Improving Pain Management

An Introduction to Continuous Quality Improvement

Gwendolen Buhr, MD

May 30, 2003

Quality Improvement Process

• Three fundamental questions– What are we trying to accomplish?

– How will we know that change is an improvement?

– What changes can we make that will result in improvement?

Quality Improvement Process

• What are we trying to accomplish?– Set aims

• Facility rate of pain

• Desire to decrease to a lower level

– Form a team (5-8 members)• Leadership, technical expert, day to day champion

• Nursing, direct care workers, rehab, medicine, pharmacy, administration

Team Functioning

• Meet regularly

• Assign members specific tasks and responsibilities between meetings

• Make the work of the team visible

• Use posters about the project

• Display the data collected

Quality Improvement Process

• How will we know that change is an improvement?– Establishing measures – necessary to assess

progress on your aim• After 1 month there will be 5% more complete pain

assessments

• 25% more patients will indicate that their pain is adequately addressed

Conduct an Audit

• MDS indicators – rate of pain and persistent pain

• Chart documentation• Family and patient perceptions of the

adequacy of pain treatment• Staff knowledge• Plot data on the key measures each month

over time

Quality Improvement Process

• What changes can we make that will result in improvement?– Identify changes

• Staff education• Pain assessment pocket cards• Comprehensive admission and quarterly pain

assessment forms• Nurse initiated nonpharmacologic treatments

– Be clear about your population of focus

Brainstorming

• Facilitator

• Ground rules– No bad ideas– Encourage participants to “think outside the

box”– But not a “free for all” or “gripe session”

Describing the Process

• Cause & Effect/ Fishbone diagramming• Flowcharting

– To allow participants to identify the flow or sequence of events in a process

– Identifies areas for data collection and analysis– Shows where simplification and standardization

may be possible– Helps to identify improvement opportunities

Fishbone Diagram

Persistent Pain

PatientPatient

NurseNurse TreatmentTreatment

MD not reachedto get order

Incorrect treat-Incorrect treat-mentment

Incorrect dose

Incorrect routeStaffing

Does notrecognize Does not see

as an urgent problem

Does not follow-up

EtiologyEtiology

Cancer Osteoarthritis

Osteoporosis

Does not want to report

Afraid of opiates

$$

Flow Diagram

Patient reports pain or someone recognizes pain

RN or LPN completes assessment & reviews meds

Is the patient in pain?

Is there a PRN pain med?

Has pain improved?

Pain under control

Givespain med

Reassess in proper time period

Call MD

yes

no

yes

no

Patient judgednot in pain

Call MD

Continue to monitor

no

yes

Changes

• Identify the changes to your system necessary to reach your aims – Today work on assessment, tomorrow on

knowledge of pain management

• Set priorities based on the aim

• Avoid low impact changes

Quality Improvement Process

• Testing changes with the Plan-Do- Study-Act (PDSA) cycle as a guide

PDSA Cycle

•Document

PlanPlan•Objective•Describe current process•Measure and analyze•Focus on an improvement opportunity

•Carry out the plan

StudyStudy•Evaluate the results•Draw conclusions

ActAct•Standardize the change•Monitor; hold the gains

DoDo •Identify root causes

•Generate and choose solutions

problems and unexpected observations

Performance Improvement Measures

• Benchmarking– State or National quality indicators– Corporate benchmarks– Literature

• Aggregating data over time to show trends

• Targets

Test the Change

• Predict how much improvement can be expected

• Learn how to adapt the change to your environment

• Evaluate costs and side-effects of the change

• Minimize resistance

Make the First Test Small

• Make the change side-by-side with the existing system

• Encourage comments

Quality Improvement Process

• Do multiple PDSA cycles each time answering the questions:– What are we trying to accomplish?– How will we know that a change is an

improvement?– What change can we make that will result in an

improvement?

Example

Initial Audit Results From Croasdaile Village

Methods for Assessment

• Test to determine staff knowledge• The Minimum Data Set (MDS) to provide rates of

pain and persistent pain • The charts of 20 patients receiving analgesics

reviewed to assess pain documentation• 20 patients and 20 family members interviewed to

glean their satisfaction

Staff Test on Pain Related Knowledge

0

2

4

6

8

10

12

14

16

Nu

mb

er

co

rre

ct

RN = Registered Nurse, LPN = Licensed Practical Nurse, RN = Registered Nurse, LPN = Licensed Practical Nurse, CNA = Certified Nursing Assistant CNA = Certified Nursing Assistant

= = meanmean

Staff Test Continued

• More than half of the staff missed questions concerning: – Nonspecific signs and symptoms of pain– Recognition of pain in the cognitively impaired– Complementary (nonpharmacologic) therapies– The difference between acute and chronic pain

0102030405060708090

100

Pain is adequatelyaddressed

Wait too long for painmedicine

% w

ho

res

po

nd

ed y

es

patient

family

Patient and Family Responses

Patients surveyed N = 20

• Mean = 3.6Mean = 3.6

stronglystronglyagreeagree

agreeagree

unsureunsure

stronglystronglydisagreedisagree

disagreedisagree

Patients Response on a 5-point Scale to “My Pain Is Adequately

Addressed”

Chart Review

Residents With Pain Medication on Their MAR

Was Pain Documented?

Number N=29 %

Residents with a pain intensity scale used to

monitor pain

1 3.4

Documented No Pain 13 44.8

Not Documented 2 6.9

Documented Pain 14 48.3

Completeness of Documentation

Number N=14 %

Location 9 64.3

Intensity 1 7.1

What made it worse 1 7.1

What made it better 2 14.3

Pain description 1 7.1

Response to treatments 1 7.1

Chart Review Continued

• No residents had effect of pain on sleep, mood, or ADLs documented

• No documentation of side effects of analgesics• 1/15 (6.7%) cognitively impaired residents had

behavioral signs or symptoms documented• 16/29 (55.1%) had a diagnosis recorded for pain

Aims

• Improve management of chronic pain in the nursing home

• Begin with assessment– 50% increase in complete pain documentation– 50% increase in use of pain intensity scales

• Increase the use of non-pharmacologic treatments for pain

Changes

• Modify existing policies & procedures– Assessment plan: assess residents with pain at each

MDS, when there is evidence of pain, with vital signs, and after each intervention

– Assessment tool: comprehensive pain assessment and pain intensity rating scales

– Implement nurse initiated non-pharmacologic treatments for pain (i.e., patient education, positioning, exercise, spiritual counseling, heat/cold or massage)

Next Steps

• Initiate staff educational program targeting deficiencies uncovered in staff testing

• Evaluate the results with a repeat audit