to creating and maintaining
other organizations, and meet recognized exemplary practice in clinical services across
experts in the field. all types of settings.
Participating in research as a test site can
be an excellent opportunity for organiza-
tions. Benefits may include access to newly
developed technology, data collection strate- C. Institutionalizing Pain
gies, education, and support services as well Management
as aggregate comparative information. To The process of integrating good pain man-
learn about research opportunities, check agement practices into an organization’s
with academic institutions, professional soci- everyday life requires a comprehensive
eties, and government agencies (e.g., the approach that includes—and goes beyond—
Agency for Healthcare Research and Quality performance improvement to overcome bar-
[formerly known as the Agency for Health riers and to achieve fundamental system
Care Policy and Research]). It is important changes. Researchers and pain management
that healthcare institutions support research experts have identified a core set of activities
through funding, active participation and characterized by the use of an interdiscipli-
dissemination of research findings at profes- nary approach to facilitate these system

15
ods. These include forming a multidiscipli-

Eight Steps to Develop an Institutional nary committee of key stakeholders, analyz-
Pain Management Program ing current pain management practice per-
formance, and improvement through contin-
■ Develop an interdisciplinary work uously evaluating performance. Although
group. many steps are common to a quality
■ Analyze current pain management in improvement initiative, they may differ in
your care setting. scope. For example, the multidisciplinary
■ Articulate and implement a standard committee charged with integrating quality
of practice. pain management throughout the organiza-
■ Establish accountability for pain tion will often be addressing mission and pol-
management. icy statements, standards of care, accounta-
■ Provide information about pharma- bility, and overall practice issues. By contrast,
cologic and nonpharmacologic inter- a quality improvement work group generally
ventions to clinicians to facilitate has responsibility for a focused improvement
order writing and interpretation and activity (see Section IV.A [Establishing the
implementation of orders. Project Team]). The multidisciplinary com-
■ Promise individuals a quick response mittee may be established as a formal body
to their reports of pain. first, or in some organizations may evolve
■ Provide education for staff. from a quality improvement project team.35
■ Continually evaluate and work to Depending on the size of the organization
improve the quality of pain manage- and available resources, the committee may
ment. fulfill both roles.
(26) Gordon DB, Dahl JL, Stevenson KK, eds. Building
an Institutional Commitment to Pain Management. The
Wisconsin Resource Manual. 2nd ed. Madison, WI:
The Resource Center of the American Alliance of
Cancer Pain Initiatives; 2000. Used with permission. D. Understanding Current Pain
Management Practices in
changes.18,26,27 Collectively, this interdisci- Your Organization
plinary approach and the related activities One of the first priorities is to complete a
have been referred to as “institutionalizing comprehensive evaluation of the organiza-
pain management.” These strategies provide tion’s structures, processes, and people, refer-
a foundation for system change and effective encing key criteria for quality pain manage-
performance improvement activities. An ment practices. This organizational assess-
example of the steps associated with institu- ment may involve multiple data collection
tionalizing pain management is provided in activities including review of organizational
the text box above. resources, documents, and medical records;
Three books that provide extensive infor- completion of a self-assessment tool; and
mation on institutionalizing pain manage- assessment of staff knowledge and attitudes.
ment include Building an Institutional These measurement approaches, including
Commitment to Pain Management: The references for organizational self-assessment
Wisconsin Resource Manual,26 Pain Clinical instruments, are further described in Section
Manual,27 and Pain Assessment and V (Measuring What You Need to Know).
Management: An Organizational Approach.30 Understanding patient (or client) factors is
Organizational experiences and successful essential to completing the picture of current
efforts to institutionalize pain management management practices. No pain initiative can
are also reported in journal articles.28,32-34,117 succeed if patient needs are not carefully eval-
Among the suggested steps to institution- uated and addressed. A common starting point
alize pain management are activities com- is an examination of the answers given by
mon to modern quality improvement meth- patients and families to the questions on satis-

16
faction surveys. It is important to note that frameworks exist, virtually all include
researchers find that satisfaction survey results, defined steps that function as an operational
though important, often indicate a high level model for implementing improvement
of satisfaction even though pain intensity rat- processes. Figure 2 presents the widely used
ings show that individuals may be experienc- PDSA (Plan, Do, Study, Act) framework
ing significant degrees of pain.36-42 Satisfaction developed by Langley et al.21 A worksheet of
surveys also fail to capture significant patient- key questions associated with this cycle is
specific issues critical to successful pain man- provided in Appendix B.
agement in that they generally do not assess
patient knowledge and beliefs. It is essential 1. The Cycle for Improving
that patients know how and to whom to Performance
report pain as well as understand their treat- This monograph has adopted JCAHO’s
ment regimen. Measurement of patients’ Framework for Improving Performance, which
knowledge, attitudes, and beliefs through the includes a cycle similar to the PDSA cycle.44
use of assessment instruments is discussed fur- The JCAHO Cycle for Improving
ther in Section V.C.3 (Test Knowledge and Performance describes critical activities com-
Attitudes). This information is important to mon to many improvement approaches and
developing needs-based education and recog- provides for systematic, scientifically oriented
nizing patient barriers (see Section VIII.A action (Figure 3). The cycle is one compo-
[Factors That Influence Change]). Other nent of the framework that also recognizes
patient-related considerations that may figure factors in the external and internal environ-
significantly in designing a pain management ment that influence organizational perform-
improvement activity include: ance.
■ Specific special-risk groups such as the As shown in Figure 3, the cycle is a con-
elderly, children, and the cognitively tinuous process with four major activities:
impaired. design, measure, assess, and improve. All four
■ Special pain relief needs related to can- activities are important and must be
cer or chronic/acute illness. addressed to achieve a balanced, effective
■ Unique demographic characteristics approach. In the design phase, a function or
(e.g., ethnic/cultural, language, educa- process is created; in the measure phase, data
tional level). are gathered about the process to create an
■ Information obtained about current pain internal database for evaluating performance;
intensity levels derived from patient- in the assess phase data are analyzed to iden-
reported ratings. tify areas for improvement or to assess
Obtaining objective data related to these changes; and in the improve phase changes
patient and institutional factors will result in required to improve upon the original func-
a better evaluation of organizational perform- tion or process are implemented. This highly
ance. A thorough understanding of your flexible cycle allows health care organiza-
organization’s current practices will provide a tions to begin at any phase, and apply it to a
solid foundation for making recommenda- single activity or an organization-wide func-
tions, gaining needed support, and designing tion.
successful improvement interventions.
2. Repeating the Cycle at Different
Phases of the Project
E. Understanding Quality Whether one selects the PDSA cycle, the
Framework for Improving Performance, or a
Improvement Principles different approach, most improvement initia-
The past decade has been marked by an tives will require repeating the cycle for dif-
evolution in health care toward the use of ferent phases of the project. For example, if
modern quality improvement the quality management staff has identified
methodologies.29 Though several different
17
Figure 2. The PDSA Cycle
Act Plan
■ What changes ■ Objective
are to be made? ■ Questions and
■ Next cycle? predictions
■ Plan to carry out
the cycle
(who, what,
where, when)
Study Do
■ Complete the ■ Carry out the
analysis of the plan
data ■ Document
■ Compare data to problems and
predictions unexpected
■ Summarize what observations
was learned ■ Begin analysis
of the data
From: Langley GJ, Nolan KM, Nolan TW. The foundation of improvement. Quality Progress. June 1994:81-86.
Reprinted in Joint Commission on Accreditation of Healthcare Organizations. Using Performance Improvement Tools in
a Health Care Setting. Rev ed. Oakbrook Terrace, IL: Joint Commission on Accreditation of Healthcare Organizations;
1996.
infrequent patient reassessment as a problem, be planned across shifts (design/plan), the

they may take steps to organize a team to education would be implemented as a pilot
determine an overall goal for improving test on a single unit by having staff complete
reassessment practices (design/plan); use self- a pretest examination before the education
assessment tools and medical record audits to (measure/do), the education would be con-
measure the extent of the problem across the ducted (improve/act), and a posttest exami-
organization (measure/do); collect and ana- nation would be completed and the change
lyze data on reassessment in representative in scores would be analyzed (assess/study). At
patient care units (assess/study); and priori- that point, the education would be modified
tize potential improvement options and as needed and incorporated into orientation
implement interventions (improve/act). and other required education activities.
After agreement among quality manage- Table 3 provides examples of some differ-
ment staff members that a multifaceted edu- ent activities associated with the cycle for
cational intervention for nurses is needed, each stage of the improvement initiative.
the cycle would repeat. The education would

18
Figure 3. Cycle for Improving Performance
Design
Function or
Objectives Me
asu
Process re
Redesign Design Internal

Database
s
ses
As
Improvement/
Impr
Innovation ove
Improvement Comparative
Priorities Information
From: Joint Commission on Accreditation of Healthcare Organizations. Framework for Improving Performance: From
Principle to Practice. Oakbrook Terrace, IL: Joint Commission on Accreditation of Healthcare Organizations; 1994.
Table 3. Examples of Tasks Associated with Each Stage of the Improvement Cycle
Phase of Quality
Improvement Initiative Design/Plan Measure/Do Assess/Study Improve/Act
Understanding the • Organize team • Collect • Compare to • Identify

problem • Set overall project goals baseline established norms potential
• Integrate with data • Identify opportunities actions
organizational priorities for improvement • Prioritize
actions
Implementing the • Set target goals, desired • Pilot-test • Assess effectiveness • Implement full
improvement/ levels of performance intervention of pilot (redesign if intervention
intervention • Plan intervention • Collect pilot necessary)
schedule data • Analyze data on
• Obtain resources, • Collect data intervention
approvals to evaluate effectiveness
effectiveness • Compare results to
of goals
intervention
Continuous monitoring • Determine who, when • Remeasure • Reanalyze • Modify

and how monitoring will at regular periodically intervention if
be done intervals • Disseminate findings needed
• Identify new
opportunities
for
improvement

19
3. Integrating With Internal Quality ■ Using Web-based communications such

Improvement Activities as the list-serv
Ideally, pain initiatives should be integrat- ■ Attending educational conferences
ed into existing improvement functions. ■ Participating in learning networks and
Taking advantage of established institutional organizational performance improvement
improvement structures will help ensure sup- workshops such as those offered by the
port of key leadership and involvement of Institute for Healthcare Improvement
staff with quality improvement expertise and (www.ihi.org) or Joint Commission
dedicated resources. Look for ways to empha- Resources, Inc. (www.jcrinc.com)
size pain management improvement within To learn from organizations that have
the context of overall organizational received special recognition for quality
improvement goals. improvement practices, examine the initia-
It is useful to examine previous successful tives of winners of national quality awards
performance improvement initiatives at your such as the Malcolm Baldridge award
organization to identify the factors that lead (administered by the U. S. Department of
to success. Studying successful pain improve- Commerce) or the Ernest Codman award
ment initiatives completed by other organi- (Ernest A. Codman Award Program,
zations also can be valuable. This can be JCAHO, www.jcaho.org).
done by:
■ Networking through professional soci-
eties

20
Section IV: Designing Your Pain Management Improvement Initiative
SECTION IV: Another approach used by some organiza-

tions utilizes a “contract,” or written state-
ment of responsibilities and commitment for
team members.
Designing Your Several additional factors important to
successful implementation of quality
Pain Management improvement teams are shown in the box on
Improvement page 23.
Initiative
B. Selecting Objectives and
Target Goals
A. Establishing the Project Once the team is in place, the next step is
to define objectives for the organization’s
Team measurement efforts. As previously noted,
The composition of the project team is criteria such as those described in Section II
extremely important to the success of the (Getting Started on Measurement to
improvement project. As with any health care Improve Pain Management) provide valu-
issue, it will be important to include key able evidence-based principles and processes
stakeholders, including people with the neces- for evaluating pain management. In particu-
sary knowledge and skill in care processes, lar, the American Pain Society quality
“change champions” (motivated individuals improvement guidelines often are used to
who reinforce effective pain management establish improvement goals and objec-
behaviors and influence peers), and those tives.18 Improvement opportunities may be
individuals with the authority to support identified by comparing your organization’s
change (administrators). Improving pain man- current practice (using objective assessment
agement will require the participation of mul- data) with criteria.
tiple groups within an organization, and the If multiple opportunities are identified,
team should reflect the interdisciplinary objectives need to be prioritized, with one or
nature of the process. As major decision mak- two eventually selected. Objectives should
ers, physicians should be engaged early in the be manageable and measurable, and should
planning stages, or efforts to change care are reflect expectations that are meaningful to
likely to fail.45 Some suggestions for engaging patients as well as to health care profession-
physicians in quality improvement activities als. The following statements are examples of
are presented in the box on page 22. Because objectives:
the pain management process could potential- ■ A pain assessment will be completed
ly involve many individuals, it may be practi- upon admission.
cal to develop a core group and enlist addi- ■ A patient-identified acceptable pain
tional members who participate as necessary level will be noted on the chart.
on specific issues.35 Be sure to keep all mem- ■ Staff that manages specialized pain thera-
bers informed, especially if they do not attend py techniques will have successfully com-
all meetings, through communications proven pleted competency testing.
to be most effective in your organization such ■ Patient-reported pain intensity scores
as minutes, e-mail, phone, or newsletters. will be recorded in their chart.
Once the team is identified, define and Some organizations may further define the
assign roles and responsibilities. For example, objective by adding a target performance
in one hospital’s initiative to increase evi- goal. For example, the first objective could
dence-based pain management practice, roles have an assigned target goal of 90%. The tar-
were specifically defined for pain team mem- get goal describes a desired level of perform-
bers during the 3-year project (see Table 4).46 ance and serves as a “ruler” for measuring
21
Getting Physicians Involved in the Quality Improvement Process
Eight questions to ask:
■ Do physicians in your organization feel excluded from the team at the outset?
■ Are incentives poorly defined and identified?
■ Is the team too rigid in laying out its tasks?
■ Are goals and objectives vague or unrealistic?
■ Are there too few data, or is there misuse of data?
■ Is there a solid connection between the problem and its relevance to patient care?
■ Does the approach emphasize scientific methods?
■ Does the team have the needed expertise in continuous quality improvement tech-
niques, skill measurement, and data analysis (i.e., a data analyst or statistician)?
Eight solutions to consider:
■ Choose an important project with clear goals.

■ Include physicians on the ground floor. Ask what quality improvement issues they
would like to see measured and monitored.
■ Focus on data that are readily available, timely, and valid.
■ Adjust outcomes data appropriately to avoid misuse.
■ Recognize physician bias. Physicians care more about clinical outcomes and less about
quality improvement processes. Clearly identify benefits of quality improvement to
physicians and their patients.
■ Use physician time wisely: avoid meetings during office hours, and use fax, phone, tele-
conferencing, and e-mail as alternatives to face-to-face meetings.
■ Avoid engaging physicians in activities that require long training sessions and excessive
use of quality improvement terminology.
■ Strive to involve a few physicians who are opinion leaders.
Adapted from reference 45.
improvement. At the same time, setting C. Establishing the Scope of

incremental goals may provide positive Measurement
incentives as success is achieved in a defined
Once the team determines what to meas-
way. One example of using target goals to
ure (setting the objectives), it needs to
develop an internal “report card” for selected
decide the scope of measurement.
measures of pain management performance is
Measurement options can be defined in a
described by Starck et al.48 A modified
number of ways:
American Pain Society Patient Outcome
■ Discipline-specific measurement focuses
Questionnaire and a second instrument to
on a particular discipline (e.g., nursing,
assess consistency of the hospital’s processes
medicine, pharmacy) and probably is
with the AHCPR guideline were used to col-
most applicable when the intervention is
lect data and to develop a pain management
exclusive to the measured group and dis-
report card. The report card established
cipline-specific knowledge and skills can
desired target goals against which actual per-
be assessed.
formance was compared.
■ Service or unit-specific measurement
may be useful when the improvement
activity is limited to a specific area such

22
Table 4. Examples of Roles and Behaviors for Pain Project Team Members
Team Member Role/Behavior
Clinical nurse specialist Lead and coordinate implementation strategies in each patient
care population; pain program faculty member for pain assess-
ment, complementary therapy, and case study sections
Clinical pharmacist Lead and coordinate implementation strategies that involve

pharmacologic strategies; especially helpful in physician order
changes; pain program faculty member for opioid, nonsteroidal
anti-inflammatory drug, and case study sections
Physician Develop, advise, and deliver physician education; lead opioid

order revision; pain program faculty member for physiology
Researcher Develop project plan and proposal; obtain funding; coordinate

implementation, data collection, analysis, and outcome dissemi-
nation; provide overall leadership for project; pain program fac-
ulty member for project processes and outcomes
Program director Develop educational material, obtain funding, assimilate project

literature and materials, and garner institutional support
Source: Miller EH, Belgrade MJ, Cook M, et al. Institutionwide pain management improvement through the use of
evidence-based content, strategies, resources, and outcomes. Quality Management in Health Care. 1999;7(2):33. Used
with permission.
as a postoperative recovery or hospice

unit.
Common Characteristics of Successful
■ Population-specific measurement based
Quality Improvement Teams
on diagnoses or symptoms targets a
defined patient group—possibly across
■ Clear goals and a written charter
more than one unit—such as sickle cell
■ Clarity of each member’s role
or chronic pain patients.
■ A standard process for team meetings
■ Organization-wide measurement deals
and the team’s work
with all patients and service areas and is
■ Trained and oriented team members
useful when implementing process
■ External support and recognition
changes such as use of a specific pain
■ Effective leadership and facilitation
assessment tool.
■ Collaborative problem solving and
■ Health system–wide measurement looks
decision making
at organizations within the same admin-
■ Presence of leadership with the
istrative management system and is used
resources to implement proposed
when assessing activities across multiple
solutions
sites. For example, the Veterans Health
■ Time for team meetings and assigned
Administration adopted a national mon-
team work
itoring strategy for pain management
which is described in Section IX. Adapted from reference 47.
Finally, the scope of measurement should
be aligned with stated measurement objec-
tives and target goals. For example, it would
be insufficient to measure a single unit for an
organization-wide objective.

23
D. Identifying Resources and Examples of some of these materials are ref-

Project Timeline erenced in Section V (Measuring What You
Need to Know). Additional publications
The final steps of the planning process
include:
include determining necessary resources and
■ Pain Clinical Manual27
a timeline. Resources will be needed to sup-
■ Building Institutional Commitment to Pain
port the quality improvement team’s work as
Management. The Wisconsin Resource
well as to implement improvement interven-
Manual26
tions. Improvement interventions may
■ Pain Assessment and Management: An
involve patient-care related equipment (e.g.,
patient-controlled analgesia pumps), written Organizational Approach30
materials (e.g., educational booklets, surveys, ■ Examples of Compliance: Pain Assessment
instructions, assessment instruments), and and Management.49
media (e.g., teaching videos). Project-related Finally, the team must develop a timeline
resources may include equipment (e.g., com- based on realistic estimates for each step of
puters, printers), supplies (e.g., paper, flip the project; underestimating the amount of
charts, poster-boards,) and staff time (e.g., for time required is a common pitfall. Important
data collection, analysis, meetings, atten- project steps include the baseline perform-
dance at educational programs). ance assessment, pilot testing, redesign (if
Whenever possible, adapt and adopt from indicated), retesting, and full-scale imple-
existing reference materials to save precious mentation. The timeline can be as short as a
staff time and benefit from previous research. few weeks for simpler improvement efforts or
Fortunately, there is a rich foundation of as long as several years, which may be
materials developed and published by pain required to complete comprehensive quality
researchers to address organizational, clini- improvement projects.32
cian, and patient assessment as well as insti-
tutional policy statements and standards.

24
Section V: Measuring What You Need to Know
SECTION V: management is provided for each:

■ Conduct organizational self-assessment
■ Review medical records
■ Test knowledge and attitudes
Measuring What You ■ Directly observe the care
■ Conduct a point prevalence study
Need to Know ■ Assess patient status and outcome over
In the design/planning phase, specific time
objectives and the scope of measurement for ■ Collect indicator data
the improvement activity are identified. ■ Utilize an externally developed perform-
Careful planning to select project objectives ance measurement system.
that are measurable will help your organiza- Regardless of the method or measurement
tion prepare for the next step: data collec- approach selected, there are some common
tion. Data collection is used throughout the data collection issues to consider. Obtaining
improvement project, beginning with the quality data that can support performance
assessment of current performance and con- assessment is critical to a successful improve-
tinuing during and after interventions to ment initiative. The following provides an
document change. Deciding how to collect overview of the issues of data quality, data
the data (i.e., the measurement approach) is quantity, and use of data collection instru-
an important decision. Several considera- ments.
tions when selecting an approach are dis-
cussed in this section, and several measure- 1. Data Quality
ment approaches are presented. Ensuring data quality is an essential compo-
nent of the measurement initiative. High-
quality data are needed to establish the valid-
ity of the measurement and improvement ini-
A. Consider Your Measurement tiative (e.g., the extent to which the concept
being assessed is accurately measured and that
Approach
the improvement is a true improvement).50
Measurement involves the collection of
There are several issues to consider relative
specified values or facts. The data selected
to data quality. Some issues apply at the data
for collection should support analysis of the
element level, while others apply after data
goals and objectives identified for the proj-
elements have been aggregated (e.g., indica-
ect. The method used in data collection,
tor rates). Data quality issues can be
together with the identified data source(s),
described by using the concepts of accuracy,
constitutes the measurement approach. In
completeness, and consistency.
some instances the approach includes well-
defined data elements and collection process- a. Accuracy
es such as those required for the Minimum The accuracy of information at the data
Data Set (MDS) by the Center for Medicare element level is a function of the definitions
and Medicaid Services (formerly the Health (e.g., clarity and thoroughness), categoriza-
Care Financing Administration) or for par- tions (e.g., whether categories are appropri-
ticipation in a performance measurement ate, comprehensive, and mutually exclusive),
system. In other approaches, the organiza- and the overall clarity and readability of the
tion-specific data elements, sources, and col- instructions and documentation (e.g., inclu-
lection process will have to be identified. sion and exclusion criteria). Often, it is nec-
Many options exist for measuring perform- essary to describe a preferred source of data,
ance. In Section V.C (Selecting a because even simple items like patient age
Measurement Approach), the following can be recorded differently and in more than
measurement approaches are described and one place (e.g., on the chart versus in the
an organizational example specific to pain admission database). When aggregating mul-

25
tiple data elements to arrive at calculated

values (e.g., rates), the number and complex- Examples of Approaches to Assesing
ity of steps can affect the accuracy of the Data Quality
information.
b. Completeness Automated edit checks. The use of data
Completeness refers to the extent of miss- collection software allows for built-in edits
ing data. The more data elements needed, to promote data integrity. This is a benefit
the greater the opportunity for missing data. of using an automated approach to collect
data because some errors can be found and
c. Consistency corrected at the point of data entry. Also,
Consistency is often referred to as reliabili- missing data can be minimized by software
ty. Reliability is the extent to which the prompts alerting the user of needed
measure or data collection tool, when repeat- responses.
edly applied to the same population, yields
the same results a high proportion of the Periodic reabstraction by a person other
time. Three categories of reliability assess- than the usual data collector for a sample
ment include: internal consistency (used for group of patient records. This approach is
scores created from multiple items), inter- commonly used for manually abstracted
rater (used for medical record abstraction), data on a monthly or quarterly basis. A
and test-retest (used for survey measures).50 certain number or percentage of patient
To enhance consistency, one may want to records are pulled at random, and someone
consider these questions: Are different reabstracts the same data by using the same
departments using different pain scales or data collection tool as the original data
assessment tools? Are all patients being collector to determine an error rate. This
instructed consistently in how to use the method is referred to as “interrater or
tool? Will data collection be completed by a interobserver reliability.” Frequently occur-
few individuals, or many staff members? How ring errors are investigated to determine
will consistency between data collectors possible causes, and actions are taken to
(interrater reliability) be ensured? prevent the errors from recurring.
No data source or data collection process is
perfect; there are always trade-offs to consid- Duplicate data entry. Companies that spe-
er. For example, data from automated sources cialize in survey research often require all
may be more reliable than data that are man- or a subset of data to be entered twice (by
ually abstracted, but the information in auto- two people or one) to assess and ensure
mated sources (e.g., administrative) may be accuracy in data entry.
less clinically robust. Using scanable forms
can decrease errors associated with data entry, Run aggregate frequencies and means on
but may limit the types of responses that can individual data elements and rates. The
be entered. In general, as more people first step in data analysis is most useful to
become engaged in data collection, the relia- identify data quality problems. Typically,
bility of the process decreases. However, lim- one uses database software (such as
iting responsibility for data collection to one Microsoft Excel or Microsoft Access
or two people risks the possibility that staff [Microsoft Corporation, Redmond, WA])
turnover, illness, or reassignments can sub- to identify cases with missing values as well
stantially derail your project. This potential as outlier values (e.g., ages over 200 years,
problem can be mitigated somewhat by cross- excessive lengths of stay). One then needs
training people to perform different functions. to follow up with original data sources to
Data quality can be greatly enhanced by confirm or correct inaccurate information.
formal training and testing of data collection
procedures. These steps may initially require
extra time and resources, but will result in

26
enhanced credibility of results and buy-in

from stakeholders in the long run. Examples of Approaches for Selecting
Early in the process, it is important to deter- Samples
mine how you will monitor the quality of your
data. Remember that monitoring data quality Simple random sampling is a process in
needs to be done at regular intervals, deter- which a predetermined number of cases
mined by the length of the project. Examples from a population as a whole are select-
of different approaches are provided in the box ed for review. It is predicated on the
on the previous page. idea that each case in the population
has an equal probability of being includ-
2. Data Quantity ed in the sample.
A second consideration is the quantity Systematic random sampling is a process
(amount) of data you will need. Quantity is in which one case is selected randomly,
affected by both the total amount of data and the next cases are selected accord-
needed and the frequency with which data ing to a fixed interval (for example,
are collected. The amount of data needed every fifth patient who undergoes a cer-
depends on the type of analysis you plan to tain procedure).
do and the level of confidence you want to
have in your results. If you plan to use Stratified sampling is a two-step process.
sophisticated statistical analyses and/or First, the population is stratified into
intend to generalize your findings from a groups (e.g., male/female); second, a
sample to the population, you may want to simple random sample is taken from
use a power analysis formula to calculate the each group.
necessary sample size. See Scheaffer et al.51 Cluster sampling is a process in which
and Fowler52 for more information on sample the population is divided into groups;
size issues. Statisticians frequently recom- then some of the groups are selected to
mend a minimum of 30 cases in each group be sampled.
for analysis. It is always wise to consult with
the experts on sample size issues. Judgment sampling is a process in which
If you cannot collect data on all patients experts in the subject matter select cer-
in the population of interest, you can use tain cases to be sampled. Unlike the
sampling techniques to reduce the data col- previously mentioned “probability ”
lection effort. One example of a simple sampling techniques, this form of sam-
method for selecting a systematic random pling is considered a “nonprobability
sample is provided in Managing Performance sample.” It is likely that the sample
Measurement Data in Health Care.47 The group will not represent the popula-
steps are as follows: 1) obtain a list of tion’s characteristics. However, the
patients in the order in which they were experts selecting the cases may be trying
treated, 2) count the number of patients on to change a particular process.
the list, and 3) divide by the number needed Adapted from reference 47.
for the sample size. The resulting number
will be the interval between one patient on
the list and the next patient on the list who domly (using a random numbers table or a
is to be selected for the sample. In other die). Some commercial software programs
words, if the list has 300 patients and the such as Microsoft Excel include a random
needed sample size is 50 cases, every sixth sampling procedure. Selected approaches to
(300/50 = 6) patient record would be select- sampling are shown in the box above.
ed for data collection. To make sure each
patient has an equal chance of being select-
ed, it is helpful to pick the starting point ran-

27
B. Collecting Data With ■ Limitations in usual role activities

Established Assessment because of emotional problems
■ Mental health (psychological distress and
Instruments well-being).
Organizations should use structured data Permission to use the SF-36 Health Survey
collection tools, which can be paper forms can be obtained from the Medical Outcomes
and/or electronic data entry screens. They Trust at www.outcomes-trust.org.
may choose to develop these forms or pro- It is useful to consider several issues when
grams themselves, or adopt or adapt one selecting clinical assessment instruments
developed by others. The result is a wide developed by others. The Medical Outcomes
array of materials ranging from a simple chart Trust has identified eight attributes for evalu-
abstraction form to a sophisticated clinical ating existing health status instruments (Table
assessment product. The following defini- 5).58 These attributes could be useful when
tions are provided to differentiate between considering the selection and use of pain
various types of tools. assessment instruments developed by others.
Data collection tool: A user-friendly com- One should determine whether and how
posite of indicators, trigger questions, or state- the instrument has been evaluated for these
ments aimed at eliciting performance data attributes. Do the results indicate the instru-
about specific issues of concern.53 Two exam- ment can be applied successfully to your orga-
ples of this type of tool are the Medical Record nization’s patient population? Learning about
Audit Form54 and the Pain Audit Tool.31 the development and testing of an instrument
Quality improvement tools (performance will help ensure that it will support collection
improvement tools): A collection of tested of data that are meaningful and meet your
activities and nonstatistical and statistical performance improvement goals.
methods designed to facilitate the process of
improvement. An example of one of these 1. Pain-Specific Instruments
tools is the cause-and-effect diagram, also
Specific instruments have been developed
called a fishbone or Ishikawa diagram.
by researchers to assess for the presence of
Quality improvement tools are further
pain, the intensity of pain being experienced,
described in Section VI (Assessing and
and the impact of pain on the individual’s
Analyzing Your Processes and Results).
activities of daily living. In general, these
Patient assessment instruments: Tested
instruments may be grouped into those that
data collection tools designed to obtain
measure a single dimension (e.g., pain inten-
structured information about patient health
sity) and those that measure multiple dimen-
status and levels of functioning. Examples of
sions (e.g., pain intensity, duration, frequen-
clinical assessment instruments include the
cy, history, and impact on activities of daily
McGill Pain Questionnaire,55 The Brief Pain living). Some examples of common unidi-
Inventory,56,57 and the SF-36 Health mensional and multidimensional instruments
Survey.57a The widely used SF-36, which can are presented in Table 6. Additional infor-
be self-administered by persons over age 14 mation also is available in the companion
years or by using trained interviewers, meas- monograph, Pain: Current Understanding of
ures the following eight health concepts: Assessment, Management, and Treatments,
■ Limitations in physical activities because Section II, Assessment of Pain,9 and later in
of health problems this section within specific measurement
■ Limitations in usual role activities approach descriptions.
because of physical health problems
■ Bodily pain 2. Choosing Pain Instruments
■ General health perceptions
Considerations when selecting instruments
■ Vitality (energy and fatigue)
for measuring pain include:
■ Limitations in social activities because of
■ The type of pain to be evaluated.
physical or emotional problems

28
Table 5. Scientific Review Criteria for Health Status Instruments
Criterion Description
Conceptual and A conceptual model is a rationale for and description of the concept(s) that the
measurement model measure is intended to assess and the relationship between those concepts. A
measurement model is defined as an instrument’s scale and subscale structure and the
procedures followed to create scale and subscale scores.
Reliability The principal definition of test reliability is the degree to which an instrument is free
from random error. A second definition of reliability is reproducibility or stability of an
instrument over time (test-retest) and interrater agreement at one point in time.
Validity The validity of an instrument is defined as the degree to which the instrument measures
what it purports to measure. There are three ways of accumulating evidence for the
validity of an instrument: 1) content-related: evidence that the content domain of an
instrument is appropriate relative to its intended use; 2) construct-related: evidence that
supports a proposed interpretation of scores on the instrument based on theoretical
implications associated with the constructs; and 3) criterion-related: evidence that
shows the extent to which scores of the instrument are related to a criterion measure.
Responsiveness Sometimes referred to as sensitivity to change, responsiveness is viewed as an

important part of the construct validation process. Responsiveness refers to an
instrument’s ability to detect change, often defined as the minimal change considered
to be important by the persons with the health condition, their significant others, or
their providers.
Interpretability Interpretability is defined as the degree to which one can assign qualitative meaning to
an instrument’s quantitative scores. Interpretability of a measure is facilitated by
information that translates a quantitative score or change in scores to a qualitative
category that has clinical or commonly understood meaning.
Respondent and Respondent burden is defined as the time, energy, and other demands placed on those
administrative burden to whom the instrument is administered. Administrative burden is defined as the
demands placed on those who administer the instrument.
Alternative forms Alternative forms of an instrument include all modes of administration other than the
original source instrument. Depending on the nature of the original source instrument,
alternative forms can include self-administered self-report, interviewer-administered
self-report, trained observer rating, computer-assisted self-report, computer-assisted
interviewer-administered report, and performance-based measures.
Cultural and language The cross-cultural adaptation of an instrument involves two primary steps: 1)
adaptations assessment of conceptual and linguistic equivalence and 2) evaluation of measurement
properties.
Source: Lohr KN, Aaronson NK, Alonso J, et al. Evaluating quality-of-life and health status instruments: development of
scientific review criteria. Clinical Therapeutics 1996;18:979-986. Used with permission.
■ The measurement goals. Are you assess- tool, the time needed to administer the
ing multidimensional aspects of pain? tool, appropriateness and
■ Characteristics of the patient population interpretability.27,47
(e.g., language, cognition, age, cultural ■ Reliability. A pain rating scale should be
factors). reliable, meaning that it consistently
■ Resources required/ease of use. Consider measures pain intensity from one time to
the comfort of staff members with using the next.27
the tool, the ability of patients to use the ■ Validity. There are a number of different

29
Table 6. Examples of Unidimensional and Multidimensional Pain-Specific

Instruments
Name Type Description
Numeric rating Unidimensional A scaling procedure where subjects use numbers from 0 (no pain) to 10
scale (worst possible pain) to describe their pain; numbers may be presented
on a vertical or horizontal line, may include words and numbers, or may
be administered verbally27
Visual analog Unidimensional A scaling procedure used to measure a variety of clinical symptoms (e.g.,
scale pain, fatigue) by having subjects indicate on a straight line (usually 10
cm in length) the intensity of the attribute being measured59
Faces scales Unidimensional A scale depicting a series of faces with expressions representing increas-
ing levels of discomfort; examples include the Oucher,60 and the Wong-
Baker Faces Scale.61,62
Brief Pain Multidimensional A series of questions covering the intensity and location of pain plus the
Inventory history, impact on activities of daily living, and treatments56
(BPI)
Initial Pain Multidimensional A tool for the clinician to use in conducting a pain assessment; areas
Assessment Tool covered include location, intensity, quality of pain, onset, duration, varia-
tions and rhythms, manner of expressing pain, what causes and relieves
pain, the effects of pain, and other comments27
McGill Pain Multidimensional An assessment of pain from three dimensions: sensory, affective, and
Questionnaire evaluative55
(MPQ)
Sources: Adapted from references 27, 55, 56, and 59-63.
types of validity (e.g., construct and cri- severity and ratings of the pain’s interference
terion). The validity of assessment with functional activities (activity, mood,
instruments has been defined as the and sleep) for patients with cancer pain.
degree to which the instrument measures Using a 0 to 10 scale, they found three dis-
what it purports to measure.58 A valid tinct levels of pain severity. Specifically, they
pain rating scale has been described by determined that pain ratings of 1-4 corre-
McCaffery and Pasero as “one that accu- sponded with mild pain, 5-6 indicated mod-
rately measures pain intensity.”27 erate pain, and 7-10 signaled severe pain in
■ Sensitivity to small fluctuations in what the cancer patients surveyed.
is being scaled.64 One organization empirically evaluated
Each instrument has advantages and disad- three pain scales in an effort to select a scale
vantages that should be understood and con- for use in their improvement initiative.66
sidered. Tables 17 and 18 in the companion Three research questions were posed: 1) Is
monograph, Pain: Current Understanding of one of the scales easier for most patients to
Assessment, Management, and Treatment, use? 2) Is the choice of scales influenced by
highlight some of the advantages and disad- nursing unit, age, education, race, socioeco-
vantages associated with each tool.9 nomic status, diagnosis, or type of pain expe-
Psychometric properties for selected instru- rienced? 3) Do patients perceive that a rating
ments have been described in the literature. scale helps them describe their pain more
For example, Serlin et al.65 explored the rela- effectively? Three scales (a visual analog
tionship between numerical ratings of pain scale, a numeric rating scale, and a faces

30
scale) were presented to patients in the and support assessment of the impact of
study, who then completed survey questions the intervention?44
about using the scales. The results revealed The following sections outline common
that the faces scale was most often selected measurement approaches used in health care.
by patients, followed by the numeric rating However, these approaches are not the only
scale and then the visual analog scale. options available. A description of the
method, suggested applications, and resource
considerations are provided for each method
discussed.
C. Selecting a Measurement
Approach 1. Conduct an Organizational
When considering which measurement Self-assessment
approach to use, there are certain questions
a. Definition /description of method
to keep in mind. These include:
This method is used to determine an orga-
■ Does the method match/support the
nization’s status in relationship to targeted
measurement objective? For example, use
areas of performance. It involves the collec-
of a point prevalence study to measure
tion of organizational data using a compre-
events or processes undergoing rapid
hensive structured instrument that captures
change and with great variability may
key structural and process elements associat-
not yield sufficient or meaningful data.
ed with performance across the organization.
■ Which approach will provide the most
These include information about the struc-
reliable and highest quality data and the
tures that support quality pain management
least bias and subjectivity; which will
such as written mission and policy state-
minimize missing data?
ments, staff qualifications/credentials, staffing
■ What are the available data sources? One
patterns, forms for documentation, capital
should assess for data availability, but do
resources, information management systems,
not let data alone determine your meas-
and organizational management style.
urement goals.67 In many organizations—
especially large ones—data may be collect- b. Applications
ed but kept within individual departments Organizational self-assessment is critical in
and therefore cannot be routinely shared establishing a baseline of the organization’s
with others, or data may be collected in performance in pain management and iden-
more than one place. For example, data tifying potential opportunities for improve-
regarding pain medication administration ment based on objective data. It also can be
may be documented in an automated used over time to conduct ongoing evalua-
pharmacy information system as well as in tions of the organization’s performance.
the individual medical record. c. Resource considerations
■ What is the most economical option Conducting an organizational assessment
that fulfills measurement requirements? will require staff time and use of a developed
Consider the data collection burden tool. It is beneficial to involve multiple peo-
(e.g., time to collect the data, the staff ple in the process to obtain input from sever-
needed, access to/use of automated infor- al perspectives.
mation systems) against the benefits Two examples of organizational assessment
derived. For example, could data tools specific to pain management are the
retrieved from an automated administra- Institutional Needs Assessment Tool68 and a
tive database (e.g., pharmacy ordering) checklist to assess institutional structures
be used to collect indicator data, or is that will support efforts of improved pain
medical record review required?
relief.31 There are also organizational self-
■ Will the measurement strategies selected
assessment tools and worksheets designed to
be sensitive enough to capture changes
help focus quality improvement activities.
that occur as a result of the intervention,
31
rent review) or after the patient has been dis-

Organizational Example charged from the health care organization
(referred to as closed or retrospective
Conduct Organizational review).69
Self-assessment Medical records are reviewed with a struc-
tured review tool for completeness and time-
Completion of an organizational self- liness of information, and the presence of
assessment was an important part of the specific data is authenticated. In relation to
pain improvement initiative at pain management, a record audit can capture
Memorial Hospital of Sheridan County critical pieces of information about pain care
in Sheridan, Wyoming. Members of a such as:
team assembled to evaluate pain man- ■ The documentation of pain assessments
agement practice and identify opportu- and pain intensity ratings.
nities for improvement, utilized the ■ The timing and types of interventions
Institutional Needs Assessment data provided.
collection tool68 to complete this ■ Patient reassessment and response to
important assessment. Input from many interventions.
people was included to obtain a com- ■ Patient education for symptom manage-
plete and accurate picture based on ment.
information and responses from across ■ Evidence of discharge planning, which
the organization. The assessment pro- includes pain management instructions.
vided a frame of reference for initiating This review often is completed on a repre-
organizational pain management sentative sample of records (as discussed in
improvement efforts; and over time, it Section V.A.2 [Data Quantity]).69
has served a blueprint for identifying
and selecting opportunities for improve- b. Applications
ment. For additional information on the The medical record review can be useful at
improvement activities in this hospital several stages of the improvement initiative,
see Section IX, Examples of including determination of current practices
Organizations Implementing Pain at your organization, identification of areas
Management-Related Measurement and for focused review and improvement oppor-
Improvement Initiatives. tunities, measurement of baseline perform-
ance before implementing an intervention,
and measurement of performance change
Examples of such tools in JCAHO’s A Guide against the baseline.
to Performance Measurement for Hospitals53
include Assessment of Stakeholders c. Resource considerations
Outcomes, Data/Information Needs, Medical record review generally involves
Assessing Organization Commitment to staff time and requires the use of a defined
Performance Measurement and data collection tool. Hard copy records will
Improvement, and Determining Areas for require manual review by a staff member.
Organization Improvement. When the medical record is computerized,
this can be an automated process.
2. Review Medical Records A few examples of medical record audit
tools specific to pain management are the
a. Definition/description of method Medical Record Pain Management Audit,27
Medical record review (also known as an the Pain Management Audit Tool,70 the
audit) is the process of ensuring that medical Patient Record Pain Assessment Tool,71 and
records properly document patient care. The the Patient Record Pain Management
process can take place either while care is Assessment Tool.72
being provided (referred to as open or concur-

32
3. Test Knowledge and Attitudes perceptions of patients as well as staff.
a. Definition/description of method c. Resource considerations

This method uses a standardized instru- The primary resource required for this
ment to assess knowledge, attitudes, behav- method is time for administration of the
iors, or perceptions of a targeted group. An assessment or testing instrument. A few
instrument is administered before an inter- examples of knowledge and attitude assess-
vention to determine learning needs and ment instruments specific to pain are RN
after an intervention to assess change in Needs Assessment: Pain Management,73 the
knowledge, attitudes, or behaviors (pretest- Pain Knowledge and Attitude Survey,27 the
ing/posttesting). Pain Management Patient Questionnaire,27
and the Patient Outcome Questionnaire.18
b. Applications
This method is very useful as part of initial
4. Directly Observe the Care
and ongoing assessment of organizational
performance in pain management. It is a. Definition/description of method
important to assess knowledge, attitudes, and This method involves watching and not-
Organizational Example
Review Medical Records
The review of medical records has been a staple in the assessment of pain management
practice at Advocate Christ Medical Center in Oak Lawn, Illinois. Multiple aspects of
pain-related care processes and outcomes are tracked through chart review for general and
specialty populations (e.g., sickle cell patients, orthopedic patients). Early in 2002, a clini-
cal nurse specialist for pain management and the hospital-wide Pain Management
Committee pondered the issue of how well physicians were documenting pain information
on admission assessments. They decided to obtain baseline data and enact measures to
heighten physician awareness and improve documentation practices.
Developing a tool for data abstraction was the first step. Initially, the tool was designed to
capture only the existence of pain assessment documentation by the physician on admis-
sion or within the first 24 hours. However, after pilot-testing, it was revised to determine
the documentation of pain characteristics (e.g., intensity, duration, location) and use of a
numeric pain scale. A third and final change to the tool was the addition of the numeric
pain rating, recorded in the nurse’s admission pain assessment.
Chart review for baseline data began in March 2002. Data from 25 to 30 charts in three
selected units are abstracted monthly by the clinical nurse specialist for pain management
and two other clinical nurse specialists. Currently, charts are being selected from the med-
ical, surgical, and orthopedic units. Over time, the review will be rotated to other units.
In June 2002, a new intervention was added to the ongoing medical staff education activi-
ties. A “business card” on bright yellow paper was inserted in a plastic holder on the front
of each patient chart. It displays the “no pain” sign and poses the following questions:
■ Do you know the score (0-10)?
■ Did you document it?
To assess the impact of the card reminder system, data from charts reviewed after imple-
mentation will be compared with data from charts reviewed at baseline. Through contin-
ued record review, the committee hopes to see a trend toward increased documentation of
initial pain assessment information and use of pain scales by physicians.

33
ing the behavior of and/or interactions pain assessment and medication administra-
between caregivers and patients/customers.29 tion. It is best used when the observer is
Typically, a process of care performed by a unobtrusive and events being observed are
clinician is observed by a specially trained routine and familiar. It is not considered a
third party, who objectively notes each activ- good choice for unpredictable events/behav-
ity using structured methods of observation iors and events that are of long duration.75
and documentation.
c. Resource considerations
b. Applications This method will require observers with
Observational measurement can be useful appropriate training and qualifications. It is
for circumstances where the subject is time intensive and therefore costly. Also, the
unaware, unable, and/or hesitant to report, subject of the observation may alter his or
or lacks awareness of the events and activi- her behavior due to the presence of the
ties that are wanted. For example, it can be observer.76 However, this method offers
used for observing professionals in the course unique advantages over other approaches in
of performing routine care processes such as that it allows researchers to assess the quality
Test Knowledge and Attitudes
When Swedish Medical Center in Seattle, Washington, began to develop organization-wide inter-
ventions to improve pain management, testing staff knowledge and attitudes was a key activity. They
selected an established instrument, developed by McCaffery and Ferrell,74 and obtained permission
for use. It was distributed to all nursing staff, and 497 completed surveys were returned (pretest).
Survey responses were anonymous, but department identification was collected. The results were
reviewed carefully, and seven questions were selected as focus areas for improvement activities. Over
the next year and a half, multiple interventions were conducted in these focus areas. These interven-
tions ranged from patient and staff education to the development of a care protocol and documenta-
tion tool (see Examples of Compliance: Pain Assessment and Management49). As part of the organiza-
tion’s educational plan, a 1-hour staff in-service entitled the “Hour of Pain” was developed. It took
about 1 year to schedule all staff to attend.
The knowledge and attitude survey was administered a second time after all staff had completed the
educational program. A total of 430 surveys were returned (posttest). To measure change, aggregate
results were compared with those from the first survey. Answers revealed improvement in six of the
seven focus areas targeted in the educational program, with significant improvement for the ques-
tion “Who is the most accurate judge of the patient’s pain?”
Testing for knowledge and attitudes also has been done by individual units to assess special needs
and customize interventions. Most units have approximately 80 nurses, and a return rate of at least
38% (30 out of 80 surveys) is targeted. The surveys are used to determine the top five questions
answered incorrectly, which become the focus of further scrutiny and possibly improvement inter-
ventions.
The manager of the Swedish Pain Center noted that measuring knowledge and attitudes has been
an effective tool for changing behavior. Following the guiding principle of “keeping it as simple as
possible” has led to results that are understandable and have effectively supported improvements in
pain management practice.

34
of interactions and qualitative factors that lected at designated intervals (e.g., quarterly
can not be captured in documentation.75 or annually) on the occurrence of a specific
Examples of applications of the observa- event or outcome of interest for a defined
tion approach related to pain management period of time such as 1 week or 1 month.
include observation of clinicians conducting
b. Applications
pain assessments and observation of delivery
This method has wide applicability and
of nonpharmacologic therapies.
can be helpful in reducing the burden of data
collection, especially when the cost of con-
5. Conduct a Point Prevalence Study tinuous data collection exceeds the benefit.
a. Definition/description of method Alternatively, when targeted goals of per-
Point prevalence is a static measure of a formance have been achieved, it can be used
rate for an event of interest at a designated for ongoing monitoring to ensure that per-
point in time, or a census-type measure.78,79 formance is not deteriorating. For example, if
A point prevalence study involves use of a a performance improvement team has
scientific approach to collect data for calcu- demonstrated 100% compliance with an
lating a point prevalence rate. Data are col- improvement initiative to document an ini-
Directly Observe the Care
The Orthopedic Department of Mercy Medical Center–North Iowa, Mason City, Iowa, has
incorporated direct observation of care into annual competency assessment related to pain
management. Clinical staff and managers worked together to develop a standardized obser-
vation tool that reflects important components from the hospital’s pain management poli-
cy, the pain management flow sheet, and the University of Iowa guideline on acute pain
management in the elderly.77 The tool focuses on pain assessment and the planning, imple-
mentation, and evaluation of interventions. The tool is further refined for different staff
positions (e.g., registered nurse, licensed practical nurse, nursing assistant).
Observers use cognitive, technical, and interpersonal skills to assess competency in pain man-
agement. These observers are fellow co-workers who have undergone additional training
related to pain management, how to conduct an observation, and how to use the documenta-
tion tool. These individuals are recognized for their skills and knowledge related to orthope-
dic surgical pain, their ability to teach, and their nonthreatening approach. The pain man-
agement competency observation is conducted before the staff member’s annual review and is
documented on his or her evaluation.
As part of the direct observation process, the observer and staff member review the written
tool before the observed patient interaction. They introduce themselves to the patient,
and the observer quietly observes as care is provided. Special actions taken by the clinician
to address age- or patient-specific needs are noted in a section of the observation tool con-
cerned with special patient considerations. Staff performance in measured competencies is
checked as acceptable or unacceptable, and individualized comments are added. If areas for
improvement are identified, the observer and clinician identify an action plan and target
date for reassessment. The rich complexity of each patient situation provides a great envi-
ronment for learning, and the observation process supports the underlying goal of providing
an individualized educational experience that is positive rather than punitive.

35
tial pain assessment for each patient, the

team may decide to monitor performance Organizational Example
using a sample of charts at regular intervals
(e.g., 1 day per month) rather than review- Conduct a Point Prevalence Study
ing all charts.
Since 1971, the Office of Statewide
c. Resource considerations Health Planning and Development in
Data collection may be automated or California has collected and disseminat-
require manual review depending on the ed important financial and clinical data
data source. These considerations, as in all from licensed health facilities (see
methods, will determine the type of resources www.oshpd.ca.gov). Staff at the
necessary. A sound method for determining University of California Medical Center
the interval and time frame for data collec- in San Diego have expanded the man-
tion should be used to ensure that measure- dated data collection effort to include
ment objectives are met. data obtained from pain assessment
interviews and chart audits conducted
6. Assess Patient Status and Outcome on a single day each quarter. Working
Over Time in pairs, members of the Nursing
Quality Council gather information
a. Definition/description of method about all available patients on each des-
This method involves the repeated meas- ignated unit through concurrent patient
urement of strategic patient factors and char- interview and chart abstraction.
acteristics with established assessment instru-
ments in an effort to demonstrate change Although these data are maintained for
over time. internal use, the organization has built
b. Applications onto an existing data collection mecha-
This essential but underutilized approach nism to provide quarterly performance
provides critical information about various information that can be used to discern
aspects of patient status and outcomes. trends and track the effectiveness of
Measurement for pain management can quality improvement actions regarding
focus on areas of patient functioning and pain management over time. For exam-
experience such as pain intensity, satisfac- ple, in two data collection efforts, the
tion, functional status, treatment response, charts of 433 patients were reviewed. It
and knowledge and attitudes. was found that one organization-speci-
fied documentation standard was met in
i. Pain intensity/severity
only 39% of charts. In their discussion
It has been suggested that measuring pain
of results, the Nurse Practice Council
severity is one of the most important indica-
identified a structural barrier related to
tors of pain management.80 This outcome
the forms used in certain units, which
usually is measured with pain assessment
could easily be corrected to improve
instruments. These include the pain rating
this score. Of the 217 patients inter-
scales and pain assessment instruments previ-
viewed during the two collection peri-
ously discussed in Section V.B.1 (Pain-
ods, 92% reported that a pain relief
Specific Instruments). Additional informa-
action was taken within 20 minutes of
tion about pain intensity may be available
their report of pain. Communicating
from treatment administration records (phar-
this result to staff provided positive
macologic and nonpharmacologic) and
feedback on their responsiveness to
patient surveys.
patient reports of pain, which was
ii. Patient satisfaction rewarding and satisfying.
This information can provide valuable
insight into the quality of care as viewed

36
Assess Patient Status and Outcome Over Time
Since 1995, the Kaiser Permanente Northwest Pain Management Program has worked to
change attitudes and beliefs about pain while effectively treating plan members who are suf-
fering. The program is built around four components: 1) a multidisciplinary Pain Board to set
policy and oversee the program; 2) Multidisciplinary Pain Group visits that support primary
care practitioners by providing assessment information, patient education, and therapeutic
options and recommendations in the primary care setting; 3) a Multidisciplinary Pain Clinic
for tertiary care and complex interventions; and 4) communication systems that offer peer
consultation and mentoring via the electronic medical record and telephone.
Together with program development, the Pain Board designed a structured evaluation of the
program’s effectiveness based on measuring patient status and outcomes over time. Originally
they tracked three pain variables (pain now, least pain in past week, worst pain in past week);
seven functional variables (interference with general activity, work, walking, mood, sleep, rela-
tionships with others, enjoyment of life); two satisfaction variables (satisfaction with efforts of
your caregivers to relieve your pain and satisfaction with the outcomes of treatment); and six
utilization variables (mental health visits, other outpatient visits, inpatient days, prescriptions
filled, laboratory tests, imaging studies).
The pain, function, and satisfaction data were collected by a mail survey conducted 6
months after each series of patient visits. The utilization data were routinely recorded by
the electronic medical record and were analyzed annually for the 12 months before and the
12 months after the series of visits by the Pain Group. Analysis of data for the first 5 years
indicated that 5 of the original variables were the most sensitive indicators: pain now,
interference with sleep, satisfaction with efforts and effects, utilization of outpatient visits,
and prescriptions filled.
Through the evaluation, Kaiser Permanente Northwest was able to document statistically
significant decreases in the percentage of patients with self-reported pain scores greater
than 5 (on a scale of 1 to 10), interference-with-activity scores greater than 5, and interfer-
ence-with-mood scores greater than 5. Interestingly, they also found that as patients
became more knowledgeable about pain management, satisfaction at baseline decreased
over time (which is consistent with reports in the literature) and satisfaction after involve-
ment in the program increased over time. The data also showed that baseline pain levels
among patients referred to the program decreased over 5 years, providing evidence that the
educational benefits of the program have extended beyond those patients in the program
and have led to improvements in primary care practice. The number of different clinicians
referring to the program has risen to include 75% of all primary care physicians. Finally,
utilization statistics show specific cost savings related to fewer hospitalizations among
patients with chronic pain. After the Multidisciplinary Pain Group visits, 16% of treated
patients were admitted to hospital in the subsequent year, compared with the admission
rate of 47% to 55% reported in literature83,84; and the number of prescriptions for pain
medicine and other drugs decreased 30%, in contrast to a national increase of 33%.85

37
by the recipient or family caregiver and on the MDS (version 2.0) pain items was
may identify opportunities for improve- highly predictive of scores measured by the
ment. It is important to remember that sat- “gold standard” visual analog scale.82
isfaction and pain relief are not synony- v. Knowledge and attitudes related to
mous. Patient satisfaction with pain man- pain management
agement often is high, even in the pres- Testing the knowledge and attitudes of
ence of moderate to severe pain. The patients can provide significant insight into
measurement of satisfaction is complicated behavior and potential barriers to pain man-
by several factors that can influence satis- agement. More details about the instruments
faction ratings. It has been hypothesized designed to measure knowledge or attitudes
that as patients’ expectations for pain relief about pain management among patients are
are raised, their satisfaction levels initially provided in Section V.C.3 (Test Knowledge
may decrease.81 Dawson et al.41 explored and Attitudes).
the paradox of patients who are in pain yet
express satisfaction with their pain man- c. Resource considerations
agement. Some factors found to be predic- Resources often will be determined by the
tive of satisfaction included the patient’s complexity of the instruments used. Analysis
satisfaction with overall pain management, of changes in outcome data over time may
if their pain over the last year went down require statistical support.
and stayed down, and if the primary
provider told the patient that treating pain 7. Collect Indicator Data
was an important goal. These researchers
a. Definition/description of method
also found that the patients’ expectations
An indicator (also known as a perform-
about pain and pain relief were significant-
ance measure) is a quantitative tool that pro-
ly related to their level of satisfaction.
vides an indication of performance in rela-
Thus, it is important to view satisfaction
tion to a specified process or outcome.53
ratings in conjunction with other organiza-
Table 7 presents examples of some indicators
tional and patient variables. Sources
that have been developed by various organi-
include proprietary tools from companies
zations to measure aspects of pain manage-
specializing in patient satisfaction measure-
ment. A recent collaborative effort between
ment.
the Joint Commission, the American
iii. Functional status Medical Association and the National
Functional status refers to the evaluation Center for Quality Assurance to develop
of the ability of an individual to perform pain-related performance measures began in
activities of daily living such as walking, September 2001.
bathing, and dressing. Sometimes these ele- Developing a clinical measure can be a
ments are incorporated into pain-related complex and difficult task.50 Indicators, like
assessment instruments, or there are specific guidelines and instruments, should reflect
functional assessment instruments. certain attributes to make them credible and
iv. Multiple dimensions of functioning effective. Characteristics or attributes of good
These instruments incorporate pain assess- indicators have been defined by multiple
ment into tools designed to obtain an overall organizations experienced in health care
assessment of health status. Examples of such measurement.67 See Table 8 for some sug-
tools include the Resident Assessment gested desirable attributes against which
Instrument used in the MDS, which is indicators should be reviewed.
administered to patients in long-term care In general, a good indicator should raise
facilities, and the Outcome and Assessment important questions about the processes and
Information Set (OASIS), which is adminis- outcomes of pain management such as assess-
tered to Medicare patients receiving home ment, documentation, and treatment selec-
care. A recent study found that a scale based (continued on page 43)

38
Table 7. Examples Of Indicator Development for Pain Managementa
Topic Area Indicator Focus Application Developer/Reference
Prevention/Screening Initial patient evaluation Population: Vulnerable Elders Assessing the Care of Vulnerable
(defined as individuals 65 and Elders (ACOVE) Project. Rand
older meeting project speci- Health, Santa Monica, California
fied criteria) Chodosh J, Ferrell BA, Shekelle
PG, et al.
Quality indicators for pain man-
agement in vulnerable elders.
Ann Intern Med. 2001; 135
(8pt2):641-758, 731-738
www.annals.org/issues/V135n8s/
full/200110161-00004.html
Prevention/Screening Screening for chronic pain Population: Ibid Ibid
Prevention/Screening Nursing home residents experi- Population: Ibid Ibid

encing a change in condition
Prevention/Screening Screening for pain Population: Ibid Ibid
Prevention/Screening Initial evaluation of cognitively Population: Ibid Ibid

impaired patients
Diagnosis Evaluation for depression in Population: Ibid Ibid

patients with significant chron-
ic pain
Diagnosis Evaluating changes in pain Population: Ibid Ibid

patterns
Diagnosis Diagnostic evaluation of Population: Ibid Ibid

patients with significant chron-
ic pain conditions
Diagnosis Therapy for underlying condi- Population: Ibid Ibid

tions responsible for significant
chronic pain
Diagnosis Quantitative pain assessment Population: Ibid Ibid

using standard pain scales in
patients with chronic pain
Treatment/management Assessment of pain in hospital- Population: Ibid Ibid

ized patients with significant
chronic pain syndrome
Treatment/management Patient education for patients Population: Ibid Ibid

with significant chronic pain
syndrome
Treatment/management NSAID therapy for the treat- Population: Ibid Ibid

ment of chronic pain
Treatment/ management Monitoring of patients on Population: Ibid Ibid

NSAID therapy for the treat-
ment of chronic pain

39
Table 7. Examples Of Indicator Development for Pain Managementa (continued)
Treatment/ management Route of administration for pain Population: Ibid Ibid

medication regimens
Treatment/management Bowel management for patients Population: Ibid Ibid

with chronic pain and treated
with opioids
Postoperative care Intramuscular route not used Population: Patients having MetaStar, Inc
one of the following surgical 2090 Landmark Place
procedures: hysterectomy, Madison, WI 53713
partial excision of the large www.metastar.com
intestines, cholecystectomy, Source: MetaStar, Inc., Used
coronary artery bypass, and with permission
hip replacement.
Postoperative care Meperidine not used Population: Ibid Ibid
Postoperative care Use of self-administered or regu- Population: Ibid Ibid

larly scheduled dosing
Postoperative care Frequency of pain assessment Population: Ibid Ibid
Postoperative care Use of self-report pain scales Population: Ibid Ibid
Postoperative care Use of nonpharmacologic pain Population: Ibid Ibid

control
Preoperative care Preoperative pain history Population: Patients age 65 Center for Clinical Quality
and older who have had non- Evaluation (formerly
cardiac thoracic,* upper American Medical Review
abdominal,* lower abdomi- Research Center [AMRRC])
nal,* or hip or orthopedic Prepared for Agency for
extremity* surgery and who Health Care Policy and
are not drug or substance Research AMRRC-AHCPR
abusers, currently receiving Guideline Criteria Project:
narcotics for chronic pain, or Develop, Apply, And Evaluate
currently under treatment for Medical Review Criteria and
schizoaffective disorders Educational Outreach Based
Upon Practice Guidelines
* Specific ICD-9-CM codes
October 1995 AHCPR
Publication No. 95-N01
Preoperative care Preoperative psychosocial history Population: Ibid Ibid
Preoperative care Preoperative pain plan Population: Ibid Ibid
Intra-operative care Intra-operative pain management Population: Ibid Ibid
Postoperative care MU agonists in first 24 hours after Population: Ibid Ibid

surgery for surgical pain
Postoperative care NSAIDs in first 24 hours after sur- Population: Ibid Ibid
gery for surgical pain

40
Postoperative care NSAIDs after first 24 hours after Population: Ibid Ibid
surgery for surgical pain
Postoperative care Meperidine not routinely given for Population: Ibid Ibid
surgical pain
Postoperative care Analgesics not given intramuscu- Population: Ibid Ibid

larly except ketorolac
Postoperative care Supervision of regional medica- Population: Ibid Ibid

tion for surgical pain
Postoperative care Medication dose & route docu- Population: Ibid Ibid
mented for control of surgical
pain
Postoperative care Behavioral methods to reduce sur- Population: Ibid Ibid

gical pain
Postoperative care Self-assessment tool used to meas- Population: Ibid Ibid

ure surgical pain
Postoperative care Surgical pain monitoring Population: Ibid Ibid
Postoperative care Sedation monitoring for post-sur- Population: Ibid Ibid

gical patients
Postoperative care Respiration monitoring for post- Population: Ibid Ibid

surgical patients
Postoperative care Catheter site monitoring for post- Population: Ibid Ibid
surgical patients
Postoperative care Treatment change for continued Population: Ibid Ibid

post-surgical pain
Postoperative care Treatment change for over seda- Population: Ibid Ibid
tion of post-surgical patients
Postoperative care Treatment change for depressed Population: Ibid Ibid

respiration among treated post-
surgical patients
Postoperative care Treatment change for other com- Population: Ibid Ibid
plications among post-surgical
patients
Postoperative care Respiratory arrest among medicat- Population: Ibid Ibid

(outcome) ed post-surgical patients
Postoperative care Infection at catheter site among Population: Ibid Ibid

(outcome) medicated post-surgical patients

41
Postoperative care Urinary retention among medicat- Population: Ibid Ibid

(outcome) ed post-surgical patients
Postoperative care Pneumonia among medicated Population: Ibid Ibid

(outcome) post-surgical patients
Postoperative care Deep vein thrombosis among Population: Ibid Ibid

(outcome) medicated post-surgical patients
Postoperative care Discharge instruction regarding Population: Ibid Ibid

pain medication
Ambulatory care Appropriate prescription of Population: Patients taking a Project to Develop and
NSAID newly prescribed NSAID Evaluate Methods to Promote
Ambulatory Care Quality
(DEMPAQ) records
Delmarva Foundation for
Medical Care Inc. Final
Report to the Health Care
Financing Administration:
Developing and Evaluating
Methods to Promote
Ambulatory Care Quality
(DEMPAQ). Nov. 15, 1993
Ambulatory care Appropriate prescription of salicy- Population: Patients taking a Ibid

late newly prescribed long-term,
high-dose salicylate
Home care Improvement in pain interfering Population: All non-maternity The Outcome and Assessment
with activity adult (age > 21 years) home Information Set (OASIS) for
care patients, regardless of use in home health agencies
whether they improved, as The OASIS is the intellectual
long as it was possible for property of the Center for
them to improve Health Services and Policy
Research, Denver, Colorado.
See www.cms.gov/oasis/
Postoperative care Pain is treated by route other than Population: Patients who have Post-Operative Pain
IM had a major surgical proce- Management Quality
dure and were able to com- Improvement Project
plete a survey within 72 University of Wisconsin-
hours postoperatively. Madison Medical School
Source: J. L. Dahl, Used with
permission
Postoperative care Pain is treated with regularly Population: Ibid Ibid

administered analgesics
Postoperative care Pain is treated with non-pharma- Population: Ibid Ibid

cologic interventions in addition
to analgesics

42
Postoperative care The intensity of pain is assessed Population: Ibid Ibid

and documented with a numeric
(e.g., 0-10, 0-5) or verbal descrip-
tive (e.g., mild, moderate, severe)
rating scale
Postoperative care Pain intensity is documented at Population: Ibid Ibid

frequent intervals
Postoperative care A balanced approach is used to Population: Ibid Ibid

treat pain (e.g., regional tech-
niques, opioid and nonopioid
analgesicis)
IM: intramuscular; NSAID: nonsteroidal anti-inflammatory drug

aThis table presents a sample of focus areas for which indicators have been developed specific to pain management. For detailed
indicator specific specifications, readers are referred to the source and developer information provided. Clinicians should evaluate
indicators for accuracy, applicability and continuing relevance to current practice recommendations.
tion and response, as well as identifying Example: The denominator is all

opportunities for improvement.67 A good patients discharged from a postopera-
indicator also should encourage a search for tive recovery unit, and the numerator is
underlying causes or explanations of collect- all patients discharged from a postoper-
ed data.44 Toward that end, indicators should ative recovery unit with a pain intensity
focus on pain management processes or out- score of less than 5.
comes that are within the organization’s con- In a second type of indicator, the numera-
trol; the indicators should be clearly defined, tor is not a subset of the denominator. When
understandable, and able to be reported in a the sources of data are different for the
manner that is accurate, easy to interpret, numerator and the denominator, the relation-
and useful.67 An indicator is useful when it ship is more accurately referred to as a ratio.78
reflects concerns of patients, providers, regu- Example: Primary bloodstream infec-
lators, accreditation bodies, or other stake- tions for patients with central lines per
holders and is able to discern variation and 1000 patient days.
improvement in performance. Finally, a good A third type is the continuous variable indi-
indicator includes complete specifications for cator, in which the value of each measure-
consistent implementation and application.50 ment can fall anywhere along a continuous
scale.
b. Types of indicators Example: Time from patient request
Indicators may be calculated in various ways. for analgesia to administration of med-
The most common approach is to state the ication.
indicator as a proportion. The indicator is Indicators are useful in evaluating perform-
expressed as the number of individuals (or ance longitudinally and can be used to cap-
events) in the category of interest divided by ture various dimensions of performance such
the total number of eligible individuals (or
as timeliness or efficacy.11 They can be struc-
events) in the group.78 The numerator is there- tured to capture desirable or undesirable
fore a subset of the denominator. This type of aspects of performance. For example, an indi-
indicator often is referred to as rate-based.

43
cator could be used to determine whether ments to calculate indicator rates may need
patients’ discharge directions included pain to be programmed. However, indicators can
management instructions and emergency be calculated manually if the volume of data
contact information for problems (desirable) is not too great and the calculation algo-
versus discharge directions that did not rithm is not too complex.
include pain management instructions and
emergency contact information for problems 8. Utilize an Externally Developed
(undesirable). Process measures focus on spe- Performance Measurement System
cific patient care interventions performed by
health care professionals and are distinct a. Definition/description of method
from outcome indicators that measure the The Joint Commission defines a perform-
results of the patient’s interaction with ance measurement system as an entity con-
health care professionals. Each has advan- sisting of an automated database that facili-
tages and disadvantages, as described in tates performance improvement in health
Table 9.87 care organizations through the collection and
dissemination of process and/or outcome
c. Applications measures of performance. Measurement sys-
Collecting indicator data is useful for the tems must be able to generate internal com-
following activities: parisons of organization performance over
■ To observe patterns and trends in per- time and external comparisons of perform-
formance and stability of processes with- ance among participating organizations at
in an organization over time with objec- comparable times (www.jcaho.org).
tive data. Donabedian described a clinical performance
■ To capture distinct dimensions of per- system (also known as a measurement sys-
formance. tem) as a tool for rational management that
■ To evaluate multiple aspects of perform- supports assessment of performance with an
ance that are related to the selected epidemiologic perspective.93 Data are report-
improvement, which helps to ensure that ed at regular intervals (e.g., daily, monthly or
attention focused on one aspect of a quarterly) to a central database at the meas-
process does not result in deterioration of urement system, most often in electronic for-
other aspects.67 mats. However, submission of hard copy data
■ To measure factors in addition to the collection forms also is possible. The per-
clinical dimension (e.g., financial aspects formance measurement system analyzes and
of care) or patient satisfaction. reports the organization’s performance on the
Measuring performance on multiple indicators and provides comparative data
dimensions simultaneously sometimes is aggregated from other participants using
referred to as a “balanced dashboard.”88-90 standard or customized reports.
Indicators can be derived from criteria
such as guidelines, standards, or consensus b. Application
statements (if available) and thereby can Performance measurement systems are use-
support the assessment of performance ful for the following:
against evidence-based practice recommen- ■ Internal performance improvement
dations.91,92 activities for which no established data
collection processes exist. For example, a
d. Resource considerations system that measures patient outcomes
If new data elements are required for the over time often will provide detailed data
indicator, these would need to be collected collection tools and training manuals.
either through enhanced fields in automated ■ Provision of comparative outcome data
programs or manual data collection. This (comparison with other organizations or
method usually requires some automated against benchmarks). Some systems
data retrieval and analysis capabilities. The apply statistical risk-adjustment tech-
steps associated with aggregating data ele-

44
niques to certain outcome data. data from the organization’s own databas-
■ Meeting external demands for data for es to a central system database.
accountability purposes. For example, ■ Data analysis. Some systems are capable
home health and long-term care organi- of providing sophisticated data analysis
zations collect pain-related data through techniques that the organization does
measurement systems with OASIS and not have in-house.
the MDS, as mandated by the Centers ■ Data interpretation. Some systems may
for Medicare and Medicaid Services. provide access to professional staff who
can assist in understanding and interpret-
c. Resource considerations
ing the data.
Resource requirements are varied and may
■ Report production. In addition to stan-
range from sophisticated information systems
dard reports, some systems offer custom,
to manual data collection. The benefits and
ad hoc reporting options.
costs should be explored when considering
■ External comparison. Systems generally
use of a performance measurement system.
aggregate data from other system partici-
Some possible benefits of using a perform-
pants, providing an opportunity for
ance measurement system include:
external comparison.
■ Data collection. In some cases, the per-
Some other issues to consider regarding
formance measurement system may func-
participation in a performance measurement
tion “invisibly” by abstracting data from
system include:
existing repositories such as administra-
■ Cost. There are generally charges associ-
tive/billing data. In other instances, the
ated with participation, although some
system may provide hard-copy forms or
systems have no specific participation
specific software for direct data entry, or
fees (e.g., MDS, OASIS), and there are
it may allow for the electronic transfer of
even a few instances in which the system
Table 8. Desirable Attributes of Measures
Attribute Definition
1. Importance of topic area

addressed by the measure
1A. High priority for maximiz- The measure addresses a process or outcome that is strategically important in
ing the health of persons maximizing the health of persons or populations. It addresses an important
or populations medical condition as defined by high prevalence, incidence, mortality, morbid-
ity, or disability.
1B. Financially important The measure addresses a clinical condition or area of health care that requires
high expenditures on inpatient or outpatient care. A condition may be finan-
cially important if it has either high per-person costs or if it affects a large num-
ber of people.
1C. Demonstrated variation in The measure addresses an aspect of health care for which there is a reasonable
care and/or potential for expectation of wide variation in care and/or potential for improvement.
improvement If the purpose of the measurement is internal quality improvement and profes-
sional accountability, then wide variation in care across physicians or hospitals
is not necessary.
2. Usefulness in improving patient

outcomes
2A. Based on established clini- For process measures, there is good evidence that the process improves health
cal recommendations outcomes. For outcome measures, there is good evidence that there are
processes or actions that providers can take to improve the outcome.

45
Table 8. Desirable Attributes of Measures (continued)
Attribute Definition
2B. Potentially actionable by The measure addresses an area of health care that potentially is under the con-
user trol of the physician, health care organization, or health care system that it
assesses.
3. Measure design
3A. Well-defined specifications The following aspects of the measure are to be well defined: numerator,
denominator, sampling methodology, data sources, allowable values, methods
of measurement, and method of reporting.
3B. Documented reliability The measure will produce the same results when repeated in the same popula-
tion and setting (low random error)
Tests of reliability include:
a) Test-retest (reproducibility): test-retest reliability is evaluated by repeated
administration of the measure in a short time frame and calculation of
agreement among the repetitions
b) Interrater: agreement between raters is measured and reported using the
kappa statistic
c) Data accuracy: data are audited for accuracy
d) Internal consistency for multi-item measures: analyses are performed to
ensure that items are internally consistent.
3C. Documented validity The measure has face validity: it should appear to a knowledgeable observer to
measure what is intended. The measure also should correlate well with other
measures of the same aspects of care (construct validity) and capture meaning-
ful aspects of this care (content validity).
3D. Allowance for risk The degree to which data collected on the measure are risk-adjusted or risk-
stratified depends on the purpose of the measure. If the purpose of the measure
is for continuous quality improvement and professional accountability, then
requirements for risk adjustment or risk stratification are not stringent. If the
purpose of the measure is comparison and accountability, then either the meas-
ure should not be appreciably affected by any variables that are beyond the
user’s control (covariates) or, to the extent possible, any extraneous factors
should be known and measurable. If case-mix and/or risk adjustment is
required, there should be well-described methods for either controlling through
risk stratification or for using validated models for calculating and adjusting
results that correct for the effects of covariates.a
3E. Proven feasibility The data required for the measure can be obtained by physicians, health care
organizations, or health care systems with reasonable effort and within the
period allowed for data collection. The cost of data collection and reporting is
justified by the potential improvement in care and outcomes that result from
the act of measurement. The measure should not be susceptible to cultural or
other barriers that might make data collection infeasible.
3F. Confidentiality The collection of data for the measures should not violate any accepted stan-
dards of confidentiality.
3G. Public availability The measure specifications are publicly available.
From: American Medical Association, Joint Commission on Accreditation of Healthcare Organizations, and National
Committee for Quality Assurance. Coordinated Performance Measurement for the Management of Adult Diabetes.
Consensus statement. Chicago, IL: AMA; April 2001.86
a In some cases, risk stratification may be preferable to risk adjustment because it will identify quality issues of importance
to different subgroups.

46
Table 9. Comparing Process and Outcomes Indicators
Advantages Disadvantages
Process Indicators
1. They can directly measure what was done for an indi- 1. They may have little meaning for patients unless the
vidual or group (e.g., screening mammography for detec- link to outcomes can be explained.
tion of breast cancer). 2. If the process measure is a rate, the “right” rate may
2. They can assess care within a relatively short time win- not be known (e.g., emergency room use rates, proce-
dow (e.g., weekly or monthly for run charts, annually for dure rates).
some preventive services, episodes for acute and chronic 3. They are often quite specific to a single disease or a
disease care). single type of medical care, so that process measures
3. They can use relatively small sample sizes for common across several clinical areas or aspects of service delivery
processes. may be required to represent quality for a particular
4. They can frequently be assessed unobtrusively (e.g., group of patients.
from data stored in administrative or medical records).
5. They can be influenced by clinically appropriate actions
taken by the health care organization or clinician.
6. They can be interpreted by clinicians who may need to
modify their care delivery.
Outcomes Indicators
1. They tend to be more meaningful to some of the 1. They tend to be influenced by many factors that are
potential users of performance measures (e.g., con- outside the control of the health care organization.
sumers, purchasers). 2. They may be insensitive for making health care organ-
2. They more clearly represent the goals of the health ization comparisons, particularly if poor outcomes are
care system. rare (e.g., mortality rates for children).
3. They can provide a summary measure of the effective- 3. They may require large sample sizes to detect a statis-
ness of medical care across a variety of conditions, types tically significant difference.
of care, or processes of care. 4. They may require obtaining data directly from
patients.
5. They may take a long period of time to observe.
6. They may be difficult to interpret if the process that
produced the outcome occurred far in the past and/or in
another health care organization.
provides some reimbursement to partici- tomization may be limited or unavail-

pants. able.
■ Predetermined measures. Participants ■ “Black box” analysis methods. Some
are sometimes limited to the measures systems may provide risk adjustment
offered within the system. where applicable, but will not share
■ Lack of customization. To enable com- specifics of the methodology used with
parisons between participants, measures participants for proprietary reasons.
must be standardized and individual cus-

47
Collect Indicator Data
The use of indicators in the postanesthesia care unit at Middlesex Hospital in Middletown,
Connecticut, began when the nurses wanted to examine patterns of patient pain levels on
admission and discharge from the unit. Working with a member of the organization’s Pain
Management Team and Quality Improvement Department, they reviewed clinical practice
guidelines and scientific literature related to postoperative pain control. Initially, the meas-
urement focus was on whether patients needed pain medication on admission, whether
they needed pain medication between 1/2 and 1 hour after admission, and whether they
reported a pain score greater than 5 (0-10 numeric rating scale) on discharge from the unit.
After review of the initial data, it was determined that collecting the reported pain intensi-
ty scores would increase the usefulness of the data. Therefore, the indicators were rede-
fined. The denominator was defined as “patients entering the post anesthesia care unit.”
Three numerators were defined, each of which is concerned with the number of patients
reporting pain intensity scores in four categories: none (0), mild (1-3), moderate (4-6), and
severe (7-10). Numerator 1 refers to the number of patients reporting each category on
admission. Numerator 2 refers to the number of patients reporting each category between
1/2 and 1 hour postadmission. Numerator 3 refers to the number of patients reporting each
category on discharge.
To facilitate calculations, a specific data collection tool was created for nursing staff to
enter patient-level data. Data elements include date, diagnosis, pain level at three desig-
nated intervals, and a comments section for documentation of medication administration,
side effects, adverse events, or other pertinent information. Quality improvement staff
members then aggregated the patient-level data monthly on all entries with no missing
data (range of 46 to 81 patients per month). Results, reported as percentages, were shared
with postanesthesia care unit nurses at staff meetings and quarterly with the Quality
Improvement Committee, the Pain Management Committee, the Department of
Anesthesiology, and the Nursing Quality Council. Results for the first 3 months of 2002
showed an initial downward trend in pain intensity levels on admission and at discharge.
In April 2002, use of the indicators was initiated in outpatient surgery and at an off-site
surgery center.

48
Utilize an Externally Developed Performance Measurement System
Crouse Hospital in Syracuse, New York, began using the Total Quality Pain
Management™ (or TQPM) system provided by Abbott Laboratories in January 1998.
Crouse made the decision to adopt TQPM as its primary adult postprocedural pain assess-
ment and management tool because it was based on the patient survey first developed by
the American Pain Society, and because it provides access to regularly updated national
data. It also affords a broad overview of organizational performance over time, as well as
access to aggregated national data for use in comparisons and identification of benchmark
performance.
Using the system survey tool, the Acute Pain Management Quality Assessment Survey,
each unit targets completion of at least 10 forms on a monthly basis. Staff and volunteers
collect the surveys, which then are submitted to the Quality Improvement Department for
entry into the TQPM software database. After setting desired filters, the quality improve-
ment professionals at Crouse can produce standard graphs and tables. The data also are
exported to other programs (e.g., Microsoft Excel, [Microsoft Corporation, Redmond, WA])
for additional analysis and display options. Approximately twice each year, a call for data is
issued by TQPM to incorporate the local databases of the participant institutions into an
aggregated national database, which is then disseminated to each of the affiliate hospitals.
The results are shared with the Pain Continuous Quality Improvement Committee, who
evaluate the data and make recommendations to the unit managers and administration
based on their findings. These data have been used by Crouse to identify opportunities for
improvement (e.g., perceived wait times for pain medication), as well as track the mean
pain levels of the surveyed population over time. Due to the comparative nature of the
data with national means, and through the use of control charts with limits set at three
standard deviations, Crouse has been able to identify and plot any changes that occur
within the system on a hospital-wide as well as a unit-specific basis. Each of the nine indi-
cators tracked (from each major section of the survey) provides an objective measure of
the overall effort to maintain control of patient pain and gauge overall patient satisfaction
with pain relief methods and medications. Together, they provide a composite picture of
the hospital’s success in meeting and exceeding pain management expectations. Crouse
plans to continue to track its performance, measure change, and document successful
improvements in pain management initiated through continued use of the TQPM data-
base.

49
Section VI: Assessing and Analyzing Your Processes and Results
SECTION VI: A. Using Quality Improvement

Tools
The assessment phase is greatly facilitated
by the use of relevant quality improvement
Assessing and tools. The tools provide an essential com-
Analyzing Your mon structure for the analyses of problems
and results and are useful for ensuring that
Processes and Results the improvement activity is planned and sys-
tematic, based on reliable data and accurate
This section describes the assessment phase
analysis, and carried out with effective team-
in the cycle for improving performance.
work and communication.44 It is important
Assessment of data means translating data
to understand the purpose and capability of
into information one can use to make judg-
each tool (see definitions in Table 10) so
ments and draw conclusions about perform-
they are used appropriately. Although devel-
ance. The assessment phase allows one to
oped for distinct purposes, the tools may be
compare performance, determine causes, and
used in several stages of a project, including
set priorities for actions/interventions (base-
planning, identification of the problem,
line data assessment), and to evaluate the
analysis of baseline and follow-up data, plan-
effect of actions (results of improvement
ning solutions to the problem, and evalua-
interventions).44
tion of the results.95 A grid to help organiza-
Broadly defined, the assessment phase
tions select tools appropriate to the phase of
includes the following processes and activi-
the project is provided in Figure 4. Because
ties:
space constraints do not permit an adequate
■ Analysis of the problem
discussion of the use and value of these tools,
■ Analysis of data
readers desiring more information may find
■ Interpretation of the results of data
the following texts to be helpful: Using
analysis
Performance Improvement Tools in a Health
■ Display of data and results
■ Dissemination of information. Care Setting, Revised Edition,96 Managing
Assessment also requires that performance Performance Measurement Data in Health
(baseline or follow-up) be compared with Care,47 and The Team Handbook.95
some reference point.44 Examples of refer- Many of these tools were originally devel-
ence points include: oped for use in industrial quality control.94,96
■ Historical patterns of performance within The application of industrial quality
the organization. improvement methodologies to health care
■ Internal policies and procedures. was tested successfully by the National
■ Desired performance goals, targets, or Demonstration Project on Quality
specifications. Improvement in Health Care. This project
■ The performance of other organizations paired industrial quality experts with teams
provided in external reference databases. from 21 health care organizations. The
■ Established practice guidelines, stan- results are reported in Curing Health Care:
dards, and consensus statements. New Strategies for Quality Improvement97 and
Assessment is not a one-time activity. It is summarized in the text box on page 53.
usually done at several points in the process
such as problem identification, baseline
assessment, and reassessment after interven-
tion. In fact, assessment often continues B. Analysis of Data
beyond the immediate quality improvement Analysis involves sorting, organizing, and
project time frame at regular intervals (e.g., summarizing data into a form that enables
annually or every 6 months) to ensure that people to interpret and make sense of the
desired levels of performance are maintained. raw data. Understandably, raw data should

50
Table 10. Quality Improvement Tools: Definition And Usea
Phases of Quality
Tool Name Definition Improvement Process
Brainstorming A structured process for generating a list of ideas about an Problem identification
issue in a short amount of time Data analysis
Solution planning
Result evaluation
Affinity diagram A diagram designed to help teams organize large volumes Problem identification
of ideas or issues into major groups Solution planning
Multivoting A voting process that narrows a broad list of ideas to those Problem identification
that are most important Data analysis
Solution planning
Result evaluation
Selection grid A grid designed to help teams select one option out of Problem identification
(prioritization matri- several possibilities Solution planning
ces)
Cause-and-effect dia- A diagram designed to help teams picture a large number Problem identification
gram of possible causes of a particular outcome Data analysis
Control chart A plotting of data on a graph indicating an upper and Problem identification
lower control limit on either side of the average Data analysis
Evaluating results
Run chart A plotting of points on a graph to show levels of perform- Problem identification
ance over time Data analysis
Results evaluation
Check sheet A form designed to record how many times a given event Data analysis
occurs
Flowchart A diagram illustrating the path a process follows Problem identification

Data analysis
Solution planning
Scatter diagram A plotting of points on a graph to show the relationship Data analysis
between two variables Result evaluation
Pareto chart A bar graph depicting in descending order (from left to Problem identification
right) the frequency of events being studied Data analysis
Result evaluation
Histogram A bar graph displaying variation in a set of data and distri- Data analysis
bution of that variation Result evaluation

aFor more information on the use of these tools the following texts may be helpful: Using Quality Improvement Tools in a
Health Care Setting,94 Managing Performance Measurement Data in Health Care,47 and The Team Handbook.95

51
Figure 4. Selection Grid: Improvement Tools
Tool Selection Grid

Tool Phase of Problem-Solving Activity
Problem Solution Evaluating

Identification Data Analysis Planning Results
Brainstorming X X X X
Cause-and Effect (Fishbone Diagram) X X
Check Sheet X
Control Chart X X X
Flowchart X X X
Affinity Diagram X X
Histograms X X
Multivoting X X X X
Pareto Analysis X X X
Run Chart X X X
Scatter Diagram X X
Selection Grid Prioritization Matrix X X
Task List X X
Adapted from: Joint Commission on Accreditation of Healthcare Organizations. Using Performance Improvement Tools in
Health Care Settings. Rev ed. Oakbrook Terrace, IL: Joint Commission on Accreditation of Healthcare Organizations;
1996.
not be used to draw conclusions about a risk-adjust for variables outside the health
process or outcome.47 care organization’s control (e.g., intrinsic
Typically, the data to be analyzed will have patient factors) that are related to the out-
been entered (either directly from the data come of interest. For example, outcomes of
sources or secondarily from paper forms) into decreased pain intensity may be influenced
an automated database software program such by patient beliefs and attitudes, which often
as a spreadsheet (e.g., Lotus 123 [IBM Lotus, are outside the control of the health care
Cambridge, MA], Microsoft Excel [Microsoft organization. More information on risk-
Corporation, Redmond, WA]) or a database adjustment approaches for performance
management and analysis software package measurement data can be found in Risk
(e.g., SAS [SAS Institute Inc., Cary, NC]; Adjustment for Measuring Healthcare
Epi Info [Centers for Disease Control and Outcomes.98
Prevention, Atlanta, GA]; SPSS [SPSS Inc., The sophistication of the analyses and
Chicago, IL]). ability to draw inferences from a sample
Data analyses can be done through the use using statistical tests depend on many factors,
of relatively simple descriptive statistics (e.g., including:
medians, means and standard deviations, fre- ■ The design of the study.
quency distributions, proportions) or more ■ The quality of the data.
complex, inferential techniques. Analyses ■ The sample size.
can involve single variables, two variables ■ The level of data collected (e.g., patient,
(e.g., bivariate correlations), or multiple vari- unit, organization).
ables (e.g. multiple regression analyses). ■ The underlying distributions of the vari-
Analysis of patient outcomes sometimes ables (e.g., normal/Gaussian versus bino-
requires multivariate statistical techniques to mial).

52
process.53 It is used to determine whether the

Ten Key Lessons From the National process is functioning within statistical
Demonstration Project on Quality norms (in control). It is particularly useful
Improvement for distinguishing between random variation
in a process (common cause variation) and
1. Quality improvement tools can changes due to specific occurrences (special
work in health care. cause variation).99 For more information on
2. Cross-functional teams are valuable this topic, refer to the literature on statistical
in improving health care processes. process control. A few references include
3. Data useful for quality improvement Carey and Lloyd,100 Wheeler and
abound in health care. Chambers,101 Grant and Leavenworth,102
4. Quality improvement methods are and Sellick.103
fun to use.
5. Costs of poor quality are high, and
savings are within reach.
6. Involving doctors is difficult. C. Interpretation of the Results
7. Training needs arise early.
of Data Analysis
8. Nonclinical processes draw early
This often-overlooked activity is an essen-
attention.
tial component of translating data into infor-
9. Health care organizations may need
mation. Defined simply, “data are numbers,
a broader definition of quality.
10. In health care, as in industry, the information is what the numbers mean.”99
fate of quality improvement is first O’Leary reports that data interpretation
of all in the hands of leaders. and dissemination are enhanced when the
person(s) involved (i.e., the interpreter)
(97) Source: Berwick D, Godfrey AB, Roessner J. Curing demonstrates certain personal and profes-
Health Care: New Strategies for Quality Improvement. sional attributes.104 These include:
San Francisco, CA: Jossey-Bass; 1990. Used with
permission. ■ Problem-solving skills.
■ Thoroughness.
■ Open-mindedness.
■ The type of data to be analyzed (nomi- ■ Awareness of one’s own limitations.
nal, ordinal, interval, ratio). ■ A healthy degree of skepticism.
■ The availability of statistical analysis pro- ■ The ability to collaborate with other
grams. people.
■ Familiarity of the analyst with statistics ■ Strong communication skills.
and data analysis techniques. ■ Numeracy (the ability to think and
Individuals without a strong background in express themselves in quantitative
data analysis may wish to seek guidance from terms).
experts within the organization (e.g., a statis- ■ Computer literacy.
tician, data analyst, or other quality improve- One suggestion for enhancing interpreta-
ment professional) or consider use of an out- tion involves narrowing the scope of inter-
side consultant. Keep in mind that complex pretation to a workable amount of focused
analyses are not necessarily better for quality data (e.g., specific indicator rates or percent-
improvement purposes. Often, simple ages) rather than all available data at once.
descriptive statistics (means, standard devia- Another important step in the interpretation
tions, and proportions) are more revealing process is evaluating the strength of data
and useful for improvement. according to five aspects: 1) their clinical rel-
One well-known approach to data-driven evance to multiple stakeholders, 2) the range
evaluation of processes is the use of statistical of health care processes and outcomes that
process control. Statistical process control is they address, 3) the degree of reliability and
the application of statistical techniques such validity of the methods and findings, 4) the
as control charts to the analysis of a
53
degree of variation (fluctuation in processes

and spread/dispersion around an average Figure 5.
value), and 5) how much control providers
have over the process or outcome measured
by the data.104
Interpreting the results of multivariate sta-
tistical analyses can be complicated; it often
is helpful to seek advice from statisticians.
For example, when determining the statisti-
cal significance of the results, the experts
remind us that a p-value of less than 0.05 is
not a magical number; p-values can be sub-
stantially affected by sample size and vari-
ance.78,105 In some cases, p-values between
0.05 and 0.10 can signal important findings.
Another important issue is the difference
between statistical significance and clinical
importance. Clinicians need to judge that add up to the total number (or 100%)
whether or not the results are clinically sig- (see Figure 5). Bar charts are effective when
nificant—a decision that often is independ- displaying differences between groups (on
ent of the level of statistical significance.78 the horizontal axis) in frequencies or per-
For example, comparing a mean patient- centages. Line graphs are particularly useful
reported pain level score of 6.2 for one large for spotting trends in a process.99
department receiving in-service education Akin to the concept of multivariate analy-
on treatment approaches with a mean score ses, more advanced data display tools are use-
of 7.1 in a similar control group may be sta- ful for demonstrating multiple findings (e.g.,
tistically significant but clinically insignifi- rates, priorities, outcomes) on the same page.
cant and unacceptable relative to the target Examples of multiple measure display tools
level of performance. include 1) the balanced scorecard, 2) a dash-
board display, 3) a performance matrix, 4) a
radar chart, and 5) a stratified multivariable
display. Additional information on these
D. Display of Data and Results data display tools can be found in Tools for
For interpretation and dissemination to be Performance Measurement in Health Care: A
effective, it is essential to convey the find- Quick Reference Guide.99
ings and key messages as clearly and accu- Displays of data should be as clear and easy
rately as possible. Several considerations in to read as possible. For example, use of the
selecting data displays include: three-dimensional option when displaying
■ Who is the audience? the bars of a histogram can make it more dif-
■ What is the most important message? ficult to determine the y-axis intersection.
(Do not drown the audience in data.) All legends and axes should be clearly
■ What do you need to present a complete labeled because the audience may not take
and accurate representation of your find- the time to read accompanying text or they
ings? Be careful to avoid the pitfall of may not grasp the point(s) without subse-
emphasizing only the positive. quent reference to the material. The scale of
■ What graphical display capabilities do the horizontal (x) and vertical (y) axes
you have? should be appropriate to the range of possible
The most commonly used display tools are values. For example, depicting a change over
the pie chart, bar chart, and line graph. time of 10% looks very different (and poten-
Pie charts are most useful for displaying tially misleading) on a vertical axis scale
frequencies (or percentages) of single items

54
Figure 6. Using Appropriate Scales on Graphs
100 70
90 68
80 66
70 64
60 62
50 60
40 58
30 56
20 54
10 52
0 50
1st 2nd 3rd 4th 1st 2nd 3rd 4th
Qtr Qtr Qtr Qtr Qtr Qtr Qtr Qtr
This figure shows that using different vertical scales can affect the perception of the change in scores.
ranging from 50 to 70 than on a vertical axis sentations at staff meetings, other gather-
scale ranging from 0 to 100 (Figure 6). ings).
■ Written reports (e.g., published articles,
newsletter).
■ Visual displays (e.g., posters, story
E. Dissemination of boards).
Information ■ Electronic dissemination (e.g., organiza-
Given that substantial time and resources tion-wide Intranet, external Internet
have been invested to collect and interpret using list-serv).
the data, it is important to share the findings It is important to know your organization
as widely as is appropriate. Disseminating the and how information is best received. Think
results of the analysis process helps raise of creative ways to communicate your results.
awareness in the organization of how it is Make the learning experience interesting—
performing with respect to pain manage- even fun. When possible, use multiple meth-
ment. ods such as a verbal representation and writ-
Strategies or formats for dissemination ten report. Consider sharing your experi-
include: ences (both successes and challenges) outside
■ Verbal representation (e.g., lecture, pre- your organization by submitting an article to
a journal.

55
Section VII: Improving Your Performance
SECTION VII: timetables, and identification of measurable

success factors also are important considera-
tions. If target performance goals are estab-
lished for the intervention, care should be
Improving Your taken that these do not represent levels
below established standards of care, regulato-
Performance ry requirements, or other requirements when
This section reviews the steps related to these are applicable. A target performance
designing and instituting actions or interven- goal can serve as a reference point for meas-
tions (design/act) to achieve desired improve- uring the success of the intervention. For
ments. Interventions can vary widely from example, one organization set a goal that
changing structural aspects that support pain 100% of their patients receive information
management (e.g., vital sign flow sheets) to on the importance of pain management.48
adding/enhancing care processes (e.g., assess- Assessing the educational needs at your
ing patient pain). Several examples of pain organization is an important part of the eval-
improvement interventions are discussed. uation of current practice. Although educa-
tion alone may not change care, improve-
ments are unlikely to occur without it.
Studies examining this area have suggested
A. Designing a Pain the need for improved professional education
curricula addressing pain management.106-110
Improvement Intervention When designing educational interventions
After the team has completed analysis of consider the needs of:
data gathered to assess current practice, ■ Clinicians. Provide a solid foundation for
hypothesized root causes, and staff to practice good pain management
prioritized/selected opportunities for and continually reinforce these practices
improvement, the team can begin to plan through an initial program and regular
interventions. These interventions will com- updates. Tailor programs as necessary
prise specific actions such as implementing based on needs identified through assess-
an educational program for patients and staff. ments and support staff attendance by
Careful planning of the intervention will providing time. Changing clinician
help ensure that it can be accurately evaluat- behavior also will require the influence
ed for success. Aspects of implementation to of role models, the application of theory
consider include designing the intervention, to actual clinical practice situations, and
conducting a pilot test before widespread feedback on performance.
application, and identifying an approach to ■ Patients. Tailor the extent of informa-
measure the impact of the intervention(s) tion based on needs (e.g., hospice
before integration into normal organizational patients probably need more comprehen-
processes.99 sive information than patients having an
Designing interventions will involve outpatient surgical procedure [K. Syrjala,
detailed planning of all aspects of the inter- PhD, personal communication, 2001]).
vention such as developing or selecting writ- Use results of knowledge and attitude
ten materials and defining changes to care assessments to evaluate unique patient
processes. Other planning considerations needs, including reading and language
include deciding who will be involved in skills, education, and so on. Use a variety
testing, what information they will need, and of approaches such as printed materials,
how will it be communicated. Roles and video, in-house TV station, and one-on-
responsibilities of project team members and one teaching.
other champions of the improvement inter- For example, consider the steps involved
vention should be clearly defined. Details of in planning an educational program about
operationalizing the intervention, projected pain management for staff. Specifics of the

56
program content must be developed and a process, or evaluation approach. Addressing

method of delivery determined (e.g., lecture, these issues early before proceeding with
self-directed learning, teleconference). Staff large-scale application of the intervention
must be identified for participation, the suc- can prevent implementation failures, an
cess factors determined (e.g., a minimum test unfortunate outcome that is costly in terms
score on a posttest), and a timetable estab- of both money and staff morale. It is worth
lished for staff attendance. noting again that improving performance is a
There are many other interventions to repetitive process, and results may lead you
consider in developing a comprehensive to redesign the intervention and conduct fur-
improvement initiative. A few examples ther testing.67 Another benefit of the pilot
include: test is that the results can serve to persuade
■ Developing policies and standards of skeptics and cement support from leadership
care. to expand the improvement intervention.
■ Enhancing documentation through revi- When proceeding with organization-wide
sion of forms or redesign of electronic implementation, be sure to include all the
data entry systems. stakeholders in the process improvement
■ Development of pocket cards, analgesic activity. Involve as many clinicians as possi-
conversion charts, and other clinical ble early in the process to foster owner-
tools to assist clinicians. ship.45,112 As has been previously discussed,
■ Assigning accountability for pain man- pain management is the responsibility of
agement to specific staff. multiple disciplines, departments, and clini-
■ Developing competency evaluation cians as well as patients. Therefore, the suc-
strategies for clinical staff involved in cess of interventions will be enhanced by
pain therapies. securing commitment from key individuals
■ Developing or revising standing orders as who can serve as champions during imple-
needed. mentation in day-to-day practice. Some
■ Defining pain assessment protocols and organizations have found it beneficial to
implementing new instruments and phase improvement interventions in one
reporting scales. unit at a time, allowing for learning and
■ Defining appropriate utilization of phar- adjustment or improvement of the imple-
macologic agents. mentation process.46 Others have focused
■ Designing effective strategies to commu- first on organizational attitudes and broad
nicate pain management information to system change. Again, knowing your organi-
caregivers, patients and families, and all zation well and adjusting your approach to
key stakeholders. what will work is important. Finally, allowing
■ Providing feedback on performance to sufficient time for implementation of
effect changes in clinician behavior.46,93 changes is critical to success.32
B. Testing and Implementing C. Monitoring for Success

a Pain Improvement After implementing changes, close moni-
Intervention toring will be required initially to assess
After designing all aspects of the interven- whether the intervention is meeting expec-
tion, it is helpful to conduct a pilot test tations and targeted improvement goals.67
before full implementation111 to identify The collection and analysis of measurement
problems that could affect the success of the data will help in evaluating the appropriate-
intervention.44,67 Results of the pilot test ness of the project goals. Data may suggest
may suggest the need to change aspects of that the goals need to be adjusted.
the intervention’s design, implementation Monitoring also will help determine whether
the intervention is being implemented con-
57
sistently across the organization and will and improved outcomes can lag months to
highlight areas needing additional support. years behind improvement efforts.112
Influences external to the implementation Ongoing assessment of clinician knowl-
process should be considered for possible edge114 and a series of educational and moti-
impact. These include organizational factors vational activities repeated over time are
such as mergers, ownership/personnel necessary for lasting improvement in pain
changes, or reorganization as well as other management practices.74
significant environmental changes (e.g., reg- It is important to set goals for ongoing
ulatory or reimbursement). Related to that, it improvement. For example, if initial imple-
is important to regularly review educational mentation of the intervention was of a limit-
materials, documentation tools, guidelines, ed scope, it could expand to additional areas
and standards compliance.113 Ongoing moni- in the organization or across the entire
toring of performance improvement litera- organization. Measurement data might sug-
ture will alert the organization of the need to gest other improvement opportunities that
make adjustments as pain management and could be acted on. Performance goals might
treatment options evolve. need to be raised. How does your organiza-
After the success of the intervention has tion’s performance compare with that
been established, the next priority is to described in external references, if available?
ensure that the improvements are main- This is the time to secure a commitment for
tained. Again, measurement will be a critical those resources and approvals necessary to
factor in evaluating the intervention over maintain progress.
time. Although it is necessary to determine As performance across health care organi-
that performance continues to meet desired zations improves, the “bar is raised” and
goals, it may be possible to reduce the inten- ongoing attention will help ensure that prac-
sity (scope and frequency) of the measure- tices remain current. Also, new advances will
ment activity. Determining the level of mon- lead to new opportunities.
itoring necessary is part of ensuring sustained Finally, success should be celebrated.
success.44,67 Communicating improvements effectively,
and in a timely and ongoing way, will help to
reinforce the permanency of the change.
Positive reinforcement is a strong motivator.
D. Sustaining Change Recognize participants and share accom-
A performance improvement initiative is plishments with others in your organization
successful when the improvements become a through formal means (e.g., employee spot-
permanent part of the organization’s routine. light, staff recognition day, poster displays,
When an initiative succeeds, temporary newsletters, Intranet) and informal means
changes in practice become operational (personal visit by organizational leaders, spe-
processes (e.g., clinical pathways). cial lunch or treats).
Be aware that change in practice behavior

58
Section VIII: Understanding Factors That Affect Organizational Improvement
SECTION VIII: an effective improvement initiative. Each

organization will have unique challenges that
will need to be addressed (such as restructur-
ing or new computer systems). The following
Understanding sections describe issues that have been iden-
tified in the literature.
Factors That Affect
Organizational 1. Patient Factors
The impact of a patient’s pain beliefs and
Improvement perceptions on his or her response to pain
should be considered. In a recent study of
This section examines the potential of var-
chronic pain patients, pain beliefs and cogni-
ious factors to enable change (i.e., to facili-
tions were found to account for a significant
tate improvement) or to be a barrier to
amount of variance in general activity, pain
change (i.e., to inhibit improvement). Also
interference, and affective distress.116 The
included is how the principles of total quality
experience of pain “is a product not only of
management can be applied to improving
physiological mechanisms but also the
pain management performance.
patient’s knowledge and beliefs, emotions,
social well-being, as well as system factors,
including the multiple caregivers involved
with the patient’s pain management.”117
A. Factors That Influence Tolerance for pain is affected by genetic,
Change cultural, or personal belief systems. Elderly
Many factors influence an organization’s patients may begin with the expectation that
ability to implement change and improve they will have pain or that not much can be
performance (see Figure 7). These factors done.118 Similarly, Warfield and Kahn found
can be grouped into the following four cate- that 77% of adults surveyed in 500 U.S. hos-
gories: pitals believed that it is necessary to experi-
■ Patient factors ence some pain after surgery.119
■ Clinician factors Patients may be reluctant to report pain32
■ Organizational factors or unwilling to “bother” staff if they perceive
■ External/environmental factors that staff members are too busy.27,120
Many of these factors can be either barriers Sometimes patients use self-distraction
or enablers, or both barriers and enablers behaviors that include laughter, reading, vis-
under some circumstances. A particular fac- iting, and so forth, which may be effective
tor’s degree of influence will likely vary for a time but are sometimes misconstrued by
according to the health care setting. For
staff to mean there is no pain.27 Many
example, patient and family factors that
patients believe that they should be stoic and
affect compliance with pain treatment proto-
bear the pain or that asking for pain medica-
cols are likely to have greater influence in
tion is a sign of weakness. They may wish to
the home health environment than in the
disguise their pain so as not to worry family
hospital setting. In long-term care, some
members.
research has suggested barriers include less
Lack of knowledge or poor understanding
frequent contact with physicians and
about pain and treatment may contribute to
increased reliance on health care providers
fears about taking medication such as fear of
with little training in pain and symptom
addiction. Patients may not adhere to treat-
management, together with the increased
ment due to unpleasant side effects from the
incidence of cognitively impaired people
medication.121 Patients may be uncomfort-
who have complex medical problems.115
able assuming responsibility for self-control
Maximizing the influence of enablers and
of pain,122 or may hesitate to use newer tech-
minimizing the influence of barriers is key to
nologies such as patient-controlled analgesia
59
Figure 7. Examples of Factors Affecting Pain Management Improvement

Initiatives
Patient
Clinician
Knowledge
Knowledge
Involvement in care
Beliefs/culture
Beliefs/expectations
Time constraints
Improved pain
Management
Organization External/environmental
Policies/procedures Regulatory/quality oversight bodies
Staff/other resources Health care payment systems
Structure/leadership Media influence/societal beliefs
(PCA) devices. High cost and inadequate 2. Clinician Factors

insurance coverage for medications can cause Clinicians maintain a pivotal role in
patients to use medication sparingly; they changing pain management practice.
may fear that the pain will get worse and Clinicians can be defined broadly to include
they should “save” the medication for later. practitioners who are involved in clinical
On the other hand, patients and their fam- practice or clinical studies as well as clinical
ilies can be powerful allies and an effective leaders in executive positions.
force for change in promoting improvements. One well-documented clinician barrier is
Due in part to the increased availability of lack of knowledge about current evidence-
information from sources such as the based treatment.107-110 This lack of knowl-
Internet, patients have become more equal edge often stems from inadequate education
partners in determining health care choic- regarding principles of pain management in
es.76 Patients have increased knowledge and educational curricula.107,108,110 Clinicians’
expectations specific to their treatment. The misconceptions about pain treatments could
prominence of pain-related issues in the include an exaggerated fear of addiction
media has led to increased public awareness resulting from use of opioids;108 confusion
of the issues of pain management. Patient about the differences between addiction,
and family involvement in self-help organiza- physical dependence, and tolerance; or
tions (e.g., the American Chronic Pain unwarranted concerns about the potential
Association) also has increased the visibility for the side effect of respiratory depression.107
of these issues. Like patients, clinicians are affected by
personal beliefs and attitudes. For example,
some clinicians may believe that pain is an
important diagnostic tool, in spite of evi-
dence that supports the use of analgesia in

60
instances where it previously was thought to 3. Organization Factors

be contraindicated.123,124 Others may believe Organizations can enhance or impede
that pain is too difficult to treat or is transi- improvement in pain care in ways that may
tory and poses no harm. Some clinicians not be obvious, yet are highly influential.
believe that a patient who is asking for pain Sometimes, well-intended policies and pro-
medication regularly or from several doctors cedures can hinder the process. For example,
is abusing medication. Additionally there documentation forms may not have a space
may be a mismatch between the clinician’s for entry of pain assessment findings.
perceived ability to successfully manage pain Standing orders may be outdated compared
and his or her actual knowledge of current with current recommendations.
practice.107,110 Clearly, adequate resources are essential for
Finally, practice also is influenced by pro- a successful effort. These include, but are not
fessional culture and mindset. Some clini- limited to, the dedication of staff and equip-
cians believe that the professional is the best ment resources for the improvement initia-
judge of the patient’s pain and are unable to tive. The regular availability of appropriate
accept the patient’s report.27 For example, if medications, supplies, and equipment needed
the patient does not display behaviors associ- in daily patient care is important to organiza-
ated with pain (such as grimacing or crying), tional improvement. For example, insuffi-
the clinician may find it difficult to accept cient numbers of PCA pumps could lead to
the patient’s report of pain. Members of the delays in initiation of therapy. Conversely,
health care team may disagree on the pre- ready availability of some items can be coun-
ferred treatment plan, or there may be lack terproductive. For example, stocking of
of consensus between the health care team meperidine on units makes it an easy choice
and patients and their families. In today’s as a first-line agent, which can reinforce
strained health care environment, competing established patterns of prescribing, while pre-
demands on professional time and other ferred agents for pain management may not
institutional responsibilities sometimes result be as readily accessed.
in inadequate attention to pain management Of course, the most important resource
issues.117 issue is staffing effectiveness, which includes
On the positive side, changing pain man- staffing levels, experience, and education of
agement care begins at the bedside. nurses and other direct and indirect care
Therefore, clinicians are critical forces for staff. When decreased numbers of profession-
improvement. Advances in pain medicine al staff (or increased numbers of nonclini-
specialty education, new certification pro- cians) are caring for increased numbers of
grams, and other educational options such as patients and/or patients who are more
preceptorships have produced a cadre of cli- severely ill, it can be difficult to give pain
nicians with heightened awareness of, and management the attention it deserves.
expertise in, pain management. Similarly, staff turnover can have a negative
Numerous professional organizations pro- effect on educational interventions and con-
mote scientific approaches to practice, such tinuity of care.
as the American Pain Society, the American Organizational structure and culture also
Academy of Pain Medicine, and the influence improvement activities. Experts
American Society of Pain Management point to lack of accountability for pain man-
Nurses. Many journals are devoted to pain agement as one of the greatest barriers to
management, such as the Journal of Pain and improvement.26,27,120 Related problems
Symptom Management, Pain, Clinical Journal include lack of coordination between depart-
of Pain, Journal of Pain, Pain Management ments and pain management teams from dif-
Nursing, and others. There also is a prolifera- ferent specialties and, in some instances, dif-
tion of clinical texts, guidelines, position ficulty in gaining organization-wide accept-
statements, and evidence-based practice rec- ance for the work of individual departmental
ommendations. initiatives.125

61
Many of these barriers are readily overcome 4) decision to adopt a course of action, 5)
by key enabling factors associated with the initiation of action within the system, 6)
organization. Organizations that have a pain implementation of change, and 7) institu-
management champion—an individual who tionalization of the change.
acts as a role model and who is highly moti-
vated, energetic, and often charismatic— can 4. External Factors
be very successful in improving Patients, clinicians, and organizations are
performance.126 subject to influences exerted by the external
Similarly, there is a greater likelihood of environment. Compared with other coun-
success when leadership is interested and tries, the United States has a pluralistic
involved in the initiative.127 The literature health care system. This system, which
shows that change is most effective when emphasizes freedom of choice, also increases
primary change agents (change champions) fragmentation of care, thus complicating the
provide clinical leadership. Sound manage- effort to provide individual patients with
ment practices play a role as well. For exam- well-coordinated care across settings over
ple, recent studies of long-term care organiza- time.
tions have found that certain characteristics Payment mechanisms relating to medica-
of top management such as job tenure, edu- tions and specialized pain treatments and
cational experience, and professional services are not always designed to optimize
involvement appear to affect the adoption of pain management.132 For example, in a
innovative practices.115,128 Computerization national survey of pain specialists, Carr et
also can be an effective tool for change by al.133 found that two thirds of 223 anesthesi-
supporting consistent documentation, on- ologists reported a trend toward reduced
line knowledge, analysis, and timely feed- reimbursement for intravenous PCA; and of
back. those, 29% believed this trend would lead to
Finally, some organizations have a struc- decreased use of this approach.
ture and culture that embraces change. Sociocultural beliefs and trends also affect
Organizational change has been studied processes. An example is cultivation of an
extensively in the organizational manage- antidrug philosophy with campaigns such as
ment field, and various theories and strate- “just say no,” which may foster misconcep-
gies have been developed.129 For example, tions or fear. High-profile drug abuse cases
Zaltman and Duncan130 identified the fol- related to pain management also influence
lowing four strategies for implementing behavior among patients and clinicians.134
change in organizations: 1) reeducation, These beliefs and values often are manifested
which is based on unbiased presentation of in statutes, laws, and regulations that seek to
fact and assumes that rational people will control clinicians’ prescribing practices.
adjust behavior accordingly; 2) persuasion, In part, through increased visibility in the
which attempts to bring change through bias media, public opinion and attitudes toward
in structuring and presentation of informa- pain relief have begun to change. Recent
tion (i.e., selling an idea); 3) facilitation, court cases concerning patients with unre-
which involves interventions designed to lieved pain have heightened awareness of
make change easier for individuals who the need for appropriate pain management.7
already recognize the problem and agree on a Scrutiny of clinician practice includes not
remedy; and 4) power, which involves the only the investigation of the overprescription
use of sanctions or coercion to implement of opioids but increasingly the study of cases
and maintain change. Beyer and Trice131 of underprescribing.
identified seven stages that organizations Another powerful enabler is the fact that
experience during a change process: 1) sens- regulatory bodies such as state hospital
ing of unsatisfied demands, 2) search for pos- licensing agencies and accrediting organiza-
sible responses, 3) evaluation of alternatives, tions have added specific requirements relat-

62
ed to pain management. A recent example is B. Improving Pain Management

the announcement by the Secretary of Through the Principles of
Health and Human Services of the intention
to publicly report nursing home comparative Total Quality Management
performance information specific to pain Though this monograph has emphasized
management and other clinical care issues.135 continuous quality improvement using a
Similarly, the advances in scientific research, structured process, it is worth noting that
as well as the explosion of electronic and continuous quality improvement is one ele-
written health-related materials for both ment of the overall principle of total quality
consumers and professionals, have greatly management.136 McCaffery and Pasero, in
enhanced the knowledge base about the their landmark publication entitled Pain
need for proper pain management. Clinical Manual, have thoughtfully applied
the 14 principles of total quality management
to improving pain management (see box
below).27 The effectiveness of organizational
improvement initiatives will be enhanced by
application of many of the points contained
within these general principles.
The 14 Points of Total Quality Management Applied to Improving Pain Management
1. Create constancy of purpose for 3. Avoid dependence on inspection only.

improvement of care and service. Traditionally, errors and problems are
Concentrate on a long-term plan based discovered after the fact through a
on a patient-focused mission (e.g., provid- process of quality assurance (inspection).
ing patients with attentive analgesic This inspection process must be replaced
care). Consistently model the vision of with an improvement process that pre-
the organization (e.g., each person is a vents errors and problems. Stop endless
unique individual with certain rights). data collection on unrelieved pain, and
Enable staff to continuously improve establish a pain care committee to ana-
costs, services, and patient satisfaction lyze and synthesize the data; develop
through well-designed pain management plans to correct current pain problems
plans. Invest in a plan for continuing edu- and prevent the occurrence of new prob-
cation and a system of rewards to encour- lems.
age innovation in staff. Treat continuous
improvement of pain management as an 4. Avoid the practice of awarding busi-
ongoing obligation to the patient. ness on price alone.
Quality outcomes are possible only
2. Adopt the new philosophy. when quality materials, supplies, and
Quality pain management must become processes are used. Consider long-term
a driving passion of the organization, so cost and appropriateness of products
that undertreatment of pain in any care rather than just their purchase price.
setting is immediately recognized as Cultivate long-term relationships with
incompatible with the institution’s mis- vendors, rather than simple short-term
sion and unacceptable to all of its staff purchasing relationships. This requires
and physicians. that the supplier must consistently meet
the needs of the organization and com-

63

(continued)
mit to continually improving its product ure the effectiveness of the training.
(e.g., equipment and supply manufacturers Assign new staff members to trained pre-
become partners in providing attentive ceptors who will perpetuate quality per-
analgesic care by requesting input on how formance. Remember to encourage, not
their product can be improved to help cli- drive, staff. Adjust the preceptor’s work-
nicians provide better pain care). For load so that quality training is possible.
example, manufacturers of PCA pumps
often rely on suggestions from clinicians 7. Ensure qualified leadership for system
who use the pumps to improve the tech- improvement.
nology. Many suppliers offer a variety of The job of management is to lead.
free consultative services and sponsor edu- Leading is moving staff toward a vision,
cational programs for institutions that are managing is helping them do a better job
interested in improving pain manage- (e.g., ensure that pain care committee
ment. This point has implications for the members attend meetings, adjust the
organization’s internal “suppliers” (staff workload of the PRN to allow time for
and physicians) as well. Cultivating loyal- assisting others with pain problems).
ty and trust provides a secure practice
environment and long-term relationships 8. Drive out fear.
with less staff and physician turnover. Many experts consider this the most
important of the 14 points because when
5. Constantly improve every process for staff fear failure, embarrassment, or retal-
planning, implementation, and service. iation, they are unwilling to make sug-
Improving pain management is not a gestions and recommendations for
one-time effort. Teamwork is essential. change. This results in a lower level of
Approve the establishment of an interdis- quality. Consider and value all staff sug-
ciplinary pain care committee. Empower gestions. Appreciate that front-line staff
front-line staff to contribute to the members are “in the trenches” and have
improvement process (e.g., encourage invaluable knowledge of how to improve
them to serve as members of the pain care pain management (e.g., extend the con-
committee), to constantly look for ways to cept of the PRN program to all levels of
reduce waste and improve quality, and to nursing staff).
become accountable for pain management
(e.g., become a pain resource nurse). 9. Break down barriers between depart-
ments.
6. Institute teaching and reteaching. The goals of the various departments
On-the-job training alone encourages must complement one another, or quali-
worker-to-worker propagation of practice. ty is jeopardized. Foster teamwork by dis-
Many practices are faulty and outdated mantling systems that stop staff from
(e.g., promoting the idea that there is a working together to accomplish a proj-
high risk of addiction when opioids are ect. Help staff understand the needs of
taken for pain relief). Teach and reteach other departments and work together
(continuing education) front-line staff toward the organization’s vision.
members the important aspects of pain Promote processes that support the
management, give adequate support for vision (e.g., initiate postoperative intra-
providing effective pain relief, and meas- venous PCA in the postanesthesia care

64

(continued)
unit to avoid the dangerous scenario of promoting the philosophy of an interdis-

patients receiving intramuscular opioid ciplinary, interdepartmental approach to
injections on the clinical unit while wait- pain management. Avoid focusing on
ing for intravenous PCA to be initiated). individual or department performance
(e.g., pain management is everyone’s
10. Avoid trite slogans, exhortations, and responsibility); support teaching nurses
targets. to titrate analgesics, individualize doses,
Avoid using derogatory and ambiguous and manage side effects.
slogans such as “Just Do It!” These types
of slogans provide no direction and may 13. Institute a vigorous program of staff
offend and repel some staff and physi- education and continuing education and
cians. If slogans and motivational phrases self-improvement.
are used, explain them (e.g., “Our slogan Encourage staff members’ ongoing per-
is ‘Preventing Pain Is Easier than Treating sonal development even in areas not
Pain.’ This means that we remind patients related to their jobs. Continually provide
to request analgesia or press their PCA updated pain management information
buttons before their pain becomes to staff and consider the need for updat-
severe.”). Let staff and physicians know ed pain management technology to
exactly what is being done to make it eas- improve performance (e.g., evaluate and
ier for them to provide better pain man- reevaluate the way pain is being assessed
agement (e.g., post in all clinical areas a and managed and update approaches on
list of the names and numbers of supervi- the basis of advances in pain knowledge
sors and PRNs available to help with pain and technology).
problems).
14. Take action to accomplish the trans-
11. Eliminate numeric quotas. formation.
Quotas place a cap on productivity and Put everyone, including top manage-
conflict with the continuous nature of ment, to work on sustaining the organi-
quality improvement. Pain issues and zation’s new mindset (e.g., discuss the
problems are ongoing and unending. institution’s philosophy of providing
Encourage staff to look for more than one attentive analgesic care with all new
problem to solve and more than one way employees during their orientation and
to improve pain management. Allow pain update long-term employees during their
improvement work groups to evolve to a annual cardiopulmonary resuscitation
permanent standing interdisciplinary pain and fire prevention recertification class-
care committee. es).
12. Remove barriers to pride of workman-

ship.
Delegate authority and responsibility to
staff members to foster autonomy while
Source: McCaffery M, Pasero C, eds. Pain Clinical Manual. 2nd ed. St. Louis, MO: Mosby; 1999:714-715. Used with
permission.

65
Section IX: Examples of Organizations Implementing Pain Management–Related Measurement and Improvement Initiatives
SECTION IX: tional example, which describes the experi-

ence of the Visiting Nurse Association &
Hospice of Western New England, Inc.,
highlights the coordination of care across
Examples of settings and demonstrates the continuous
nature of the improvement cycle.
Organizations Small and rural hospitals sometimes oper-
Implementing Pain ate under extremely tight resource con-
straints, which can result in staff serving
Management–Related multiple roles. With an average daily census
of 32, Memorial Hospital of Sheridan
Measurement and County, Wyoming, overcame challenges
Improvement when the Pain Team implemented their “No
Pain, Big Gain” campaign. This example
Initiatives demonstrates the benefits of participation in
external educational programs and collabora-
tive activities to maximize internal resources.
Strong leadership support, creative improve-
ment strategies, and positive recognition are
A. Overview highlights of the initiative.
The purpose of describing these initiatives The pain management improvement
is to provide examples of how quality efforts conducted within the University of
improvement techniques can effectively sup- Iowa Hospitals and Clinics (UIHC), an 831-
port pain management improvement. The bed teaching facility, highlight the coordina-
examples illustrate how organizations used tion of pain management initiatives within a
systematic processes for improvement and large, sophisticated, and complex quality
how measurement provided important data improvement organizational structure. This
to support improvement activities. example illustrates how UIHC uses both
These are real-world examples, rather than centralized and decentralized approaches to
hypothetical ones. They illustrate how peo- pain management.
ple committed to quality improvement in As health care systems increase in com-
pain management achieved success within plexity, the process of improving pain man-
their organizations. The particular examples agement also becomes more complicated.
were chosen both to provide a diversity of Broad-scale initiatives require a substantial
settings and experiences and to suggest investment of time and resources. One key
strategies for overcoming obstacles to pain to success is giving organizations within a
management improvement initiatives. The health care system the option to customize
settings are a home health agency, a rural initiatives to suit their particular needs. The
hospital, an academic medical center, and fourth example describes the implementation
the hundreds of facilities under the Veterans of the National Pain Management Strategy
Health Administration. within the Veterans Health Administration
Improving pain management in home (VHA). The example presents strategies for
care, away from the institutional setting measurement and improvement driven from
where there is greater control over medica- the Washington, DC office, as well as the
tion delivery and therapeutic options, has its experience of two hospitals participating in a
own special challenges. Patient and family VHA-sponsored Institute for Healthcare
social, cultural, and economic factors greatly Improvement “Breakthrough Series” model
influence the care received in the home. collaborative.
Staff involved in quality improvement initia- There are more similarities than differ-
tives are geographically dispersed thereby ences in these four case examples. They
adding to the complexity. The first organiza- demonstrate that quality measurement and

66
improvement techniques can be used effec- 1. Special Challenges

tively in organizations of varying size and Agency staff recognized that the special
complexity. Many of the lessons described challenges of this pain improvement initia-
are consistent with the basic tenets of the tive included those that are common to the
quality improvement field, such as ensuring provision of health care in the home envi-
leadership commitment early in the process, ronment (e.g., earlier discharge from acute
using multidisciplinary teams, collecting and care settings have resulted in increased acu-
disseminating data effectively, sharing success ity of illness among home care patients,
and providing positive feedback to staff, and while the length of home care service is
accepting the fact that change takes time, decreasing) and those specific to this organi-
while understanding that perseverance will zation (e.g., coordinating activities across
pay off in the long run. Of course, each multiple offices that are geographically dis-
organization—as well as each improvement tant and between VNA and Hospice servic-
project—is unique. Readers are encouraged to es). Another challenge involved language
use these case studies not as blueprints, but as barriers in the special populations served by
resources to adopt and adapt to their particu- this agency, including people of Russian,
lar needs. Spanish, and Vietnamese origin. Also of spe-
cial concern are the clinically complex
patients and those requiring highly technical
equipment or procedures. These external and
B. Educational Effectiveness in organization-specific factors presented addi-
a Home Health Agency: tional dimensions for consideration in
Visiting Nurse Association designing a successful pain management
& Hospice of Western New improvement project.
England, Inc. 2. Choosing a Methodology
Late in 1998, the home and community
The Juran Institute’s Performance
services division of the Visiting Nurse
Improvement methodology was used for this
Association & Hospice of Western New
project.137 In preliminary meetings, team
England decided to evaluate pain manage-
members received education on the four steps
ment practice across its home care and hos-
of the Juran process: 1) identification and
pice divisions. This agency, originally estab-
establishment of the project, 2) determination
lished in 1907, is now part of the Baystate
of the root cause of the problem, 3) imple-
Health System, which includes three hospi-
mentation of a solution, and 4) holding the
tals and an infusion and respiratory services
gains. To facilitate goals of care coordination
company. The home and community services
across the system and integration with system
division has three sites in suburban and rural
quality improvement activities, a member of
locations; all three sites offer Visiting Nurse
this project team also served on the hospital
Association (VNA) programs and two offer
quality improvement committee. Quarterly
hospice care. The need to know whether
reports on the project were provided.
pain was being managed effectively through-
out the division, coupled with customer sat-
isfaction opportunities and external factors,
3. Assembling a Team
led the hospice staff to propose this initia- Members of the pain improvement project
tive. In addition, it was one in which the team were recruited from volunteers within
entire division could participate, thus pro- each program and from each site. Other
moting unity and teamwork among staff that members included a representative from both
includes more than 150 nurses as well as 95 the quality assurance and the education
home care aides. departments as well as the clinical supervisor
for the infusion and respiratory services com-
pany; the team was chaired by the hospice

67
director. Team members were chosen based 4. Identifying the Problem

on an expressed interest in pain management The members of the team began by look-
and a willingness to serve as a resource and ing at criteria, including guidelines (e.g.,
change agent at their respective offices. those of the World Health Organization and
Meetings were held monthly until project the Agency for Healthcare Research and
completion in December 2000 (see Table Quality [formerly the Agency for Healthcare
11). The medical director received and Policy and Research]) and standards (e.g.,
reviewed minutes, providing input as indicat- those of the Joint Commission on
ed. Authority for supporting the project- Accreditation of Healthcare Organizations).
identified changes and allocating resources They completed a literature search and used
was provided through the director of risk brainstorming to identify potential opportu-
management and the vice-president of the nities for improvement. Among the items
agency. The team’s overall mission was to identified in the brainstorming process, clini-
evaluate, improve, and standardize pain cian knowledge was selected for further
management across the home and communi- examination. The team decided to evaluate
ty services division.138 the knowledge and attitudes of nurses. They
also decided to conduct a medical record
audit and to review patient and family satis-
Table 11. Visiting Nurse Association &
faction surveys and organizational documents
(internal agency policies and procedures) to
Hospice Of Western New England Pain
further pinpoint opportunities for improve-
Performance Improvement Time Line ment.
a. Test knowledge and attitudes
Date Event To assess staff knowledge, the team adopt-
ed the survey tool developed previously with-
March 1999 First team meeting
in the Baystate Health System, but made
December 1999 Pain assessment tool evaluation and revi- slight modifications to address home care
sion to create a standard form; Pretest issues. The survey was completed by approxi-
given; Pretest results tabulated mately 80% of the nursing staff. Results
January 2000 Equianalgesic card finalized
pointed to opportunities for improvement
related to conducting pain assessments,
March 2000 Project presented at Baystate Health equianalgesic dosing, pain management in
System performance improvement meet- the elderly, and opioid side effects.
ing; Home care aides in-service
b. Review medical records
April 2000 Protocol/procedure review, revision, and Chart audits were conducted to evaluate
creation; In-services conducted for nurs-
ing staff
multiple aspects of pain management. The
review highlighted the need to improve the
June 2000 Competency testing after in-services; consistency and completeness of documenta-
Electronic medical record enhancement tion related to pain assessments and treat-
ment. For example, the documentation of
September/ Focus audit; Distribution of pain newslet-
October 2000 ter (self-learning model) patient response to treatment in visits fol-
lowing interventions for pain management
December 2000 Competency retest was inconsistent. It also was noted that pain
reports were not always described using dis-
January/February Focus audit
2001
crete ratings.
c. Review organizational documents
Organizational documents addressing
Source: C. Rodrigues, Visiting Nurse Association & Hospice of
Western New England. Used with permission. issues related to pain management were
reviewed. Policies and procedures such as a

68
patient rights statement and a pain assess- and families, focusing on the importance of
ment policy were evaluated. Many of these recognizing and reporting pain, using a pain
documents had been developed 4 to 5 years scale to describe pain, and understanding
earlier and needed updating or revision. their treatment regimen. All patients experi-
Based on the results of this baseline assess- encing pain as a problem received a pain
ment, some goals for improving pain man- scale for use in reporting their pain. Finally,
agement across the division were identified. to address the goal of enhancing the transi-
Particular goals included: tion from acute care to home care, the
■ Education of staff, patients, and family agency provided information to the hospital
regarding good pain management. about common problems such as patients dis-
■ Improvement of availability and timeli- charged with prescriptions that are difficult
ness of analgesic medications. to fill or that require titration every 4 hours.
■ Enhanced continuity when transitioning
b. Documentation
from the acute care setting to home care.
Pain assessment documentation was
■ Improved documentation of pain assess-
another area addressed by the project team.
ments and treatments.
Combining the best-practice findings from
■ Improvement or maintenance of high
the literature review with previously devel-
levels of patient satisfaction.
oped tools, they created a comprehensive but
■ Increased use of nonpharmacologic
user-friendly tool to capture pain assessment
approaches.
information. Next, the agency’s electronic
documentation system was reviewed for ways
5. Implementing Interventions
to better capture pain-specific information.
a. Education Updates were made to include pain as an
Educational interventions were identified identified problem. When pain was selected
by the team to address staff and patient as a problem, the system would trigger specif-
knowledge deficits, and to enhance the tran- ic questions for the clinician to ask at each
sition from acute care to home care. To subsequent visit. Documentation capabilities
address staff needs, a 2-hour curriculum (two were further enhanced with the introduction
sessions of 1 hour each) was designed that of a completely new electronic medical
had multiple learning formats and offered record system in 2002. The new system offers
continuing education credits. Staff attended more detailed care plans, a focus on processes
lectures and participated in small group dis- such as reassessment, and the ability to
cussions and role-playing exercises. Content update the central database from any phone
for the sessions included: line, allowing all staff access to the latest
■ Physical, psychological, and social visit information. The central database also
aspects of pain. will support the analysis of patient-specific
■ Misconceptions in assessing pain. data over time to create reports of patterns
■ Evidence-based pain interventions. and trends in care. Finally, organizational
■ Communicating pain information to pain management policies and procedures as
physicians. well as the patient’s rights statement were
The pain committee member at each updated or revised as necessary.
office actively participated in conducting the c. Treatment interventions
educational sessions, helping to establish To improve the availability and timeliness
these individuals as mentors and change of analgesic medications, the team identified
champions. A laminated trifold pocket card local pharmacies that maintain a 3-day sup-
was provided to all staff for quick reference ply of critical medications. Additionally, an
to the World Health Organization analgesic arrangement was established with a special-
ladder, opioid equianalgesic dosing, and opi- ized hospice pharmacy that provides
oid/coanalgesic equivalency tables. Nurses overnight delivery of medications for hospice
provided one-on-one education for patients patients.

69
Another intervention involved the addi- between the acute and home care setting
tion of nonpharmacologic treatments for have been improved through educational
hospice patients, including massage, aroma exchanges between the hospital and home
therapy, guided imagery, and heat/cold appli- care staff. Pain specialists from the health
cations. Treatments were provided by a vol- system pain clinic provide home care staff
unteer specialist. with special in-services on new technology
once or twice each year, as well as consulting
6. Analyzing Processes and Results on complex treatments or difficult-to-man-
Leads to Redesign age pain.
As a result of education, patients and fami-
a. Education lies have become increasingly aware of the
To assess the results of the clinician educa- importance of reporting and managing pain.
tional intervention, the annual nursing com- In fact, phone messages from patients fre-
petency assessment process was used. A med- quently include specific pain rating scores,
ication exam was developed that included noted Hospice Director Carol Rodrigues,
four questions specific to pain management. RN, MS, CHPN.
They were designed to test the areas of weak-
est performance on the initial knowledge b. Documentation
and assessment survey. The results showed Ongoing quarterly audits, focused on docu-
that across the agency, scores on these ques- mentation related to assessments, interven-
tions averaged a disappointing 63%. The tions, and reassessments, show a trend
pain project team began to examine the edu- toward more consistent and complete infor-
cational interventions and processes to mation. The team anticipates that the newly
understand why scores were not higher. They introduced electronic record will provide
identified the following problems: additional analysis capabilities and patient-
■ Only 25% of the staff were able to attend level data.
both in-services.
■ Timing of the sessions during the sum- 7. Sharing the Success and Sustaining
mer was complicated by vacations and Change
heavy caseloads. Improvements were shared with all staff
■ New staff had joined the agency and had through their office pain team member/men-
not received the educational interven- tor. This pain improvement initiative was
tion. selected as one of the Baystate Health
The pain team took action to redesign the System’s eight most successful initiatives for
educational intervention. A self-guided 2000. Team representatives did a poster pres-
learning approach was developed with the entation and attended a reception in April
same materials. A series of one-page newslet- 2001. A presentation also was made at the
ters was created and distributed weekly to all Hospice Federation annual meeting, and
staff and also incorporated into the new information was shared at the Massachusetts
employee orientation. Examples of covered meeting of the National Association of
topics include assessment of pain and types Home Care. The agency further shared their
of pain, titration and equianalgesic dosing, experience in an article that was published
and side effects of medication related to pain in the American Journal of Hospice &
management (Figure 8 shows a sample Palliative Care.138 The initiative has engen-
newsletter). They also received Management dered excitement in staff and served as the
of Cancer Pain: Adults139 and the pocket cue springboard for further improvement activi-
card. Retesting of all staff was conducted ties.
after the second educational intervention, Measures are being taken to sustain the
and results showed significant improvement, improvements in pain management. The
with a mean score of 94% (Figure 9). new electronic documentation system will
Transition and coordination of care continue to enhance pain-related documen-

70
Figure 8. Second Pain Management Newsletter Distributed by the Visiting Nurse

Association & Hospice of Western New England
Pain Newsletter 2: Reasons for Good Pain Assessment and Management
■ Improved patient satisfaction and quality of life

■ Required by JCAHO for home health as well as hospice
■ Supported by evidence-based practice
■ May prevent litigation (several cases against RN staff for poor pain management)
What effect does pain have on a person’s quality of life?

Physical
• decreased functional ability
• diminished strength, endurance
• nausea, poor appetite
• poor or interrupted sleep, no restorative sleep
Psychological
• diminished leisure, enjoyment
• increased anxiety, fear
• depression, personal distress
• difficulty concentrating
• somatic preoccupation
• loss of control
Social
• diminished social relationships
• decreased sexual functions, affection
• altered appearance
• increased caregiver burden
Spiritual
• increased suffering
• altered meaning
• reevaluation of religious beliefs
There are many common misconceptions on pain held by health care providers. Yet we know that:
■ The patient and not the health care provider is the authority on his/her own pain.
■ There are physiologic and behavioral adaptations to pain; the lack of expression does not equal lack of pain.
■ Not all causes of pain are identified; no cause does not mean no pain.
■ Respiratory tolerance is rapid.
■ Sleep is possible with pain.
■ Elders experience pain—do not express it as much.
■ Addiction is rare: 0.1% to 0.3%.
Source: C. Rodrigues, Visiting Nurse Association & Hospice of Western New England. Used with permission.
tation. Medical record review will enable cialized education to serve as pain resource
monitoring of gains. Clinicians will be tested nurses. A new admission booklet is being
annually regarding their knowledge of pain designed to include important pain-related
management. Pain education has been inte- material along with general agency informa-
grated into the orientation program for new tion. This is part of an ongoing commitment
staff. Family and patient satisfaction will to make pain management a normal part of
continue to be monitored via questionnaires. the organizational culture.
To expand expertise within the agency, two This pain improvement initiative required
new staff members each year will receive spe- time, patience, a willingness to redesign

71
taken in November 1999, when the director

Figure 9. Mean Score on Staff Pain of nursing at Memorial Hospital, Micki
Management Knowledge Survey: Bonnette, RNC (home care/hospice), and
Visiting Nurse Association & Hospice Pam Hall, RN (radiation oncology), attend-
ed a 1-day program entitled “Cancer Pain
of Western New England, Inc.
Role Model Program,” conducted by the
100
Wisconsin Pain Initiative. Subsequently, Ms.
Bonnette and Ms. Hall applied to and com-
90 94 pleted the pain nurse preceptorship program
80 at the Medical College of Wisconsin–
70 Milwaukee to further develop their pain
60
management expertise and support develop-
63
ment of an institutional program.
50
Upon return to Memorial Hospital, Ms.
40 Bonnette spearheaded activities to assess cur-
30 rent organization-wide practice. The first
20
step was an organizational self-assessment
utilizing a structured instrument. Second, a
10
knowledge and attitude survey specific to
0 pain management was distributed to nursing
Pretest Posttest
staff. One section of the survey asked the
This histogram shows the mean scores on a staff pain
nurses to identify barriers they experienced
management knowledge survey before and after an to providing quality pain management.
educational intervention at the VNA & Hospice of Lastly, an organization-wide sample of charts
Western New England, Inc. (C. Rodrigues).
was reviewed by using a slightly modified
version of the Medical Record Audit Form.54
interventions, and use of nontraditional The results of these measures of current
approaches. These lessons can be applied to performance provided an indication of both
any pain improvement project in any health the strengths and opportunities for improve-
care setting. ment in pain management practice across
the organization. Specifically, the chart
audits revealed inconsistent documentation
of pain assessments and patient-reported pain
C. Creative Improvement in a intensity ratings. In part, this was because
Rural Hospital: Memorial there was no specific location to document
Hospital of Sheridan County pain-related information on existing medical
record forms. The staff survey results identi-
Memorial Hospital of Sheridan County, an
fied the following priority areas for educa-
80-bed facility nestled beneath the Big Horn
tional interventions: 1) pain assessment and
Mountains of Wyoming, serves the medical
managing pain in specialty populations, 2)
needs of a largely rural county with a popula-
pharmacologic management of pain, 3) non-
tion of 26,000 people as well as the sur-
pharmacologic interventions, and 4) psy-
rounding area. The organization’s mission,
chosocial issues in pain. After compiling
“to provide quality health care services that
these data, Ms. Bonnette and Ms. Hall felt
improve the well-being of our community,” is
ready to convene a dedicated Pain Team to
exemplified in their pain management
facilitate a pain improvement initiative.
improvement efforts.
2. Establishing a Team
1. Doing Some Homework
A notice calling for interested persons to
The first steps toward developing this pain
form a Pain Team was posted in May and
management improvement initiative were

72
June 2000 on the hospital Intranet. Efforts No Pain, Big Gain, was launched with numer-
were made to identify potential members ous fun and educational activities to raise
from multiple disciplines and departments. awareness among staff and the community of
The 12-member team met for the first time the organizational commitment to pain man-
in August 2000 and included representatives agement (see the text box on pg. 75).
from pharmacy, nursing (inpatient services In March 2001, the patients’ rights state-
and home care/hospice), radiation oncology, ment was posted in all units and departments
and anesthesiology. A nurse who specialized of the hospital next to the hospital’s mission
in counseling and chronic pain, and a nurse statement. A pain resource manual was
director of complementary medicine joined developed and placed on all units and in the
the team a year later. The Director of physicians’ lounge, along with a copy of Pain
Nursing, also an active team member, pro- Clinical Manual.27 Information about the
vided strong management support and vali- campaign was placed in medical staff mail-
dated pain improvement as an institutional boxes and the public was alerted through a
priority. The team first evaluated the results special news release in the local paper.
of the current practice assessments, consid-
b. Education
ered the aspects of good pain management
Multiple educational interventions were
practice already in place, and developed a
conducted during and after the campaign
mission statement: “All patients have the
kick-off week. These included a pain sympo-
right to pain relief.”
sium, a movie, a self-directed learning exer-
Meeting monthly from August through
cise, and printed materials. The traveling
December 2000, the team selected objec-
educational exhibit included a posttest with
tives, defined interventions, and proposed a
an optional extra-credit medication conver-
timeline for 2001. Additionally, a library of
sion problem. All patient-care staff were
pain resource information was established,
encouraged to complete the quiz. Special off-
including a selection of key journal articles
site educational interventions were offered
and guidelines, a copy of Building An
for medical staff through collaboration with
Institutional Commitment to Pain Management,
other community health care organizations.
The Wisconsin Resource Manual,26 and 30
For example, in March 2001 a program was
copies of McCaffery and Pasero’s Pain Clinical
arranged with guest speaker Michael
Manual27 for distribution on individual units.
Ashburn, MD, President of the American
Two surveys, one for nursing and one for
Pain Society. A newsletter, Pain News Weekly
medical staff, were distributed to elicit infor-
was developed to further highlight and rein-
mation on educational needs (content) and
force information. Finally, patient education
preferences for teaching methods as well as
interventions included the provision and
scheduling options.
review of information about patients’ rights
and responsibilities, pain reporting and use of
3. Implementing Improvements scales, and discharge instructions.
The objectives for pain management
improvement selected for 2001(which are c. Documents and forms
described in Table 12) fell into three general One of the first actions taken by the team
areas: was to identify and select a designated pain
■ Increasing awareness of pain manage- scale. They combined a numeric rating scale
ment of 0-10 with the Wong-Baker Faces scale62
■ Staff and patient/family education on a laminated card and also selected the
■ Assessment and documentation (forms). FLACC140 pain intensity scale for preverbal,
nonverbal, and cognitively impaired patients.
a. Increased awareness Pocket cards with dosing guidelines for anal-
The planning and initial work of the Pain gesics and equianalgesic charts were prepared
Team was showcased in a weeklong kick-off in for clinicians. Policies and procedures were
February 2001. The campaign, designated as revised and updated during 2001.

73
Table 12. Memorial Hospital of Sheridan County Pain Management Improvement

Initiative
Measurement
Objective Actions Approach Status
Establish organization- Invitation placed on Intranet Not Full team convened August 2000
wide multidisciplinary Volunteers identified applicable Team meets monthly or more frequently, if needed
team Team members selected
Develop organizational Develop mission statement Review Completed June 1, 2001

mission statement and Revise/develop policies and organizational Statement posted in rooms December 2001
update policy and proce- procedures documents Policy and procedures approved and implemented
dure documents related to August 2001
pain management
Patients receive notifica- Develop rights and respon- Review Admission process task force evaluates admission
tion of rights/responsibili- sibilities brochure medical forms
ties regarding pain man- Provide education during records Brochure completed July 2001
agement. the admission process Organization-wide in-service on brochure/educa-
Document teaching tion in July 2001
Revise admission form to Admission form revision received December 2001;
document patient rights reaudit April 2002
education
Patients will receive infor- Staff education on objective Assess Survey of patients (n = 101) using the American
mation about pain control and process patients over Pain Society Patient Outcomes Survey in June 2001
methods within first 24 time Resurvey June 2002
hours
Patients on the Develop new assessment Review Pain tool template finalized in July 2001
medical/surgical units will tool medical Form delayed at printer; final form received
be assessed for pain using Pilot-test tool records January 2001
new pain documentation Educate staff on use of tool Quarterly chart review showed steady improve-
tool ment (93% compliance by third quarter 2001)
Patients are provided with Review discharge process Review med- Previous change in discharge process documentation
pain education materials Assess documentation forms ical records created a barrier (November 2001)
before discharge as appli- Develop new form to docu- New discharge form development (ongoing)
cable ment discharge
Provide reference materi- Develop reference manual Not applica- Pain reference manuals on every unit and in physi-
als and guidelines house- for each unit and physician ble cian lounge in March 2001
wide lounge Pain Clinical Manual obtained and distributed to
Obtain copy of Pain Clinical each unit in December 2000
Manual for each unit Health Information Center supplied with patient
Obtain reference materials education materials
for new Health Information
Center
Provide staff education Develop educational inter- Knowledge Clinician survey for learning needs/preferences
ventions assessments Pain News Weekly distributed monthly
Test for knowledge and atti- Posters: myths and tips
tudes In-services
Utilize multiple approaches Off-site physician education
Self-directed learning
“No Pain, Big Gain” campaign
Source: M. Bonnette, Memorial Hospital of Sheridan County, Wyoming. Used with permission.

74
A separate forms committee (including

No Pain, Big Gain Kick-off Activities some Pain Team members) focused on revis-
in February 2001 ing forms to document patient assessments.
This committee developed a new multidisci-
■ An activity featuring cake and distri- plinary screening and assessment tool that
bution of campaign buttons took documents pain intensity, patterns and char-
place every day for the first week. acteristics, psychosocial/cultural/spiritual
■ There was a 45-minute in-service issues, nutrition, and functional status. They
program on pain assessment and also created a flow sheet to detail care when
management, provided through a a patient’s reported pain is greater than or
pharmaceutical company. equal to 4 in intensity and frequent monitor-
■ There was a popcorn and movie day, ing is required.
featuring I Got My Life Back, a movie
about chronic pain patients and phar- 4. Collaborating for Improvement
macologic management. The Pain Team decided that the identifi-
■ The Traveling Show (Lions and Tigers cation of clinician mentors or pain champi-
and Pain—Oh NO!), a portable edu- ons from the nursing staff on each shift
cational exhibit created on a pedi- would further reinforce changes in practice.
atric bed frame, was taken to each Invitations were extended for interested par-
unit and left there for at least 24 ties, and three individuals were selected and
hours to accommodate all shifts. This added to the Pain Team. Shortly after the
exhibit provided key pieces of infor- selection of the clinician mentors, participa-
mation about pain management, and tion in a multi-hospital pain improvement
introduced selected pain scales and collaborative was approved by hospital lead-
examples of good documentation. ership. The project presented an excellent
Staff could take a quiz after studying opportunity for the mentors to develop their
the exhibit; 117 individuals did so. new roles. In April 2001, the three clinical
■ Laminated pain scales were distrib- mentors went to Denver, Colorado, for train-
uted to all staff. ing associated with a collaborative project
■ Raffles and other rewards generated offered through the Voluntary Hospitals of
enthusiasm and provided additional America. In addition to project specifics,
incentives for participation. they received education about quality
■ Special materials for physicians were improvement principles and serving as a role
initially placed in their mailboxes model/preceptor. The project also included
and then delivered via fax to their monthly “coaching calls,” on-site visits, three
offices. live audio educational interventions, and
■ A news release was sent to the local networking with other organizations.
paper. Through participation in this collaborative
■ Information on the campaign was project, Memorial Hospital received defined
provided to the recently opened data collection tools, data analysis, and com-
Health Information Center. The parative feedback. Four indicators were
Center is open to any community measured at baseline and again 6 months
resident and provides Internet access later. They were:
(online documents), a library, educa- ■ Receipt upon admission of written evi-
tional materials (including pain-relat- dence of the organization’s position on
ed materials), and access to health pain management.
information. ■ Receipt, prior to discharge, of educa-
tion/explanation regarding pain and pain
From M. Bonnette, Memorial Hospital of Sheridan
County, Wyoming. management.
■ Screening at initial assessment.
■ Pain assessment at discharge.

75
Based on a target sample of 30 records,

improvements were seen in two of the indi- Figure 10. Baseline and Post (6
cators (education and assessment prior to dis- Months) Indicator Data: Memorial
charge; see Figure 10). Although initiated in Hospital of Sheridan County
practice, delays in printing the revised admis-
Clinical Indicators
sion form resulted in no evidence of
improvement on the other two indicators.
120
The team anticipates documentation will
improve after implementation of the form in
100
the first quarter of 2002 and will remeasure
the indicators later in 2002.
80
5. Integrating Nonpharmacologic
60
Approaches
One of the most exciting interventions
40
was the addition of nonpharmacologic
approaches to pain management. A regis-
20
tered nurse who is a certified massage thera-
pist was chosen to develop a complementary
0
healing program, now known as the 1 2 3 4 1 2 3 4
Integrated Healthcare Program. To promote Baseline Post
awareness and address misconceptions, she
made office visits to physicians to share Indicators
information and discuss the program. She 1. Receipt, upon admission, of written evidence of
recently completed certification in imagery organization’s position on pain management.
2. Receipt, prior to discharge, of education/explana-
and has held in-services for staff on relax-
tion regarding pain and pain management.
ation, imagery, and massage techniques. By 3. Screening at initial assessment.
providing massage therapy and imagery to 4. Pain assessment at discharge.
inpatients, she helps nonpharmacologic
This figure shows change across four indicators from
approaches gain acceptance. Some physi- the Memorial Hospital of Sheridan County Wyoming
cians have established standing orders for (M. Bonnette).
massage therapy for their patients.
The No Pain, Big Gain campaign faced
6. Sustaining Change challenges such as competing demands for
The Pain Team, with administrative sup- resources from other educational programs
port, has made pain an institutional priority. and delayed arrival of the revised documen-
The initiative has been marked by creativity. tation forms. A major building expansion
Efforts were made to make educational activ- project requiring unit relocations occurred
ities interesting, fun, and accessible. concurrent with the effort. Despite these
Information is shared regularly at staff meet- challenges, those involved in the campaign
ings, and desired changes in pain manage- continued to believe that the goal of
ment practice are recognized. For example, improved pain management was important.
team members may randomly check charts They accepted that the process would take a
for examples of good documentation or look long time and valued the progress they made.
for staff wearing the campaign buttons. The clinical mentors have proven to be a
Individuals are immediately acknowledged key factor in effecting changes in day-to-day
and treated to a special award such as a practice, and nurses feel more empowered to
movie pass or gift certificate. This use of pos- advocate for their patients’ pain relief needs.
itive reinforcement has marked all aspects of The members of the pain committee are
the initiative. clearly focused on maintaining and continu-

76
ing the improvement efforts. Annual compe- 1. History of Pain Management

tency testing has been instituted, and a pain Activities at UIHC
management component has been added to The management of pain has been a focus
the skills lab and to new employee educa- in clinical care and research for over a
tion. Ongoing medical record audits are decade in both the health care and the uni-
being completed to determine trends in versity systems. Multiple pain improvement
important aspects of care. With the arrival of initiatives have been undertaken by various
a new pharmacy director in spring 2002, divisions and clinical departments since the
pharmacologic aspects of pain management early 1990s. Table 13 lists examples of some
practice will be studied. recent departmental activities. Similarly,
The success of the pain improvement ini- clinical research has been a significant ele-
tiative at Memorial Hospital highlights the ment of pain management practice develop-
value of participation in preceptorship pro- ment at UIHC. For example, the
grams, collaborative measurement/improve- Department of Nursing has collaborated with
ment initiatives, careful assessment of cur- the University of Iowa College of Nursing to
rent practice by measuring performance, cre- pursue research in pain management that
ative learning experiences, and positive supports evidence-based practice. The inves-
recognition of practice changes. These are tigation of the effectiveness of a brief distrac-
valuable insights for organizations of any size tion educational intervention for parents of
or location. preschool children undergoing intravenous
catheter insertion,141 the evaluation of appli-
cation time for effectiveness of local anes-
thetic gels,142 and the development of an
D. Integrating Pain infant pain rating scale are just a few exam-
Management Improvement ples. Translating research evidence into prac-
Activities in an Academic tice, a long-standing commitment for both
Medical Center: University the College of Nursing and the Department
of Iowa Hospitals and of Nursing, is exemplified in the Iowa Model
of Evidence-Based Practice to Improve
Clinics Quality of Care.143,144 It is the focus of a cur-
The University of Iowa Hospitals and rent study examining acute pain manage-
Clinics is a comprehensive teaching and ment in the elderly, funded by the Agency
health care center serving patients from all for Healthcare Research and Quality (grant
counties in Iowa as well as other states and RO1 HS 10482; principal investigator: M.
countries. It is one of the largest university- Titler); this study is being conducted by sci-
owned teaching hospitals in the country. entists from UIHC and the University of
Established in 1898 as a 50-bed hospital, the Iowa Colleges of Nursing, Medicine,
current 831-bed facility and clinics serve Pharmacy, and Public Health.
more than 41,000 patients annually. Located Patient-related pain management services
within UIHC, Children’s Hospital of Iowa are comprehensive and include:
provides family-centered pediatric clinical ■ The Acute Pain Service. This service
services. As a major health training resource, actively manages acute postoperative and
UIHC serves students from five health sci- cancer pain for inpatients and commonly
ence colleges and provides supervised clinical uses advanced pain management treat-
settings for community college programs in ment modalities.
nursing education, surgical technology, and ■ The Pain Medicine Clinic. The center
respiratory therapy. A commitment to excel- provides evaluation and treatment for
lence in research marks another important patients with chronic pain, cancer-relat-
component of the organization’s mission and ed pain, and nerve or musculoskeletal
service. injuries.
Currently, a new state-of-the-art facility is
77
Table 13. Examples of Departmental Pain Improvement Activities: University of

Iowa
Department Activity
Pharmacy Educational program for pharmacists

Case presentations (e.g., chronic, acute, pediatric)
Addition of pharmacist with specialty in pain management (June 2001) who also works with the
pain team
Medication use evaluation: evaluate use of meperidine through chart review with a goal of
decreasing the rate of use; Development of criteria and recommendations for use
Participate in review and update of policies and procedures as part of the Interdisciplinary Pain
Management Subcommittee to evaluate for consistency between nursing and pharmacy (e.g.,
patient-controlled analgesia, epidural)
Review of preprinted order forms for drug-related issues (e.g., abbreviations, doses)
Preparation of articles related to pharmaceutical treatments for pain for the P & T News, a publica-
tion of the Pharmacy and Therapeutics Subcommittee
Nursing Development of an analgesic guide (including equianalgesic charts) that was approved by the
Pharmacy and Therapeutics Subcommittee of University Hospital Advisory Committee; available as
a pocket guide and poster
Chart audits by each clinical nursing division to determine documentation practices regarding pain
assessment and reassessment
Registered nurse knowledge surveys completed within each clinical nursing division
Development and implementation of pain standards for ambulatory care
Inservices by ambulatory care nurse managers for staff on the ambulatory pain standard
Adult pain standard of practice for inpatient pain management presented to clinical staff
Standardization of pain intensity scales
Children’s Development of standards of care

Hospital Creation of an interdisciplinary task force to look at pain management issues
Development of a policy regarding the use of a local anesthetic gel before procedures and research
on the effectiveness of two products
Identification of a pain intensity scale
Research and development of a pain rating system for infants
Creation of a Pain Resource Manual for specialty units
Source: M. Titler, University of Iowa Hospitals and Clinics. Used with permission.
being constructed that will locate both the would act as an advisory body to address crit-
chronic and acute programs in one suite. ical and long-term issues associated with pain
The Acute Pain Service area will have direct management. The Interdisciplinary Pain
access to the surgical department, and the Management Subcommittee was created
Pain Medicine Clinic will have an entrance under the Pharmacy and Therapeutics
for outpatients. Subcommittee of the University Hospital
Advisory Committee. Structurally, the com-
2. Forming a Standing Committee mittee is part of the Quality and
The work completed by a multidisciplinary Performance Improvement Program frame-
pain committee in the early 1990s and the work (see Figure 11). This framework illus-
successful ongoing efforts within and across trates the reporting lines for communication
departments have built a strong foundation of centralized and decentralized quality
for pain management practice. In early 2000, improvement activities conducted by other
the administration of UIHC proposed the subcommittees of the University Hospital
establishment of a standing committee that Advisory Committee (n = 20), 19 clinical

78
Figure 11. Quality and Performance Improvement Program Framework

Illustrating the Reporting Lines for Communication: University of Iowa Hospitals
and Clinics
University of Iowa University of College of

Hospitals and Iowa Medicine
Clinics Health Care
University
Hospital Advisory
Committee (HAC)
Professional
Practice
Subcommittee
Other HAC Subcommittees (20) Performance, Value and

(Interdisciplinary Pain Management Service Management
Subcommittee of the Pharmacy and Committee
Therapeutics Subcommittee)
Clinical
Outcomes and Interdisciplinary Quality
Resource and Performance
Management Improvement Teams
Clinical Department (19) (CO/RM) (8 Types)
Multidisciplinary Clinical Centers (4) Hospital Departments (12)
Source: University of Iowa Hospitals an Clinics Web site. Used with Permission, Available at
www.uihc.uiowa.edu/corm/QPOPReport.htm
departments, 12 hospital departments, 4 following charges:

multidisciplinary clinical centers, and multi- ■ Increase awareness of the need for ade-
ple interdisciplinary teams. Central within quate pain management for all patients
the structure of the Quality and Performance who seek care at the UIHC.
Improvement Program is the Clinical ■ Identify and develop effective pain man-
Outcomes and Resource Management office, agement strategies for UIHC patients.
which supports quality improvement initia- ■ Identify methods for patient referral to
tives through use of data management sys- appropriate existing clinical consultation
tems and expert staff. services for pain management.
The Interdisciplinary Pain Management ■ Identify ways to reduce adverse drug
Subcommittee is co-chaired by Marita Titler, events through the safe and appropriate
PhD, RN (Nursing Services and Patient use of analgesics.
Care), Richard Rosenquist, MD ■ Coordinate educational initiatives for
(Anesthesia), and Steve Nelson, MS care providers.
(Pharmaceutical Care). The other 15 mem- ■ Coordinate and review data associated
bers also are drawn from multiple disciplines. with pain management as part of UIHC’s
This committee began their work with the quality improvement program.

79
■ Routinely evaluate the hospital’s pain documentation across departments and levels
management programs and identify/rec- of care, the work group posed the following
ommend needed changes. questions:
The co-chairs began by identifying multi- 1. Do nurses use standardized pain
ple data sources within the organization’s assessment techniques for pain assessment
documentation (automated and nonautomat- (intensity, location, quality, duration) of
ed) and quality improvement systems that patients?
could provide information on current prac- 2. How frequently is pain assessed and
tice. When the full committee met for the documented in the inpatient and ambulatory
first time in August 2000, they were able to care setting?
review the information and begin exploring 3. Is a standardized tool used to assess
opportunities for improvement. They used and document pain intensity?
the quality improvement tool of brainstorm- 4. What pain treatments do patients
ing and identified 25 possible focus areas. receive for management of:
Acute pain?
3. Establishing an Action Plan Cancer pain?
The subcommittee members were then Chronic pain?
asked to rank the top 10 priority areas in 5. What mechanisms are used to pro-
order of importance from the initial list of vide patient and family education regarding
25. In the month before the next meeting, rights and responsibilities for management of
they solicited input from colleagues and oth- pain?
ers in the organization. When the full com- 6. What are the educational needs of
mittee met again in September, they were nurses to provide optimal pain assessment
able to identify 10 priority areas that com- and treatment?
bined most of the items on the original list. 7. Are the departmental standards for
They then grouped the priority areas into pain management congruent with current
four work groups: research evidence and American Pain
■ Assessment and documentation Society Guidelines?
■ Patient education 8. What system changes are needed to
■ Patient rights and responsibilities provide optimal pain management to
■ Clinician education. patients receiving care at UIHC?
Each work group was charged with devel- The work plan they developed used multi-
oping an improvement plan, interventions, ple interventions, including the review and
and a strategy to measure the impact of the revision of departmental standards for pain
interventions. All work groups reported back management, knowledge assessment of nurs-
to the Interdisciplinary Pain Management es, and education of nurses, patients, and
Subcommittee on their progress. families. The work group obtained baseline
and postintervention data through the use of
4. Fulfilling the Charge: The retrospective chart audits, data from the
Assessment and Documentation online Nursing Information Documentation
Work Group System, and knowledge and assessment sur-
veys.
The Assessment and Documentation
Work Group included individuals who also a. Implementing and evaluating interven-
sat on departmental pain teams such as the tions
Department of Nursing Pain Management i. Departmental/divisional standards of
Subcommittee of the Quality Improvement care for pain management
Committee. In this way, the group built on The following standards were updated
the substantial work related to pain manage- and/or revised by the Department of Nursing
ment already completed in decentralized ini- Pain Management Subcommittee of the
tiatives. In their plan to understand and Quality Improvement Committee, the
improve the quality of pain assessment and
80
Department of Nursing Policy and Procedure the Quality Improvement Pain Monitor.
Committee, and the Children’s Hospital of This chart audit tool used data from charts
Iowa (for pediatrics): and the online documentation system to
■ Pain Screening in the Ambulatory determine the number of times pain was
Setting assessed/reassessed and if the intensity, quali-
■ Pain Management for Adults: Inpatient ty, location, and interventions were noted
■ Pain Management: Pediatrics. (quality indicators for pain). As can be seen
The Interdisciplinary Pain Management in Figure 12, there was significant improve-
Subcommittee then forwarded these stan- ment in the number of times pain intensity
dards for review and approval. A “train the was documented in 24 hours for the units
trainer” approach was used to educate nurse displayed. Additionally, knowledge surveys
managers, assistant managers, and supervisors were repeated to evaluate for improvement
in the new pain management standards so in deficit areas. Between September 2000
they, in turn, could teach nursing staff. In and September 2001, the work group had
addition, materials were incorporated into accomplished much. They had stated goals,
the annual competency review for staff and posed important questions, obtained baseline
are included in both the central and divi- data, designed and implemented interven-
sional new employee orientation. tions, and monitored change. The work
ii. Knowledge assessment and education group successfully fulfilled their charge and,
Knowledge surveys for nurses were cus- as part of the subcommittee, helped meet the
tomized and distributed by care areas (pedi- overall goals of coordinating educational ini-
atrics, perinatal, adult medical/surgical and tiatives for care providers and collecting pain
critical care, and perioperative). Based on management data for use in quality improve-
the survey results, each nursing clinical divi- ment activities.
sion devised a plan unique to their educa-
tional deficits. For example, the adult med- 5. Complementing Centralized Pain
ical/surgical, perioperative, and critical care Improvement Activities: A
nursing divisions addressed the identified Division-level Initiative to Manage
educational needs by: Circumcision Pain
■ Developing and implementing an adult The Interdisciplinary Pain Management
analgesic guide approved by the Subcommittee has worked to coalesce pain
Pharmacy and Therapeutics management activities across the organiza-
Subcommittee of the University Hospital tion through a centralized approach, while
Advisory Committee. supporting the continued development of
■ Purchasing and distributing the complementary initiatives to address special
American Pain Society’s Principles of populations, types of pain, and unique proce-
Analgesic Use in the Treatment of Acute dures. The development of a protocol to
Pain and Cancer Pain, 4th edition,145 and manage circumcision pain is an example of a
Pain Clinical Manual, 2nd edition,27 for pain management initiative completed with-
each nursing division. in one division at UIHC.
■ Displaying posters on units regarding
a. Identifying an opportunity
drug interactions, drug dosing, and pain
Within the Division of Children’s and
assessment.
Women’s Services, multiple units care for
■ Providing education regarding the pain
infants undergoing a circumcision procedure.
standards and use of pain rating scales.
A recent American Academy of Pediatrics
b. Measuring the effectiveness of work position statement on circumcision that
group activities included the management of pain (see
To assess the impact of the interventions “Circumcision Policy Statement,” Table 2)
to improve the quality of pain assessment caught the attention of Janet Geyer,
and documentation, the work group designed Advanced Practice Nurse. Together with col-

81
Figure 12. Mean Number of Times Pain Intensity Is Documented Every 24 Hours:
Department of Nursing Services and Patient Care Intensive Care Units,
University of Iowa Hospitals and Clinics
ICU #2
9.7
10
ICU #1 9.1
9
7
6.1 6.0
6
5
4.5
4
3.9
3
0
May June July August Sept. Oct. Nov. Dec. Jan. Feb. March April May
2000 2001
Baseline Post Post Flowsheet
(n=20) Education changes (n=20)
(n=20)
Source: M. Titler, University of Iowa Hospitals and Clinics. Used with permission.
leagues on other units, she began to explore b. Forming a plan

the issue of how pain was managed during Once the opportunity was identified, the
this procedure at UIHC. The first step was to nurses began by forming a committee and
understand current practice by reviewing enlisting participation from key stakeholders.
medical charts. In fall 1999, 51 charts of The resulting team of eight people included
infants undergoing a circumcision were nurse representatives from all applicable care
examined. Results showed that nearly all units, a neonatologist, and an obstetrician.
babies (96%) received a dorsal block. It also Additionally, consultations were obtained
was noted that although acetaminophen was from a lactation specialist, pharmacist, den-
ordered in 71% of the charts reviewed, only tist, urologist, music therapist, and lawyer for
59% of the charts indicated that it was specific issues. Initially, the team began by
administered at least once. Although the conducting a literature search for evidence-
results indicated consistent use of blocks, the based pain management recommendations
nurses believed the administration rate for specific to infants or this procedure. Staff
acetaminophen could be improved and over- physicians were solicited to participate in
all pain management could be enhanced this process and review articles. Over the
through the development of a comprehensive course of several months, the team began to
pain management protocol for this procedure. identify a set of specific care processes such

82
as the use of buffered lidocaine and a smaller- team also met with pharmacy staff to estab-
gauge needle for the block, as well as the use lish a process that ensured the availability of
of soft music during the procedure. These buffered lidocaine, which must be mixed
processes were incorporated into a compre- daily.
hensive protocol. Examples of recommended By spring 2000, all necessary approvals had
practices are shown in Table 14. been obtained for use of the protocol. The
next step involved providing education to all
c. Implementing the protocol
clinicians. For nursing and patient care per-
In planning the implementation of the
sonnel, a self-learning module was devel-
new protocol, the team worked to ensure
oped. Nurses involved in the team also
that related documents and required services
served as resources for other staff and provid-
were ready. First, an update to the operative
ed one-on-one training. The protocol has
permit was completed to include information
been added to new staff orientation materi-
on pain management, in addition to proce-
als. Physician members of the team were key
dure-related risks and benefits. Also, educa-
in communicating the protocol to colleagues
tional materials for parents were revised to
both individually and through faculty or
include similar information. These educa-
departmental meetings. All residents were
tional materials are provided to parents dur-
sent information via e-mail and were super-
ing prenatal visits to physician offices and
vised by the chief resident during the first
also on admission to UIHC for delivery. The
few procedures. This process is repeated
every year when new residents begin their
Table 14. Examples of Pain training. The protocol also has been includ-
ed in the agenda for a special 1-day postgrad-
Management Interventions for
uate course for pediatric residents to be held
Circumcision: University of Iowa in fall 2002.
Hospitals and Clinics (UIHC)
d. Assessing for success
To measure the success of the project,
1. Premedicate with acetaminophen 10-15 mg/kg medical records were reviewed a second time
within 1 hour before procedure per physician or 6 months after implementing the protocol
nurse practitioner order.
2. Swaddle infant on padded circumcision board (January 2001). An audit tool was developed
and restrain legs (allows infant to put hand to (Circumcision Evaluation Tool) to check for
mouth). compliance with each component of the pro-
3. Assess infant comfort/pain level and provide inter-
ventions:
tocol. The tool also documents the number
a. Shield patient eyes from direct light. of doses of analgesia given. Twenty-nine
b. Provide pacifier dipped in sucrose after discus- charts were reviewed with findings of full
sion with parents/guardian. compliance (100%) for use of a dorsal block,
c. Music therapy may be utilized per standard of
practice. acetaminophen ordered, infant swaddled,
d. Ensure patient is kept appropriately warm. and sucrose pacifier offered. The rate for
4. Following block, wait 3-5 minutes before pro- administration of at least one dose of aceta-
ceeding with circumcision.
5. Following procedure, remove infant from circum-
minophen rose to 84%. The chart review
cision board. also revealed that the electronic medical
6. Assess infant comfort/pain and provide interven- records facilitated documentation of the pro-
tions: tocol, whereas manual records did not.
a. Swaddle and hold infant.
b. Have parent/guardian or nurse provide feeding. Therefore, for those units not using electron-
c. Provide acetaminophen 10-15 mg/kg as ic medical records, a special sticker was
ordered by physician or nurse practitioner 4 developed with the protocol steps and a
hours after initial dose and every 4-6 hours for
24 hours.
place to check completion.
The success of the project has been shared
Source: J. Geyer, University of Iowa Hospitals and in several ways, including a poster presenta-
Clinics. Used with permission.
tion at a regional pediatric conference, a
statewide educational conference, and a
83
national evidence-based practice conference. and numerous contract care programs. In

Team members also have shared their success 1999, the VHA staff included 53,000 nurs-
in an article detailing the use of evidence as ing personnel, 13,000 physicians, more than
the basis for the protocol.146 The team noted 3500 pharmacists, and thousands of other
that some of the keys to the success of the health care professionals.147
project were involving important stakehold- In 1995, the VHA, which manages the
ers, engaging physicians in the process, and care, began to reorganize the delivery system
keeping people informed. They had strong into 22 Veterans Integrated Service
support from nursing leadership, and medical Networks (VISNs) to enhance the continu-
staff was receptive. Finally, conducting chart um of primary to tertiary care within geo-
reviews provided objective measures of per- graphical regions.147 As in the private sector,
formance that validated the successful imple- there is great variation across VISNs in the
mentation of the protocol. demand for care, the resources available, and
the priority issues. For example, resources for
chronic care are greater in southern states
with large elderly populations.
E. Improving Care Across Because of its centralized structure, the
Hundreds of Facilities: The VHA is able to mandate certain activities
Veterans Health such as use of a nationwide computerized
patient record system (CPRS) and a selec-
Administration’s National tion of indicators for performance improve-
Pain Management Strategy ment. Although the national leaders in
Washington, DC set general priorities for
improvement, it is up to each VISN to deter-
W e dedicate this section of the monograph
to Margaret Berrio, RN, MS who died
unexpectedly in July 2002. Ms. Berrio was
mine how to implement these priority initia-
tives. For example, the VHA central office
Quality Management Specialist/Management mandated use of the 0-10 scale for initial
Information System Nursing Coordinator at the pain screening across all facilities, but
Boston VA Healthcare System and a key mem- allowed individual facilities to determine the
ber of the VISN 1 Pain Management Quality content and format of a tool for comprehen-
Improvement Team. She played a pivotal role in sive pain assessment.
helping to improve the pain care of veterans at
The flexibility to customize initiatives
several facilities and in the development of this
section. Most importantly, Ms. Berrio was an
within VISNs and facilities (e.g., by adding
inspiration to all who knew her. She was pas- specific data elements) helps overcome
sionate about her work, had an unwavering bureaucratic delays that can occur with very
commitment to and compassion for her patients, large organizations. One potential drawback
and a steadfast faith in the positive nature of the is that even within the VHA system, facili-
human condition. Her smile, sense of humor, ties may be using different forms for docu-
and friendship encouraged us all and will not mentation and different approaches for pain
soon be forgotten. (R. Kerns ) assessment, treatment, and follow-up. The
following description of the VHA pain man-
The veterans health care system is the agement improvement initiative exemplifies
largest fully integrated health care system in this balance and interplay between national
the United States. In fiscal year 1999, the planning and VISN/facility-level implemen-
VHA provided direct care in more than tation. After an overview of the national-
1100 different sites to more than 3.6 mil- level pain management initiatives, a descrip-
lion persons. Those sites included 172 hos- tion is provided of how two facilities within
pitals, more than 600 ambulatory and com- VISN 1 (VA New England Healthcare
munity-based clinics, 132 nursing homes, System) implemented one component of the
206 counseling centers, 40 residential care national initiative: participation in a collabo-
domiciliaries, 73 home health programs, rative improvement project using the

84
Institute for Healthcare Improvement (IHI) ■ Include patients and families as active
Breakthrough Series Model for participants in pain management.
Improvement. The IHI Breakthrough Series ■ Provide strategies for continual monitor-
model was designed to help organizations ing and improvement in pain manage-
make rapid, measurable, and sustainable ment outcomes.
improvements in the specific focus areas ■ Provide for an interdisciplinary, multi-
within 9 to 15 months. In addition, this modal approach to pain management.
process was intended to help organizations ■ Ensure that VHA clinicians are ade-
build the capacity to improve beyond the quately prepared to assess and manage
time frame of the collaborative.148 pain effectively.
1. Organizing the National Initiative 3. Implementing Multiple

In late 1990s, the organization of VHA Interventions
anesthesiologists conducted a national survey In the past 3 years, several major initia-
that identified system-wide inconsistencies in tives have been undertaken to improve pain
the areas of pain assessment, access to treat- management. Best known is the VHA’s deci-
ment, and standards of practice. The group sion to consider documentation of pain as
put forth a position paper that recommended “the fifth vital sign.” In early 1999, the VHA
development of a national coordinating mandated that every patient in every
strategy for pain management–related activi- encounter in every facility should be
ties. In late 1998, Dr. Kenneth Kizer, then screened with a 0-10 numeric rating scale for
VA undersecretary for health, announced the presence and intensity of pain. At the
the vision for a national pain management same time, an initial version of a toolkit
strategy and established a National Pain “Pain as the 5th Vital Sign” was published to
Management Coordinating Committee facilitate national implementation of the
(NPMCC). The NPMCC consisted of a mandate. Subsequently, a revised version of
multidisciplinary group of experts from the the toolkit was authorized, which was devel-
VHA and was co-chaired by Judith Salerno, oped under the leadership of Dr. Robert
MD, MS, and Tony Mitchell, MD. Jane Kerns (chair of the NPMCC toolkit working
Tollett, PhD, was appointed as program coor- group and Chief, Psychology Services, VA
dinator for the national strategy. The Connecticut Healthcare System). The tool-
NPMCC was operationalized as several kit contains details and resource materials for
working groups, including pain screening and implementing the mandate, including an
assessment, clinical guideline development, introduction to comprehensive pain assess-
education, research, and outcome measurement and an extensive bibliography.149 The
ment. Each VISN designated a single person tool kit is accessible at
as the point of contact to serve as a liaison to www.vachronicpain.org.
the NPMCC and facilitate dissemination To implement the pain screening mandate,
and implementation. the committee worked with information
management staff to incorporate screening
2. National Goals and Objectives scores on the 0-10 scale into the vital signs
The primary goal of the national initiative component of the CPRS. The Outcomes
was to provide a system-wide standard of care Measurement Work Group is developing a
for pain management that reduces suffering template and reminder system for completing
from preventable pain. Several additional a comprehensive pain assessment (including
goals were specified: duration, location, etc.) if the pain screen
■ Ensure that pain screening is performed score was greater than 3 or if there was some
in a consistent manner. other potential or obvious indication for pain
■ Ensure that pain treatment is prompt and treatment.
appropriate. The Clinical Guideline Work Group, co-
chaired by Jack Rosenberg, MD of the Ann

85
Arbor VAMC and Richard Rosenquist, MD includes 1500 general primary care, 1500
of the Iowa City VAMC, worked together mental health, 1500 diabetes, 1000 previous
with experts from the Department of acute myocardial infarction, 1000 chronic
Defense to develop clinical practice guide- obstructive pulmonary disease, and 1000
lines for the management of acute postopera- congestive heart failure patients (D. Walder,
tive pain. The guidelines were accompanied personal communication, August 1, 2002).
by extensive toolkits, including posters, The EPRP has been highly successful in
videotapes, reminder cards, and key articles, stimulating improvement in a wide variety of
to facilitate implementation. Use of the clinical areas, in part because performance
guidelines and associated protocols was also on these indicators (monitors) is directly
mandated. linked to the medical center director’s per-
The VHA has dedicated substantial effort formance evaluation. With established
and resources to provider education, which thresholds for each indicator and regular
represented the largest working group of feedback of EPRP scores to individual facili-
NPMCC. Two national pain ties, the goal is clear. Therefore, all who ren-
management–related conferences have been der care are aware of the expectation for
held, in conjunction with conferences individual and organizational performance.
addressing care at the end of life. Other In 1999, the following pain management
forms of provider education included satellite indicator was added for ambulatory primary
broadcasts, Web-based educational programs, care facilities and eight specialty clinics: the
pain management list-servs, and extensive proportion of patient visits during the time
reference materials for VISN libraries. period of interest that showed documenta-
tion of pain scores at least once within the
4. Evaluating Effectiveness Through last year. Results from October 1999 through
System-wide Measurement September 2001 showed steadily improving
The External Peer Review Program performance (see Figure 13). Because the
(EPRP) is one of several quality measure- most recent scores were over 95%, this indi-
ment systems for the VHA.150 The VHA cator was determined by the central office to
contracts for external review of more than be less useful for identifying opportunities for
200,000 records annually. Each month, the improvement. Thus, for fiscal year 2002,
central office draws a random sample of three new monitors are in development:
records from each facility (inpatient, ambula- 1. Percentage of patients with a document-
tory, home health, etc) based on patients ed pain screen on a scale of 0-10 on the
who had at least one encounter (visit/admis- most recent visit.
sion) in the previous month and an 2. Percentage of patients with a pain score
encounter within the past 2 years. greater than 3 for whom an intervention
Immediately after completing the review, the was recorded.
external reviewers provide patient-specific 3. Percentage of patients with a pain inter-
feedback directly to the clinical staff, usually vention recorded who had a follow-up
within days or weeks of the selected assessment.
encounter, which facilitates rapid improve- Since 1994, the VHA has conducted an
ment on identified opportunities. The data is annual national patient satisfaction survey
trended at the VISN level quarterly. The sta- that is sent to a stratified sample of 175
tistically meaningful national sample recently discharged patients and 175 outpa-
includes monthly review of all inpatients tients from each facility.151 The inpatient
with diagnoses of acute myocardial infarc- satisfaction survey, which was modified from
tion, congestive heart failure, and chronic instruments developed by the Picker
obstructive pulmonary disease and biannual Institute of Boston, includes five questions
review of 5000 spinal cord injury patients. In related to pain management.
the ambulatory setting, the monthly sample 1. When you had pain, was it usually
severe, moderate, or mild?

86
2. How many minutes after you asked for One of the first priorities of the VHA-IHI
pain medicine did it usually take before collaborative planning group was to develop
you got it? a set of attributes of a successful pain man-
3. Do you think you would have had less agement system (see Table 15). Like other
pain if the hospital staff had acted faster? topic areas in the Breakthrough Series initia-
4. Overall, how much pain medicine did tives (e.g., see Leape et al.152 and Wagner et
you get? al.153), the VA-IHI pain management collab-
5. Did you experience pain and not report orative was built around the following princi-
it? If yes, why? ples and activities:
■ Explicit leadership support and commit-
ment to change.
5. VHA-IHI Collaborative ■ Establishment of organization-specific,
The NPMCC, the IHI, and outside con- measurable goals based on the agreed-
tent experts such as Dr. Charles Cleeland, upon theory for improvement.
who served as chairman of the initiative, col- ■ Creation of teams that include persons
laboratively planned the content for the pro- with system leadership to institute
gram. The VHA provided financial support change, persons with technical expertise,
to allow 70 teams (more than 300 people) persons who can provide day-to-day lead-
from various settings, including long-term ership, and change champions.
care, behavioral health, and home care, to ■ Sharing knowledge and experience
participate in the initiative over a 9-month through three 2-day in-person learning
period. sessions (an initial meeting, a meeting at
3 months, and a meeting at 9 months),
Figure 13. Percentage of Records With Documented Pain Scores Within The Last
Year: Veterans Health Administration, National External Peer Review Program
100
90
80
70
60
50
40
30
20
10
0
Oct-99 Jan-00 Apr-00 Jul-00 Oct-00 Jan-01 Apr-01 Jul-01
Source: R. Kerns. Used with permission.

87
access to Web sites with resource materi-

Table 15. Attributes of a Successful als.
Pain Management Program: VHA- At a planning group meeting in January
IHI Collaborative Planning Group 2000, the following improvement goals were
specified:
■ Pain scores should be reduced by 25%
1. Pain should be assessed in a routine and timely among patients experiencing moderate
manner.
or severe pain.
• Pain should be documented as the 5th vital sign
during every clinical encounter. ■ One hundred percent of patients should
2. Patients should have access to an appropriate level have pain screening documented in their
of treatment. medical record.
• Multidisciplinary team should be available for
specialty consultations as needed.
■ The number of patients with pain scores
3. Treatment protocols should be in place and of 4 or higher who have a documented
understood by all staff. plan of care should be increased by at
• Protocol should be available for most common
least 20%.
conditions.
• Reminder systems should be used for adherence ■ At least 50% of patients should receive
to protocols. appropriate education.
• Protocols should contain expectations for the Each VISN then decided how many and
time between assessment of pain and action,
and the response time to medication requests.
what types of facilities could participate in
4. Providers should receive education through a this initiative, as well as which clinical areas
variety of strategies. to focus on (e.g., postoperative pain, oncolo-
• Criteria for assessing the competency of
gy, chronic pain). Each team was expected to
providers also should be established.
5. A comprehensive plan for patient and family select two or more of these goals for the pilot
education should be in place. projects.
6. Each organization should have standards of
practice, some of which should be organization-
wide and some of which may be discipline 6. Implementing the IHI Initiative in
specific. Two New England Hospitals
7. Each organization should have a plan for
performance improvement that includes goals and
Since 1999, VISN 1 (VA New England
key outcomes as well as a schedule for progress Healthcare System) has taken a leadership
review. role in efforts to improve pain management
Source: R. Kerns. Used with permission.
within the VHA. VISN 1 consists of nine
IHI: Institute for Healthcare Improvement; VHA: VA medical centers (VAMCs) and 40 ambu-
Veterans Health Administration. latory care clinics across six New England
states. VISN 1 chose to focus on primary
with action periods and frequent care pain management because the VHA as
exchange between meetings via e-mail a whole has shifted emphasis from inpatient
groups. care to primary care.
■ Testing changes on a small scale before The VISN 1 team selected the Togus,
widespread implementation. Maine, VAMC and the Providence, Rhode
■ Rigorous but parsimonious measurement Island, VAMC as pilot sites for the IHI-
of a few key processes or outcomes, often VHA initiative. These two facilities were
using sampling. selected because their clinical leaders (one
■ Objective evaluation of team success by physician and one nurse practitioner) were
using monthly progress reports and open primary care providers with a commitment
sharing of data on a secure Web-based to and a passion for improving pain manage-
bulletin board maintained by IHI. ment. Importantly, it was felt that these lead-
■ Other educational services, including ers could commit the necessary time to this
monthly educational conference calls initiative (i.e., their sites were considered fer-
moderated by experts in quality measure- tile ground in which to sow the seeds of
ment and pain management, as well as change). Unlike other sites in VISN 1, these

88
two sites were not distracted by competing meetings by conference call.

initiatives such as organizational restructur- Centralized support for data collection,
ing or technology upgrades. database development, and analysis at VA
The Togus VAMC, the only VA hospital Boston Jamaica Plain played an important
in Maine, is the oldest facility in the role. Using the CPRS, Ms. Berrio initially
Department of Veterans Affairs, having generated weekly facility-specific reports to
served veterans for 138 years. It has 67 acute provide feedback on four rates: 1) the pro-
medical, surgical, mental health, and inter- portion of patients with pain scores noted
mediate-care beds, along with a 100-bed among all patients seen; 2) the proportion of
nursing home, half of which is devoted to patients with a comprehensive assessment
residents with dementia. Togus’s primary care among all patients who had pain scores
program, together with five community- greater than 3; 3) the proportion of patients
based outpatient centers across the state, with a treatment plan among all patients
serves approximately 25,000 veterans annu- who had pain scores greater than 3; and 4)
ally. The Providence VAMC provides com- the proportion of patients with documenta-
prehensive outpatient and inpatient health tion of patient education among all patients
care to veterans residing in Rhode Island and who had pain scores greater than 3. The
southeastern Massachusetts. The ambulatory- results, along with questions and answers,
care program of 32 subspecialty clinics is sup- were reported to all team members via a bul-
ported by a general medical and surgical letin board list-serv so that members did not
inpatient facility currently operating 66 beds. need to access the Web site directly.
The VISN 1 team was composed of the Both hospitals implemented a variety of
following members by function: chair, VISN interventions to achieve the pilot project
1 pain management subcommittee, Robert goals. These interventions included:
Kerns, PhD (VA Connecticut Healthcare ■ Simplifying and increasing the font size
System); team leader, Fred Silverblatt, MD of the patient comprehensive pain self-
(Chief, Primary Care, Providence VAMC, assessment tool based on feedback from
Rhode Island); day-to-day leadership and users (patients and staff).
coordination, Bonnie Lundquist, MS (Nurse ■ Implementing a template that incorpo-
Practitioner, Togus VAMC, Maine); reviewer rated functional assessment information
support, Marcia Kelly, RN (Performance for clinicians to use when entering com-
Management, Northampton VAMC, prehensive assessment information in the
Massachusetts); patient education support, CPRS.
Elizabeth Fiscella, RN (Nurse Manager, ■ Educating patients through distribution
Northampton VAMC, Massachusetts); clini- of the Channing-Bete booklet, conduct-
cal and technical expertise, Margaret Berrio, ing an ongoing lecture series, posting
RN, MS (Quality Management/Management material on clinic bulletin boards, and
Information System Nursing Coordinator, providing a detailed pain chart in every
VA Boston Healthcare System, exam room.
Massachusetts); and management analyst, ■ Educating primary care providers, with a
Genez Orejola, MHA, MT, Boston. focus on review of pain management
Because the VISN 1 initiative involved guidelines and training in the use of the
two sites (unlike most other initiatives, where comprehensive assessment tool through
the teams were drawn from a single site), the lectures and workshops.
team had to modify the IHI model for certain
team member functions and implementation 7. Operational Strategies
strategies. Toward that end, the VISN 1 team Despite similar interventions, there were
undertook the key steps in the IHI initiative. hospital-specific differences in the approach-
The team developed a comprehensive assesses used to screen and educate patients. For
ment tool, solicited leadership involvement, example, the Togus VAMC targeted the pri-
and communicated through weekly team mary care clinics run by two providers (one

89
physician and one nurse practitioner). The performance between the two sites may have
support staff for these clinics consisted of a been due to the different steps and personnel
patient care associate, a nurse, and a clerk. involved in operationalizing the assessment
After receiving education on use of the pain and the education processes.
screening scale, the group recognized the Both medical centers have implemented
need to allow additional time for patient several other pain management improve-
assessment and education. The clerk cre- ment activities not described here. For exam-
atively designed bright yellow stickers to ple, the Togus VAMC has created a full-time
attach to clinic appointment letters, asking pain management coordinator position.
patients in the pilot clinics to arrive 15 min- After completing the IHI initiative, both
utes early. Upon arrival, the patient care hospitals expanded the interventions and
assistant conducted the pain screening. If the data collection activities to include all pri-
pain score was greater than 3, the patient mary care clinics and community-based out-
care associate gave the comprehensive self- patient centers, as well as the appropriate
assessment tool and the educational booklet medical and geriatric clinics. Other sites
to the patient and notified the nurse. The within VISN 1 whose staff were part of the
nurse completed the comprehensive assess- team have implemented activities similar to
ment with the patient and discussed the con- the IHI process in their own facilities.
tents of the booklet. The nurse entered Additional information can be obtained by
information regarding patient education into contacting the team members directly at
the template progress note in the CPRS. To their respective facilities.
identify which patients had completed the
assessment and education, the nurse high- 8. Sharing Success and Next Steps
lighted a note on top of the chart. The Over time, the VHA and several of its
provider developed the pain treatment plan facilities have become recognized as a model
and ordered telephone follow-up by the of excellence in the pain management field.
nurse at 6 weeks to assess the effectiveness of There have been several presentations and
the treatment plan and review patient educa- symposia led by NPMCC members at
tion. Providers were notified of the results of American Pain Society, American Geriatric
the calls. Society, and New England Pain Society
The medical primary care clinic was tar- annual meetings. Several articles have been
geted at the Providence VAMC. The patient published, including those by Kerns154 and
care associate conducted the initial pain Montrey.155 A report on the aggregate results
screening at the time of the visit. If the pain of the experience of the 70 VHA teams is
score was greater than 3, the patient care forthcoming.156
associate gave the educational booklet and Next steps at the national level include
comprehensive assessment tool to the the development of new guidelines related to
patient. The patient completed the compre- the use of opioids in patients with chronic
hensive assessment tool, and the primary pain. Additionally, the Outcome Measures
care provider reviewed it with the patient Work Group is developing a toolkit of pain
during the physical exam. The provider com- management–related measures and resources
pleted the assessment, provided the educa- designed to guide staff in quality improve-
tion, and arranged the telephone follow-up. ment efforts. The VHA Health Services
The approach at the Providence VAMC Research and Development Service estab-
excluded the role of the nurse as intermedi- lished pain as a priority area for research
ary between patient and provider. funding in 2002. The NPMCC Pharmacy
The effectiveness of providing weekly Work Group (chaired by Charles Sintek,
facility-specific feedback is demonstrated in MS, RPh, Denver VAMC) has implemented
Figure 14, which shows evidence of substan- a Web-based learning system on opioid use
tial improvement on two indicators within 6 for continuing education credits. Finally, the
weeks of project initiation. The variation in

90
Figure 14. Performance on Two Indicators Within 6 Weeks of Initiation of the

Veterans Health Administration/Institute for Healthcare Improvement Pain
Management Collaborative at the Togus, Maine, and Providence, Rhode Island,
Veterans Affairs Medical Centers
Percentage of Primary Care Patients With Pain Scores
100% 100% 100%

100 91% 91% 91% 92%
90
91%
86% 87% 88% 87%
80
70
60
50 Togus
50% 50%
40
Providence
30
20
10
0
6/1 6/8 6/13 6/20 6/27 7/6 7/11
Percentage of Primary Care Patients With Moderate Pain
60 Togus
50% 50%
50 Providence
40
30
21%
18%
20
9% 9% 8%
10 14%
9% 9%
7% 7% 8%
5%
0
6/1 6/8 6/13 6/20 6/27 7/6 7/11
Source: M. Berrio, VA Boston Health Care System. Used with permission.
VHA has provided funding for new pain 9. Summary: Key Lessons
management fellowships in anesthesiology, The following lessons learned from partici-
psychiatry, neurology, and rehabilitation pation in the VHA-IHI collaborative should
medicine. Additional information about be generally applicable to organizations striv-
VHA pain management initiatives is avail- ing to promote change in existing processes
able at the Web site www.vachronicpain.org. or practices:

91
■ Build the initiative step by step; show ■ Give regular feedback to all involved;
success in one small location; plant the data were critical to making the VHA-
seeds and allow them to take root. IHI initiative a success.
■ Use facility-based pain champions and ■ Make the changes easy for those
role models; work with those who will involved; integrate the changes into
work with you. daily practice.
■ Involve top administration personnel ■ Publicize successes.
from the beginning.
■ Implement change when you are not
likely to be confronted by conflicting pri-
orities such as major reorganization.

92
Appendix A: A Selection of Resources Related to Pain Management and Improvement
Agency for Healthcare Research and Quality American Geriatrics Society

2101 E. Jefferson Street, Suite 501 The Empire State Building
Rockville, MD 20852 350 Fifth Avenue, Suite 801
301-594-1364 New York, NY 10118
www.ahrq.gov 212-308-1414
www.americangeriatrics.org
American Academy of Orofacial Pain
19 Mantua Road American Medical Directors Association
Mount Royal, NJ 08061 10480 Little Patuxent Parkway, Suite 760
856-423-3629 Columbia, MD 21044
www.aaop.org 800-876-2632
www.amda.com
American Academy of Pain Medicine
4700 West Lake Avenue American Pain Foundation
Glenview, IL 60025 201 North Charles Street, Suite 710
847-375-4731 Baltimore, MD 21201-4111
www.painmed.org 888-615-7246
www.painfoundation.org
American Academy of Pediatrics
141 Northwest Point Boulevard American Pain Society
Elk Grove Village, IL 60007 4700 West Lake Avenue
847-434-4000 Glenview, IL 60025
www.aap.org 847-375-4715
www.ampainsoc.org
American Alliance of Cancer Pain Initiatives
1300 University Avenue, Room 4720 American Society of Addiction Medicine
Madison, WI 53706 4601 North Park Avenue, Arcade Suite 101
608-265-4012 Chevy Chase, MD 20815
www.aacpi.org 301-656-3920
www.asam.org
American Council for Headache Education
(ACHE) American Society of Anesthesiologists
19 Mantua Road 520 North Northwest Highway
Mount Royal, NJ 08061 Park Ridge, IL 60068-2573
856-423-0258 847-825-5586
www.achenet.org www.asahq.org
American Cancer Society American Society of Clinical Oncology

1599 Clifton Road, NE 1900 Duke Street, Suite 200
Atlanta, GA 30329-4251 Alexandria, VA 22314
800-ACS-2345 703-299-0150
www.cancer.org www.asco.org
American Chronic Pain Association American Society of Consultant Pharmacists

P.O. Box 850 1321 Duke Street
Rocklin, CA 95677 Alexandria, VA 22314
800-533-3231 703-739-1300
www.theacpa.org www.ascp.com
American College of Rheumatology The American Society of Law, Medicine & Ethics
1800 Century Place, Suite 250 765 Commonwealth Avenue, Suite 1634
Atlanta, GA 30345 Boston, MA 02215
404-633-3777 617-262-4990
www.rheumatology.org www.aslme.org

93
American Society of Pain Management Nurses International Association for the Study of Pain
7794 Grow Drive 909 Northeast 43rd Street, Suite 306
Pensacola, FL 32514 Seattle, WA 98105-6020
888-342-7766 206-547-6409
www.aspmn.org www.iasp-pain.org
American Society of Regional Anesthesia & Pain Joint Commission on Accreditation of Healthcare
Medicine Organizations
P.O. Box 11086 One Renaissance Boulevard
Richmond, VA 23230-1086 Oakbrook Terrace, IL 60181
804-282-0010 630-792-5000
www.asra.com www.jcaho.org
The Rehabilitation Accreditation Commission Joint Commission Resources, Inc.

(CARF) One Lincoln Center, Suite 1340
4891 East Grant Road Oakbrook Terrace, IL 60181
Tucson, AZ 85712 630-268-7400
520-325-1044 www.jcrinc.com
www.carf.org
The Mayday Pain Project
Center to Advance Palliative Care www.painandhealth.org
The Mount Sinai School of Medicine
1255 5th Avenue, Suite C-2 Medical College of Wisconsin
New York, NY 10029-6574 Palliative Medicine
212-201-2767 9200 West Wisconsin Avenue
Milwaukee, WI 53226
City of Hope, Pain/Palliative Care Resource 414-805-4605
Center www.mcw.edu/pallmed
1500 E Duarte Road
Duarte, CA 91010 National Chronic Pain Outreach Association
626-359-8111 7979 Old Georgetown Road, Suite 100
www.cityofhope.org/prc/web Bethesda, MD 20814-2429
301-652-4948
Federation of State Medical Boards of the United neurosurgery.mgh.harvard.edu/ncpainoa.htm
States, Inc.
P.O. Box 619850 The National Guideline Clearinghouse
Dallas, TX 75261-9741 info@guideline.gov
817-868-4000 www.guideline.gov
www.fsmb.org
National Headache Foundation
Hospice & Palliative Nurses Association 428 West Saint James Place, 2nd Floor
Penn Center West One, Suite 229 Chicago, IL 60614-2754
Pittsburgh, PA 15276 888-NHF-5552
412-787-9301 www.headaches.org
www.hpna.org
National Hospice and Palliative Care
Institute for Healthcare Improvement Organization
375 Longwood Avenue, 4th Floor 1700 Diagonal Road, Suite 300
Boston, MA 02215 Alexandria, VA 22314
617-754-4800 703-837-1500
www.ihi.org www.nhpo.org

94
Oncology Nursing Society PRECEPTORSHIPS, OBSERVERSHIPS, FELLOW-

501 Holiday Drive SHIPS
Pittsburgh, PA 15220
412-921-7373 Beth Israel Deaconess Medical Center
www.ons.org 330 Brookline Avenue
Boston, MA 02215
Pain and Policy Studies Group (PPSG) 617-667-5558
University of Wisconsin-Madison
406 Science Drive, Suite 202 Mercy Medical Center
Madison, WI 53711-1068 Pain Management Services
608-263-7662 1111 Sixth Avenue
www.medsch.wisc.edu/painpolicy Des Moines, IA 50314-1101
515-247-3172 or 515-247-3239
The Resource Center of the American Alliance of
Cancer Pain Initiatives Memorial Sloan-Kettering Cancer Center
1300 University Avenue, Rm 4720 Nurse Fellowship in Pain and Palliative Care
Madison, WI 53706 Department of Pain and Palliative Care
608-262-0978 1275 York Avenue
www.wiscinfo.doit.wisc.edu/trc New York, NY 10021
212-639-2662
Sickle Cell Information Center
P.O. Box 109, Grady Memorial Hospital
80 Jesse Hill Jr Drive Southeast
Atlanta, GA 30303
404-616-3572
www.emory.edu/PEDS/SICKLE
Toolkit of Instruments to Measure End-of-Life

Care
Dr. Joan Teno
Center for Gerontology and Health Care Research
Brown Medical School
P.O. Box G-HLL
Providence, RI 02912
www.chcr.brown.edu/pcoc/toolkit.htm
Wisconsin Cancer Pain Initiative

www.wisc.edu/wcpi
World Health Organization

20 Avenue Appia
CH-1211 Geneva 27
Switzerland
+41-22-791-3634
www.who.int
Worldwide Congress on Pain

Dannemiller Memorial Education Foundation
12500 Network Blvd., Suite 101
San Antonio, TX 78249
www.pain.com

95
Appendix B: A Plan-Do-Check-Act Worksheet
A Plan-Do-Check-Act Worksheet
1. What are we trying to accomplish?

Some questions to consider: (a) What is our aim? (b) What need is tied to that aim? What exactly
do we know about that need? (c) What is the process we are working on? (d) What is the link
between our aim and this process? Does this process offer us the most leverage for work in support
of our aim? (e) What background information do we have available about this improvement—cus-
tomer, other?
2. How will we know that change is an improvement?

Some questions to consider: (a) Who are the customers? What would constitute improvement in
their eyes? (b) What is the output of the process? (c) How does the process work? (d) How does
the process currently vary?
3. What changes can we make that we predict will lead to improvement?

Some questions to consider: (a) Reflecting on the process described, are there ideas for improve-
ment that come readily to mind? (b) Would a simple decision matrix help you decide which to
work on first? (c) Are all our decision criteria worded to make their scoring in the same direction?
(d) For the change we’d like to try, what is our prediction? (e) What questions do we have about
the change, the process, and our prediction? What will you need to check? Do these questions
help us link to the overall aim and need?

96
4. How shall we PLAN the pilot?

Some questions to consider: (a) Who is going to do What, by When, Where, and How? (b) Is the
“owner” of the process involved? (c) How shall we measure to answer our questions-to confirm or
reject our prediction?
5. What are we learning as we DO the pilot?

Some questions to consider: (a) What have we learned from our planned pilot and collection of
information? (b) What have we learned from the unplanned information we collected? (c) Was
the pilot congruent with the plan?
6. As we CHECK and study what happened, what have we learned?

Some questions to consider: (a) Was our prediction correct? (b) Did the pilot work better for all
types of customers—or just some of them? (c) What did we learn about planning the next change?

97
7. As we ACT to hold the gains or abandon our pilot efforts, what needs to be done?
Some questions to consider: (a) What should be standardized? (b) What training should be con-
sidered to provide continuity? (c) How should continued monitoring be undertaken? (d) If the
pilot efforts should be abandoned, what has been learned?
8. Looking back over the whole pilot, what have we learned?

Some questions to consider: (a) What was learned that we expected to learn? (b) What unantici-
pated things did we learn? (c) What did we learn about our predictive ability? (d) Who might be
interested in learning what we’ve learned?
Source: Batalden, PB, Stoltz PK. A framework for the continual improvement of health care: building and applying professional
and improvement knowledge to test changes in daily work. Joint Commission Journal on Quality Improvement.
1993;19(10):446-447.43 Worksheet developed with the help of Tom Nolan, PhD, of Associates in Process Improvement. ©1992
HCA Quality Resource Group, June 1993. Used with permission.

98
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Improving the Quality of

@ 2003 by the Joint Commission on Accreditation of Healthcare Organizations

June L. Dahl, PhD Mark Stillman, MD

Joint Commission Project Team

Project Director Editorial Consultant

Improving the Quality of Pain Management Through Measurement and Action

Joint Commission on Accreditation of Healthcare Organizations

D. Integrating Pain Management Improvement Activities in an

List of Tables, Figures, Text Boxes, and Appendices

Improving the Quality of Pain Management Through Measurement and Action

Table 13. Examples of Departmental Pain Improvement Activities:

Joint Commission on Accreditation of Healthcare Organizations

Comparing Criteria: Guidelines, Standards, Consensus Statements ...............................11

Improving the Quality of Pain Management Through Measurement and Action

Joint Commission on Accreditation of Healthcare Organizations

SECTION II: ■ Identification of knowledge, attitudes,

Improving the Quality of Pain Management Through Measurement and Action

nicate findings. Prior negative experiences enhance effectiveness by:

Joint Commission on Accreditation of Healthcare Organizations

management–related guidelines have been

Table 1. Pain Management Guidelines

Acute Pain Release date:1992 U.S. Department of The Quick AHRQ

Joint Commission on Accreditation of Healthcare Organizations

Table 1. Pain Management Guidelines (continued)

Clinical Practice Release date: March U.S. Department of AHRQ

NCCN Practice Revision date: June National Recommendations National

Improving the Quality of Pain Management Through Measurement and Action

Table 1. Pain Management Guidelines (continued)

Joint Commission on Accreditation of Healthcare Organizations

Table 1. Pain Management Guidelines (continued)

Improving the Quality of Pain Management Through Measurement and Action

Table 1. Pain Management Guidelines (continued)

Joint Commission on Accreditation of Healthcare Organizations

to the recommendation that, as a general

Improving the Quality of Pain Management Through Measurement and Action

Comparing Criteria: Guidelines, Standards and Consensus Statements

expected or desired levels of per- widely. For example, guidelines are

■ They can be multidisciplinary in For example, standards of all types

can vary across and even within

Joint Commission on Accreditation of Healthcare Organizations

Table 2. Consensus and Position Statements

Improving the Quality of Pain Management Through Measurement and Action

Table 2. Consensus and Position Statements (continued)

Circumcision Policy March American Academy A policy statement American Academy of

Prevention and February American Academy A policy statement American Academy of

Joint Commission on Accreditation of Healthcare Organizations

SECTION III: ■ Inputs—including patients, clinicians,

Improving the Quality of Pain Management Through Measurement and Action

Figure 1. Dynamics of Systems Thinking in Relation to the Health Care

• Create a shared strategic • Identify key strategic work

Joint Commission on Accreditation of Healthcare Organizations

ods. These include forming a multidiscipli-

Improving the Quality of Pain Management Through Measurement and Action

Figure 2. The PDSA Cycle

infrequent patient reassessment as a problem, be planned across shifts (design/plan), the

Improving the Quality of Pain Management Through Measurement and Action

Figure 3. Cycle for Improving Performance

Redesign Design Internal

Understanding the • Organize team • Collect • Compare to • Identify

Continuous monitoring • Determine who, when • Remeasure • Reanalyze • Modify

Joint Commission on Accreditation of Healthcare Organizations

3. Integrating With Internal Quality ■ Using Web-based communications such

Improving the Quality of Pain Management Through Measurement and Action