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AnOverview

of TwoMonographs

Pain: Current Understanding of Assessment,Management, and Treatments

Improving the Quality of Pain ManagementThrough Measurement and Action

The United States Congress declared the decade beginning

on January 1, 2001 as the Decade of Pain Control and

Research. But despite the importance of pain management,

pain remains grossly undertreated. In 2001, the Joint

Commission on Accreditation of Healthcare Organizations

and the National Pharmaceutical Council began a collabora-

tive effort to facilitate improvements in pain management.

To date, this effort has produced a set of monographs intend-

ed for those involved in pain management activities, includ-

ing clinicians, quality management professionals, and others

involved in pain management performance, assessment,

improvement, education, and policy making. The two mono-

graphs, Pain: Current Understanding of Assessment,

Management, and Treatments, and Improving the Quality of Pain

Management Through Measurement and Action, are intended to

be used as complementary resources. We hope that readers

will find the material relevant and helpful in their efforts to

improve pain management processes and patient outcomes.

The Importance Pain, both chronic and acute, isprevalent and undertreated. Oneof the primary reasons for under-treatment is the complexity ofpain assessment and monitoring.Pain is a subjective experiencewith no objective measures, andwas perhaps best defined byMargo McCaffrey as “whateverthe experiencing person says it is,existing whenever s/he says itdoes.”1 Pain is the most commonreason individuals seek healthcare, and about 9 in 10Americans regularly suffer frompain.2 Each year, an estimated 25million Americans experienceacute pain due to injuries or sur-gery, and another 50 million suf-fer from chronic pain.3,4 Almostone-third of all Americans willexperience severe chronic pain atsome point in their lives. As thepopulation ages, the number ofpeople who will need treatmentfor pain—from back disorders,degenerative joint disease,rheumatologic conditions, viscer-al diseases, and cancer—isexpected to rise tremendously.

There are significant adverse con-sequences from untreated, under-treated or inappropriately treatedpain. Poorly managed acute painmay cause serious medical compli-cations, impair recovery frominjury or procedures, and canprogress to chronic pain.Untreated chronic pain canimpair an individual’s ability tocarry out daily activities anddiminish quality of their life. Inaddition to disability, undertreat-ed pain causes significant suffer-ing. Poorly controlled pain maylead to anxiety, fear, anger,depression, and in some cases,

AnOverview

of TwoMonographs

of Pain Management even premature death or suicide.Pain is also a major cause of workabsenteeism, underemployment,and unemployment.

Increasing health care costs anddisability compensation reflectundertreatment for pain-relatedconditions. Data from a 1999 sur-vey suggest than only 1 in 4 indi-viduals with pain receives appro-priate therapy, despite the factthat there are numerous effectivetreatments available to managepain.5 Even when pain is treated,treatment may be ineffective orunder-utilized. Both pharmaco-logic and nonpharmacologic ther-apies may be used to treat pain,and sometimes a combination oftherapies is necessary to achieveoptimum pain management. Inaddition to their pain-relievingproperties, nonpharmacologictherapies may also improve mood,reduce anxiety, increase apatient’s sense of control,strengthen coping abilities, assistwith sleep, relax muscles, andimprove quality of life.

In order to truly improve painmanagement, health care organi-zations and institutions need tosupport system changes. Expertsconsistently emphasize the needfor a system-wide, collaborative,and interdisciplinary approach topain management that focuses onprocesses of care across theorgranization. In addition to pro-viding staff with practical clinicalresources for pain management,health care organizations andinstitutions need to make pain“visible” and establish mecha-nisms to ensure accountability forpain control. Organizational per-formance measurement is one of

the key strategies for attainingvisible, accountable and effectiveimplementation of pain manage-ment initiatives while improvingexisting programs.

Two reasons to measure perform-ance in health care organizationsare to assess change for qualityimprovement purposes within anorganization (internal) and tocompare quality of care betweendifferent entities (external).6

Data collection is crucialthroughout any quality improve-ment project to document changeand facilitate lasting improve-ment. Determining how to col-lect the data is an important deci-sion. Many options exist formeasuring performance including1) organizational self-assessment,2) medical records review 3) test-ing knowledge and attitudes, 4)direct observation of care, 5)point prevalence studies, 6)assessment of patient status andoutcomes over time, 7) indicatordata collection, and 8) utilizationof an externally developed per-formance measurement system.

Assessing and translating datainto information that can be usedto make judgments and draw con-clusions about performance is acritical step. It allows currentperformance to be compared withpast performance or establishedstandards, actions to be priori-tized, and the effects of theseactions to be evaluated.Assessment is not a one-timeactivity. In fact, systematic datacollection and assessment oftencontinues beyond the immediatequality improvement project timeframe to ensure that desired levelsof performance are maintained.

In addition to assessment andanalysis of data, key findings mustbe effectively conveyed withinthe organization. This means,among other things, presentingthe information in a format andat a level of detail appropriate tothe audience, and differentiatingbetween statistical significanceand clinical importance.Disseminating results helps toraise awareness within the organi-zation of how it is performingwith respect to pain management.Providing performance feedbackover time can be an effective toolin promoting and institutionaliz-ing pain management practicechanges.

At the most fundamental level,improving pain management issimply the right thing to do. As atangible expression of compas-sion, it is a cornerstone of healthcare’s humanitarian mission. Yetit is just as important from a clini-cal standpoint, because under-treated pain has significant physi-cal, psychological, and financialconsequences.

More detailed information aboutpain management is available intwo complementary publications,Pain: Current Understanding ofAssessment, Management, andTreatments and Improving theQuality of Pain ManagementThrough Measurement and Action.

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References:1. McCaffrey M. Nursing practice theo-

ries related to cognition, bodily painand man-environmental interactions,Los Angeles, CA: 1968. UCLAStudents Store.

2. Gallup survey. Conducted by theGallup Organization from May 21 toJune 9, 1999. Supported by theArthritis Foundation and Merck &Company, Inc.

3. National Pain Survey, Conducted forOrtho-McNeil Pharmaceutical, 1999.

4. American Pain Foundation. Factsabout pain. Available at:http://www.painfoundation.org/page_fastfacts.asp. Accessed September2001.

5. Chronic Pain in America Survey.Conducted for American PainSociety, the American Academy ofPain Medicine, and JanssenPharmaceutica, 1999.

6. Eddy DM. Performance measure-ment: problems and solutions.Health Aff. 1998;17:7-25.

For more information or additionalresources, please contact:

Joint Commission on Accreditationof Healthcare Organizations One Renaissance Boulevard Oakbrook Terrace, IL 60181 ph: 630-792-5000www.jcaho.org

National Pharmaceutical Council1894 Preston White DriveReston, VA 20191-5433ph: 703-620-6390www.npcnow.org

About Pain: Current Understanding ofAssessment, Management, and Treatments

Pain: Current Understanding of Assessment, Management, and Treatments primarilyaddresses noncancer pain and reviews the causes of pain, definitions of pain, typesof pain and classification systems for pain. The monograph also explores somecommon barriers to pain assessment, treatment and monitoring, as well as some ofthe consequences of untreated or undertreated pain. Assessment tools, treatmentstrategies and information on existing therapies are presented. Finally, the mono-graph emphasizes the importance of clinical practice guidelines, standards, andoutcome measures in improving pain management.

About Improving the Quality of PainManagement Through Measurement and Action

Improving the Quality of Pain Management Through Measurement and Actionaddresses the application of continuous quality improvement techniques to painmanagement and the implementation of performance measurement processes. Theuse of a multidisciplinary systems point of view is described and the Cycle forImproving Performance, a structured approach to improvement activities, is out-lined. Factors that influence an organization’s ability to implement change andimprove performance are also discussed. In addition, the real-world experience offour organizations in improving pain management is described. The examplesillustrate how the organizations used systematic processes for improvement, howmeasurement provided important data to support improvement activities, and howpeople committed to quality improvement in pain management achieved success.The examples provided encompass a diversity of settings and experiences—includ-ing a home health agency, a rural hospital, an academic medical center, and thehundreds of facilities under the Veterans Health Administration—and suggest strate-gies for overcoming obstacles to pain management improvement initiatives.

AcknowledgementsSpecial thanks to the Editorial Advisory Board members for each monograph, theVisiting Nurse Association & Hospice of Western New England, Inc., MemorialHospital of Sheridan County, the University of Iowa Hospitals and Clinics, theVeterans Health Administration, and the staffs of the Joint Commission onAccreditation of Healthcare Organizations and the National PharmaceuticalCouncil for their contributions and hard work on this project.