Publications
APS Bulletin • Volume 12, Number 6, November/December 2002
Pain and Public Policy
Corey D. Fox, PhD, Department Editor
Joint Commission Pain Standards:
A Progress Report
June L. Dahl, PhD and Debra B. Gordon, MS RN CS
Few actions have generated as much interest in the field of pain management as the release of pain management standards by the Joint Commission on Accreditation of Healthcare Organizations. These standards were the outgrowth of a 2-year collaboration between the University of Wisconsin Medical School and the Joint Commission standards department. Supported by a grant from the Robert Wood Johnson Foundation, the collaboration’s goal was to integrate pain assessment and management into standards to accredit the nation’s healthcare organizations to make pain management a priority in the healthcare system.
Although the standards were approved in July 1999, they did not become a formal part of the survey and accreditation process until January 2001 because it was believed the field needed additional time to prepare for compliance. Now that almost 2 years have passed since organizations became accountable for pain assessment and management, this is an appropriate time to reflect on the rationale for development of the standards, to examine some of the controversies surrounding them, and to share early survey data from the Joint Commission. Unfortunately, there are no data to tell us if these standards have improved pain management in accredited facilities.
The need to make pain visible
In 1990, the chair of the APS Quality of Care Committee wrote that if there were to be improvement in the quality of pain care, it would be necessary to move beyond traditional educational and advocacy efforts—focusing on increasing pain’s visibility in the clinical environment—to establish systems to support, reinforce, and reward good pain management practices (Max, 1990). “Make pain visible” became a central theme in many settings, leading to the genesis of the now-familiar “pain as a fifth vital sign” campaign. While this slogan was never literally intended to make pain intensity a vital sign, it heightened awareness of the need to document pain in a prominent place. This place could be the vital signs section of a patient’s chart to alert clinicians to the problem and elicit a prompt response.
Max’s comments, and the resultant APS Quality Assurance Standards (1991), provided the framework for a series of national guidelines for pain management (Jacox et al., 1994) and a refined APS Quality Improvement (QI) Guideline (1995). All of these guidelines stress the need to develop processes that increase provider accountability for assessment and treatment of pain. They identify five elements that are key to establishing institutional responsibility:
- Recognize and treat pain promptly.
- Make information about analgesics readily available to clinicians in a way that facilitates order writing and interpretation of orders.
- Promise patients attentive analgesic care.
- Define explicit policies for the use of advanced analgesic technologies.
- Examine the process and outcomes of pain management with the goal of continuous improvement.
Why standards?
Unfortunately, through the 1990s there continued to be reports of poor pain control for postoperative and trauma pain, cancer pain, and many chronic pain problems not related to cancer. Guidelines, professional curricula, and a multiplicity of professional education programs were not improving the quality of pain management by themselves. An added approach was suggested: the use of accreditation standards from the Joint Commission to provide a framework to guide efforts for making pain management an essential and integral part of patient care. The Joint Commission has comprehensive quality review programs for hospitals, healthcare plans, home care agencies, laboratories, behavioral healthcare settings, long-term care facilities, ambulatory care clinics, and networks of services that often serve as alternatives to state and federal inspections of these organizations. Many organizations use their Joint Commission accreditation to obtain Medicare certification through the deemed status process.
Because the Joint Commission evaluates and accredits more than 19,000 healthcare organizations in the United States, Joint Commission pain standards have the potential to have a powerful impact on the quality of pain management. For example, Joint Commission accredits 80% of the nation’s hospitals (more than 5,000 facilities) that account for 96% of inpatient admissions. The standards approved more than 3 years ago require accredited healthcare facilities to recognize patients’ rights to appropriate assessment and management of pain; to assess pain in all patients; to record the assessment in a way that facilitates regular reassessment and follow-up; to educate patients, families, and providers; to establish policies that support appropriate prescription or ordering of pain medicines; to include patient needs for symptom control in discharge planning; and to collect data to monitor the appropriateness and effectiveness of pain management.
Reaction to the Standards
Pain management advocates have enthusiastically embraced the standards because they address the documented impediments in the healthcare system, including failure to (1) assess pain appropriately, (2) hold anyone accountable for poor pain management, (3) assure that pain is addressed as patients move from one care setting to another, and (4) make patients aware of their right to and the benefits of effective pain control (Chapman, 2000; Frankenstein, 2000; Berry & Dahl, 2000). On the other hand, many physicians have expressed resentment toward the standards, viewing them as yet another unwelcome intrusion in their practices—something that could impede rather than enhance patient care and ultimately drive up the cost of health care. Some accused the Joint Commission of practicing medicine or forcing physicians to prescribe opioids in cases in which this is not appropriate (Hansen, 2000). Others have expressed concern about the survey process itself, with reports from the field that some surveyors ask few questions about pain management or alternatively tell facilities how to specifically assess and manage pain. The Joint Commission has repeatedly emphasized it does not write clinical practice guidelines, nor does it dictate how facilities must specifically assess and manage pain. It does, however, require accredited organizations to develop and implement processes and policies likely to result in improvement in quality of care. The Joint Commission also says its pain standards are its first evidenced-based standards. The pain standards directly reiterate recommendations of institutional responsibility provided in evidence-based guidelines developed by groups such as APS and the Agency for Healthcare Research and Quality (formerly the Agency for Healthcare Policy and Research).
As is so often the case, the devil is in the details. We have heard no concerns about the validity of the standards themselves; the anxiety and confusion relate to interpretation of the standards and their practical implications. Nurses, for example, became concerned about statements on the Joint Commission Web site that implied organizations could no longer use PRN range analgesic orders without specific implementation protocols. Nurses felt this would limit their clinical judgement and force them to follow rigid, unsafe protocols and prevent them from responding appropriately to patients’ individual dosing needs. The controversy was resolved when the Joint Commission clarified patient safety was the issue. Said D. S. Rich, the Joint Commission’s associate director, surveyor development and management, “The litmus test on survey would be if two nurses would interpret the range orders for a patient in the same way” (personal communication, April 2002). Interactive dialogue between clinicians in the field, the Joint Commission Standards Interpretation Group, and Joint Commission surveyors has been ongoing and necessary to clarify the intent and examples of implementation of a number of pain standards.
In another example, many clinicians jumped to the conclusion that pain intensity had to literally be documented each time vital signs were recorded as the “fifth vital sign.” Indeed, in the Joint Commission’s Comprehensive Accreditation Manual for Hospitals, “Pain is considered the ‘fifth’ vital sign in the hospital’s care of patients” (p. RI-14) was cited as an example of implementation of the patient rights standard RI.1.2.8 (patients have the right to appropriate assessment and management of pain). The Joint Commission emphasizes examples are not scoreable items: they are just examples of how one might comply with a particular standard. In response to this confusion and to support what was said earlier (that the fifth vital sign slogan was never intended to mandate pain intensity as a fifth vital sign), this implementation example has been removed from all standards manuals.
Outpatient facilities were confused about their mandate, as well. Would the Joint Commission demand documentation and treatment for every patient who presented in an outpatient setting? The answer is clearly no. The Standards Interpretation Group has clarified the requirement by stating, “Pain should be assessed as warranted based on the reason the patient is presenting for care.” Obviously, this leaves the field with considerable latitude. To help clarify, Carole Patterson, former director of the Standards Interpretation Group, said the Joint Commission “will always measure your performance against your own requirements” (personal communication, July 2002).
Reports of individual surveyors providing inappropriate recommendations during accreditation surveys have been an ongoing concern. In particular, several settings reported pressure from surveyors to use pediatric scales to assess pain in cognitively impaired adults—scales that have not been validated in adult populations. Others have reported surveyors acted outside the Joint Commission’s scope of authority by providing feedback specific to treatment (such as suggesting meperidine be taken off the hospital formulary).
State medical societies have voiced concern about the burdens these standards place on members of the medical profession. Some physicians feel caught between the proverbial “rock and a hard place.” They are chastised (or sued) if their pain control efforts are not effective, and reprimanded if they are perceived to be prescribing too many opioids. A resolution introduced at the 2001 Annual Meeting of the American Medical Association (AMA) and adopted by the House of Delegates in 2002, asks
That the American Medical Association, with or without partnership with other Joint Commission corporate members, appoint a committee or task force of regularly practicing healthcare professionals, including a multi-specialty panel of physicians, nurses, and other mid-level practitioners and administrators, to objectively study and evaluate the efficacy to date of the new Joint Commission Standard as it is currently being applied and identify who is responsible for its origins; and that this task force be urged to report back to the AMA Board of Trustees at an early date so that the Board can formulate recommendations to the Joint Commission. (p. 1)
The AMA’s Council on Scientific Affairs (2002) concluded much physician concern reflects a misunderstanding of the standards requirements. The council recommended the AMA encourage continued collaborative efforts between the Joint Commission and relevant medical specialty organizations to help clarify the standards and support continued improvement in undergraduate medical education on pain management as well as the AMA-Joint Commission-NCQA (National Committee on Quality Assurance) collaborative project to develop evidence-based performance measures for pain management.
Joint Commission survey data
The Joint Commission (2002) generously shared a summary of the results of surveys of accredited facilities for the period July 1, 2001, through June 30, 2002. The data show high rates of compliance with the pain standards. Surveyors use interviews with staff, direct observation, and medical records to arrive at a score for a particular standard. Scoring is based on a complex set of aggregation and decision rules (Joint Commission, 2002). A score of 1 indicates good compliance, a score of 2, acceptable compliance; scores of 3, 4, and 5 indicate deficiencies. If an organization has at least one score of 3, 4, or 5, a Type I recommendation is assigned. A Type I recommendation means an organization may be conditionally accredited or its accreditation may be withdrawn if it does not correct or document the correction of the specified deficiencies within the time specified in the notice of the decision to the organization, or, when applicable, fails to demonstrate compliance with interim life safety measures.
Settings with highest levels of Type I recommendations on pain standards included behavioral health (20% of 571), long-term care (17% of 682), and ambulatory care (13% of 402), followed by hospitals (7.4% of 1,462). In all, Type I recommendations were most common with the initial assessment standard. Nevertheless, the much-stated fear that large numbers of healthcare facilities would lose their accreditation due to failure to implement the pain assessment and management standards is not supported by Joint Commission survey data.
Furthermore, on September 24, 2002, Joint Commission Resources (JCR) announced the launch of a database that offers hospitals practical examples to meet accreditation requirements related to patient assessment, patient care, staff competency, performance improvement, environment of care, pain management, and patient rights and responsibilities. This resource may help to dispel myths and misunderstandings about implementation of the pain standards. For the complete text, visit www.jcaho.org.
Conclusions
There is little question the standards have increased visibility and accountability for pain management in settings across the United States. Accredited facilities can no longer ignore pain. It is more difficult to determine if the standards have resulted in improvements in the quality of pain management. Certainly it appears the standards have improved assessment practices. But compliance with Joint Commission standards may provide a false sense of improvement. As APS President Chris Miaskowski (2000) points out, the standards are a double-edged sword: “Universal implementation of pain assessment standards without effective pain management approaches will be extremely frustrating for both patients and their family caregivers. Asking patients about pain, without action, is a needless activity (p. 27). From their inception, it was recognized Joint Commission standards could not address, nor overcome, all the complex barriers that affect pain treatment. As with previous change strategies, Joint Commission standards cannot by themselves improve the quality of pain management. The standards still present an important tool for clinicians, however. During his APS presidency, C. Richard Chapman (2000) said it well: “We have an opportunity to create a climate of enthusiastic change, instead of grudging compliance, if we seize the moment and step forward to help” (p. 3).
References
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Frankenstein, R.S. (2000). Assessment and management of pain. Journal of the American Medical Association, 284, 2317–2318.
Hansen, G. (2000). Assessment and management of pain. Journal of the American Medical Association, 284, 2317.
Jacox, A., Carr, D.B., Payne, R. Berde, C.B., Breitbart, W., Cain, J.M., et al. (1994). Management of cancer pain: Clinical practice guideline No. 9 (AHCPR publication 94–0592). Rockville, MD: U.S. Public Health Service, Agency for Health Care Policy and Research.
Joint Commission on Accreditation of Healthcare Organizations. (2000). Comprehensive accreditation manual for hospitals (CAMH). Oakbrook Terrace, IL: Author.
Max, M. (1990). Improving outcomes of analgesic treatment: Is education enough? Annals of Internal Medicine, 113, 885-889.
Miaskowski, C. (2000). Two double-edged swords. Pain Management Nursing, 1, 27-28.
June L. Dahl is professor of pharmacology at the University of Wisconsin Medical School and Debra B. Gordon is senior clinical nurse specialist at the University of Wisconsin Hospital & Clinics, Madison, WI. The authors thank the Robert Wood Johnson Foundation for its support.