Hospitals should be prepared for JCAHO surveys on pain management
Hospitals can expect to see a new set of pain management measures in early 2003. That's when the Joint Commission on Accreditation of Healthcare Organizations expects to begin field-testing its initial set of standardized pain management performance measures.
"We're not talking about measuring pain, but measuring organizations on how well they manage pain," said Jerod Loeb, v.p. for research and performance measurement at JCAHO. "We all think we're doing a good job managing pain, but we don't have any national comparisons or standards. For now, there is no broad agreement on which measures are reliable, valid, and well tested."
Loeb announced the pain management evaluation measures at a national summit on pain management held in San Francisco in early October. A similar session is scheduled for Washington, D.C., in early November. "There are numerous measures, but there is a lack of credibility behind many of them," he said. "We absolutely need standardized measures of pain management that transcend the setting, patient mix, and practitioner."
The new measures began as a project of the Performance Measurement Coordinating Council. PMCC is a collaboration formed by JCAHO, the American Medical Association, and the National Committee For Quality Assurance. The three groups each appointed four members to a 12- member clinical expert panel that will create the pain management measures for JCAHO. Purdue Pharma is providing unrestricted funding to develop what JCAHO is currently calling the "Standardized Performance Measures for Pain Management."
The clinical expert panel was scheduled to complete an initial review of existing pain management measures and indictors by the end of October. Specific recommendations for uniform pain management performance measures will follow later this year or early in 2003. Loeb said JCAHO surveyors could begin using the new performance measures during compliance audits by 2004.
"We don't have any problem evaluating the assessment of pain by an organization, just the management of pain," said Patricia Berry, R.N., assistant professor at the University of Utah College of Nursing. She is also an adviser to the clinical ex- pert panel writing JCAHO's pain performance measures.
The new pain management measures are in addition to existing standards requiring healthcare organizations to evaluate all patients for pain. "There has to be an organizational commitment to managing pain," Berry said. "You look at pain intensely and you do something about it, just as you do something for an adult patient with a temperature of 104°. Pain management has to be operationalized."
Current plans call for evaluating pain management in cancer, arthritis, and back disorders across the continuum of care delivery. Later measures will focus on other types of pain and specific populations, such as infants and other nonverbal populations.
"The greatest bang is identifying specific tools and techniques for pain management," Loeb said. "The commission wants to create good practices for pain management." Eventually, he said, JCAHO will develop multiple sets of evaluations that give surveyors menus of different standards that apply to different conditions, settings, and functional areas.
Confusing? JCAHO doesn't think so. Patients must be evaluated for pain, Berry noted, but that doesn't mean every patient in every facility at every setting needs the same degree of evaluation or pain management. She cited a recent study conducted by Kaiser Permanente in the Portland, Ore., area. Pain was an issue for 80% of hospital patients, 75% of long-term care patients, and 55% of home care patients. But less than 5% of patients at prenatal clinics, well-baby clinics, and travel clinics reported pain problems.
Berry said it makes sense to assess every patient in hospitals and other high-pain settings. It also makes sense to assess pain on a more selective basis in well-patient and preventive care clinics, where pain is an infrequent issue. "The organization must make a decision [about who to assess for pain] and be able to defend it in terms of its procedures and patient mix," she said.
Even high-pain settings such as hospitals and long-term care facilities are likely to find a lot of flexibility in pain management. JCAHO is concerned that pain is managed appropriately, said surveyor Steve Chinn, not in prescribing the details of how to manage it. A typical problem, he said, is assessing and treating surgery site pain but forgetting about pain due to intubation or other causes. Range orders are particularly useful tools to manage pain, he noted. The sole proviso from the surveyor's perspective is that the group's policy and procedure manual contain adequate guidance for R.Ph.s, nurses, and physicians.
"Pain is personal," Chinn said. "I can't know in advance how much morphine a postoperative patient needs, but the nurse who sees my patient does. That nurse needs an order that allows freedom to make treatment decisions with no second-guessing."
Fred Gebhart. JCAHO to release more pain management measures.