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APS Bulletin • Volume 13, Number 5, 2003
Articles
Pain Management Improvement Strategies in the Veteran’s Health Administration
Michael Craine, PhD, and Robert D. Kerns, PhD
On May 2, 2003, the under secretary for health of the Veteran’s Health Administration (VHA), Dr. Robert H. Roswell, issued a national directive: VHA Directive 2003-21: Pain Management (Veteran’s Health Administration, 2003). This landmark directive provides policy and implementation guidance for improved pain management throughout the veterans’ healthcare system. It represents a major step in the ongoing process to improve pain care in the VA—a process that began in 1998 with the enactment of the VHA National Pain Management Strategy, which established pain management as a national priority for the VHA.
Kerns (2001) described the initial planning and early accomplishments of the National Pain Management Strategy. This article will review the evolution, organization, and implementation of key elements of the strategy, and report on tasks accomplished to date.
VHA National Pain Management Strategy
Developed under the vision of then-under secretary for health, Dr. Kenneth Kizer, the VHA National Pain Management Strategy grew out of the efforts of the VHA’s acute care and geriatrics and extended care strategic healthcare groups. It was largely precipitated by the work of anesthesiologists who conducted a national survey on pain management in the VA. This survey, conducted in 1997, described the status of pain management and identified inconsistencies in pain assessment methods, access to treatment, and standards of care across VHA facilities. The national strategy was developed to address these problems.
The strategy’s primary objective is to develop a comprehensive, multicultural, integrated, system-wide approach to pain management that reduces pain for veterans with acute and chronic pain associated with a wide range of illnesses, including terminal illness. Specific objectives are to:
- Provide a system-wide VHA standard of care for pain management that reduces suffering from preventable pain.
- Ensure pain assessment is performed in a consistent manner.
- Ensure pain treatment is prompt and appropriate.
- Include patients and families as active participants in pain management.
- Provide for continuous monitoring and improved outcomes of pain management.
- Provide for an interdisciplinary, multimodal approach to pain management.
- Ensure clinicians practicing in the VA healthcare system are adequately prepared to effectively assess and manage pain.
Organizational Structure for Strategic Implementation
To successfully improve pain management, the healthcare system needed guidance and tools developed nationally for application at both the facility and caregiver levels. A multidisciplinary approach also was embraced at the outset.
VHA National Pain Management Strategy Coordinating Committee (NPMSCC). This committee (NPMSCC) was formed by the under secretary for health to accomplish these objectives. It was initially cochaired by the national chief consultant of the Geriatrics and Extended Strategic Healthcare Group and the national chief consultant of the Acute Care Strategic Healthcare Group. A national program coordinator also was appointed and continues to direct committee and program development. In addition, a multidisciplinary group of experts from facilities throughout the VA was identified and recruited to join the NPMSCC and help implement the national strategy; experts were selected for their expertise in pain management, education, research, and information technology. Experts from areas outside of pain are central to the success of the committee and its component working groups.
The NPMSCC comprises several work groups chaired by committee members. Each work group has responsibility central to the strategy objectives. So far, work groups have tackled clinical guideline development, education, research, outcome measurement, pharmacy, and pain resource toolkit development. Their accomplishments will be reviewed later in this article.
VISN and Facility Level Agents for Implementation. The VHA is organized into 21 Veterans Integrative Service Networks (VISNs). Each VISN includes inpatient and outpatient care settings. In many parts of the country, a VISN spans several states. Educational service representatives from all VISNs were enlisted to help develop and disseminate educational materials to facilities. Building clinical competency and pain management awareness are key objectives.
A point of contact (POC) is designated for each VISN. The POC serves as a liaison between the NPMSCC and VISN facilities. Many VISNs and facilities also have instituted local pain management oversight committees. Other actions consistent with the national strategy include creating local policy statements, establishing multidisciplinary pain teams, and offering increased access to specialty pain care and education for staff, patients, and families. At many sites, these activities are combined with efforts to comply with pain management standards set by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) in 2001.
Highlights of the Implementation Process to Date
Once the organizational structure was in place, it was time to implement pain management objectives. As the coordinating board, the NPMSCC defines and initiates the tasks that implement the pain management strategy. The work group structure provides the format for this effort. Work groups draw on expertise from within the VA and from non-VA experts, collaborating with the Department of Defense in clinical guideline development and with pain experts in academic settings. Work groups operate simultaneously, allowing a number of key objectives to be addressed concurrently. This work results in numerous major products and organizational changes in a short period of time (Click here for Table 1).
Screening for the Presence and Intensity of Pain. Using the model initially promoted by APS, the NPMSCC devoted its first efforts to establishing a national initiative for Pain as the 5th Vital Sign to make screening for the presence and intensity of pain a routine part of patient care in all facilities. The NPMSCC created a special pain assessment toolkit, “Pain as the 5th Vital Sign,” which was revised by the toolkit work group (Veteran’s Health Administration, 2000). This computer-based toolkit was distributed to all healthcare facilities through the point of contact system and administrative channels. The kit provides an overview of the national pain management strategy, guidance for implementing pain assessment in healthcare facilities, instructions on basic pain assessment, and the use of assessment in patient and family education. It also contains extensive bibliographic references and resource information, such as a summary of the JCAHO pain management standards and links to Web sites of national pain organizations such as APS, the International Association for the Study of Pain, Talaria Cancer Pain Management, and the University of Wisconsin Pain and Policy Studies Group. The kit is available to all VHA clinicians at www.va.gov/pain_management and the VA intranet pain Web site.
In 1998, the VHA external peer review program was used to monitor the progress of the Pain as the 5th Vital Sign initiative. This program employs a quarterly sampling of patient charts across the healthcare system to track the occurrence of key healthcare events. The most recent data available indicate pain screening and intensity scores were documented for approximately 98% of the patients reviewed within the past year from the time of the review. This represents a significant shift from the initial survey in late 1999, which showed pain screening and intensity scores for approximately 60% of patient records (Figure 1). Additional monitors are now being piloted; they examine the percentage of patient records in which a pain score is documented at the time of the most recent encounter, cases in which pain scores indicate at least a moderate pain level, documented plans of pain care, and reassessment of pain following plan implementation.
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Figure 1.
VHA External Peer Review Program Percentage of Patient Records with Pain Intensity Scores 
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VHA-IHI Pain Collaborative. In May of 2000, in a creative collaboration with the Institute of Healthcare Improvement (IHI), the VHA employed the IHI “breakthrough series” model for rapid change in a healthcare system. Chaired by Charles Cleeland, PhD, of M.D. Anderson Cancer Center in Houston, the planning group for this collaborative included several members of the NPMSCC, staff from IHI, and community experts in pain management. During the 9 months of the collaborative cycle, 73 teams from each of the VISNs achieved improved pain management in a variety of settings, including ambulatory care, inpatient rehabilitation, oncology, and long-term care. The collaborative set five goals for improved pain management: a 25% reduction in pain intensity scores, pain screening documentation for 100% of patients, a 20% or greater increase in documented care plans for patients with pain scores equal to or greater than 4, and a 50% or higher percentage of patients receiving education about pain management. Each team worked on one or more of these goals. Tracking goals and reviewing feedback to help promote change were primary components of the model.
The collaborative series included three national meetings at which teams presented their results, received education from experts in the field, and addressed barriers to change. A core staff with experience in promoting change in their healthcare settings emerged. An internet mail group of more than 600 people involved in pain treatment provides a forum for exchange of information in areas such as educational material and clinical practices and policies.
Results reveal success related to each of these goals. Moderate or severe pain on study units dropped from 24% to 17%; pain assessment increased from 75% to 85%; pain care plans for patients with at least mild pain increased from 58% to 78%; and the number of patients who received pain educational materials increased from 35% to 62%. A paper reporting the results of this important performance improvement effort is now in press (Cleeland, et al., in press). It is hoped this effort will be used as a model to promote additional system-wide change to improve pain management throughout the VHA and in other public and private healthcare delivery systems.
Working Groups
As noted earlier, the NPMSCC coordinates several multidisciplinary work groups that develop resources and tools to help healthcare facilities support the national pain management strategy. The pain assessment toolkit is just one product developed by a work group to address assessment and treatment. The clinical guidelines working group, working through the VA Office of Quality and Performance, has collaborated with the Department of Defense and community experts to produce clinical guidelines and treatment algorithms for acute postoperative pain. Clinical guidelines are available on the internet at www.oqp.med.va.gov and on the VA intranet. Acute and Post-Operative Pain Guideline Toolkits were distributed to all the VISNs. This group recently finished guidelines for the use of opioid medications in chronic nonmalignant pain, which are under review prior to being disseminated to healthcare facilities. The VHA also offers a set of guidelines and a toolkit for assessing and treating low back pain in primary care settings. These guidelines also were developed in collaboration with the Department of Defense and the VA Office of Quality and Performance, and are available on the VA intranet and at www.oqp.med.va.gov (but the NPMSCC was not involved in their development).
The pharmacy working group addresses issues related to pharmacologic interventions in pain management. This group has created a Web-based education course on the use of opioids in acute and chronic pain. The course is accredited for continuing education for physicians, nurses, psychologists, and dentists, and is available to all VHA clinical staff through the VA intranet.
Another working group focuses on outcome measurement in pain treatment. This work group completed an outcomes measurement toolkit that provides guidelines for the assessment of pain treatment interventions and pain treatment delivery systems. This toolkit was distributed nationally, and is available to all providers at the VA pain Web site. This group also has worked extensively with the VA’s Information Technological Service to create computerized pain assessment templates that offer a standard for pain assessment throughout the system. These templates are part of a comprehensive clinical reminder system that cues providers to perform pain assessments and provide a topic outline for chart documentation that follows pain management standards of care. It is consistent with standards set by accrediting agencies such as JCAHO and the Commission on Accreditation of Rehabilitation Facilities (CARF).
The research working group works with the VHA Office of Research and Development to encourage pain-relevant research. This group has been successful in promoting pain management as key to the VA Health Services Research and Development Service’s (HSR&D) strategic plan. It also has promoted pain management as an area of emphasis in several formal requests for proposals from HSR&D and the other divisions of the VA research program. The working group also sponsored an open forum in conjunction with the most recent VHA Faculty Leadership Conference on Pain Management and End-of-Life Care, during which investigators were apprised of these initiatives and the development of investigator-initiated research projects related to the study of pain and pain management.
Educating providers, patients, and families is a cornerstone of pain management, and one of the key objectives of the national strategy. The education working group is one of the largest and most productive working groups. Examples of educational offerings in support of the national strategy include pain education materials such as interactive CDs, reference books, and videotapes for staff and patients. Numerous interactive satellite broadcasts have been produced with expert consultants who have presented these topics: Interdisciplinary Approaches to Chronic Pain Management; Pain Management in Unique Populations: elderly, persons with a history of substance diversion, abuse, or addictions, and cognitively impaired patients; Pain Management and Chemical Dependency; and Biopsychosocial Approaches to Pain Management. The VA Pain Management Web site on the VA intranet offers continuing education information and links to pain education resources.
The VA Office of Academic Affiliations has worked with the NPMSCC to establish advanced clinical training in pain management. Special pain management residency training positions with clinical research components are now offered in the specialties of anesthesiology, physiatry, neurology, and psychiatry.
The NPMSCC has conducted three VHA National Leadership Conferences on Pain Management and End of Life Care, in which participants of all healthcare disciplines nationwide have met to share clinical presentations and research from across a broad spectrum of pain management issues. These conferences also provide training workshops and the opportunity to hear from national experts. Conference proceedings, which have been published and distributed, offer continuing medical education credit. The conferences also created a forum that provides an ongoing exchange of education and information through monthly national conference calls featuring expert guest speakers on pain management topics. More than 200 people participate in this call each month.
Future Directions
The collaborative efforts of professionals from multiple disciplines have gone a long way toward accomplishing the objectives of the VHA national pain management strategy. Another strength of the VHA’s national pain management strategy’s organizational structure has been its capacity to develop and disseminate clinical and educational resources to the healthcare system, accomplished through traditional VA lines of communication and new networks and individuals committed to pain management. Computer-based resources also have been key in this endeavor.
Achievements aside, a great deal remains to be done to bring pain management to the highest level across the VHA healthcare system and accomplish all the objectives of the national pain management strategy. Along with the continued development of the activities described here, future plans include the development of national performance measures to assist in administrative tracking of pain management healthcare events, and the development of models for access to pain management care to support clinicians in settings remote from pain experts, centers, or clinics. It is important to maintain momentum generated by the VHA National Pain Management Strategy and stimulated by the recently published Pain Management Directive as the VHA moves towards its goals in the Decade of Pain Control and Research.
Author Note
The views expressed in this article are those of the authors. No official endorsement by the Department of Veterans Affairs should be inferred. Correspondence concerning this article should be addressed to Michael Craine, PhD, Psychology (116B), VA Eastern Colorado Health Care System, 1055 Clermont Street, Denver, CO 80220. e-mail: Michael.Craine@med.va.gov.
References
Cleeland, C.S., Schall, M., Nolan, K., Reyes-Gibby, C.C., Paice, J., Rosenberg, J.M., et al. (in press). Rapid improvement in pain management: The Veterans Health Administration and the Institute for Healthcare Improvement Collaborative. Clinical Journal of Pain.
Kerns, R. (2001). Improving pain management in the VA. Federal Practitioner, Suppl. August, 18-25.
Veterans Health Administration (2000). Pain as the 5th vital sign toolkit. V.2. Washington, DC: Author.
Veterans Health Administration (2003). VHA directive 2003-021: Pain management. Washington, DC: Author.
Michael Craine, PhD, is supervisory psychologist, Clinical Health Psychology Section, and Director, Interdisciplinary Pain Team, at VA Eastern Colorado Health Care System, and assistant professor, Physical Medicine and Rehabilitation Service, University of Colorado Health Sciences Center.
Robert D. Kerns, PhD, is chief, Psychology Service, VA Connecticut Healthcare System, and professor of psychiatry and neurology and associate professor of psychology at Yale University.
