QI project cuts patients' chronic pain dramatically: facility earns Codman Award from JCAHO - Joint Commission on Accreditation of Healthcare Organizations

HealthCare Benchmarks and Quality Improvement, August, 2003

A quality improvement project at a Michigan long-term care facility resulted in a decrease in the prevalence of chronic pain among its residents from 33% in March 2000 to 18% now.

The reduction is even more significant given that the assessment of an individual's pain is a highly complex procedure, particularly among the elderly, who may experience cognitive or communication difficulties.

The Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL, recently presented Marwood Nursing & Rehab in Port Huron, MI, with the Ernest A. Codman Award, which recognizes excellence in the use of outcomes measurement by health care organizations to achieve improvements in the quality and safety of health care.

Assessment tool meets CMS requirements

Marwood's nursing team focused on the potential benefits of better pain management by developing a resident assessment protocol tool consistent with the Minimum Data Set requirements of the Centers for Medicare & Medicaid Services.

Individual resident care plans then were revised to address the specific pain issues identified by using the new tool, in addition to other pain assessment and medication management tools developed through the initiative.

One of the first steps was the formation of two pain management teams. The first, which worked together on the overall program, comprised 30 members from all disciplines, including Marwood's medical director.

Suzanne Walker, RN, unit coordinator and leader of the clinical pain management team, says the team's large size and varied backgrounds proved to be helpful.

Another important component of the program was the revision of forms that now call for more specific information about the physical and emotional conditions of residents being assessed.

Originally built as a 50-bed nursing home in 1963, today Marwood Nursing & Rehab is a 240-bed not-for-profit skilled nursing facility that has been affiliated with Port Huron Hospital since 1987.

The focus on pain management began in 1999, Walker says. The first efforts involved education of staff, residents, and family. Using research showing that pain is not a normal part of aging and often not a result of the patient's diagnosis, Walker and her colleagues sought to change the way people look at pain.

"The cause could be spiritual, psychosocial, or emotional. It's broader than we really thought it was," she says. "We educated our housekeeping staff, maintenance staff, office staff, and all non-nursing staff in basic pain assessment. So a housekeeper who goes into a patient room to sweep can listen when the patient says she has a headache, or can notice that she is different from yesterday. Maybe the housekeeper can't explain why the patient is different, but the housekeeper knows something is wrong."

Pain management is 'everybody's job'

That nonclinical staffer is expected to report the observation to a nurse or physician, who can make a more thorough assessment. The idea is to empower the ancillary staff by educating them, Walker says, and the staff take this idea very seriously.

"They know it's not just the nurse's job. It's everybody's job," she says. "It's the job of the activity person walking down the hall who sees a resident who is restless or agitated. They know it's their responsibility to notify the nursing staff."

This type of shared responsibility didn't come easily, Walker says. It never would have worked previously, because the nonclinical staff didn't know what to look for, and the nursing staff didn't respect their concerns if they did speak up. But now, she says, the ancillary staff feel confident while still knowing their limitations, and the nursing staff know everyone has been trained in the basics of recognizing pain.

And the education didn't stop with the ancillary staff. There still was plenty to teach the nurses about pain management, she says.

As in most health care settings, medication always had been the No. 1 defense against pain, but now Marwood looks for nonpharmacological approaches--back rubs, quiet environments, soft music, music therapy, pet therapy, or just someone to sit and talk with the resident.

Walker and her colleagues used proven quality improvement processes for the project, first collecting data and conducting audits to get baseline information.

One immediate revelation was that the facility's documentation could be better. The existing documentation was "fair, but it wasn't great," she says, which made follow-up difficult. The pain management teams also quickly saw the need to improve forms.

"There were lots of form changes, and the input on form changes came from the nursing staff because they use the forms," she says. "Then we went back and audited it to see if the changes were effective."

Baseline data collection started with 25 residents who were monitored over a two-year period. The QI team also did a staff survey. The survey revealed that staff were very frustrated over poor communication related to pain management.

"We had complaints that some people would hear of a resident's pain and blow it off, saying an 85-year-old patient is going to be in pain," Walker says. "That clearly had to change."