Pain Management - Leadership Responsibilities for Monitoring and Performance Improvement Activities - LD.04.03.13 EP 1

Leadership is responsible for developing and monitoring performance improvement activities specific to pain management. Does having a policy meet the intent of this requirement? What are leadership’s responsibilities?

Any examples are for illustrative purposes only.

No, simply having a policy does not meet the intent of leadership engagement in quality assessment and performance improvement activities, e.g., on monitoring the use of opioids (See also PI.02.01.01, EP 19). Active leadership engagement ensures the implementation of safe and effective practices, sustainable improvements and accountability across disciplines and services involved in pain assessment, management and opioid prescribing practices.
 
Each organization determines whether an individual 'leader' will be is assigned this responsibility, or if a 'team' model is used. Evaluating the scope of services provided and patient populations served will help determine which model would be most effective. If the 'team' approach is adopted, organizations would determine if the responsibilities would be assumed by an existing team (committee, etc.), or if a separate team would be more effective.
 
Compliance is determined based on the following actions by leader(s):
1. Leader(s) participate in defining the goals and metrics for performance improvement activities, e.g., on monitoring the use of opioids;
2. Leader(s) allocate resources to conduct performance improvement activities, if needed;
3. Leader(s) review performance improvement data;
4. Leaders(s) promote improvements in practices and accountability across disciplines and services involved in opioid prescribing practices.
 
Survey activities may include: staff interviews, review of applicable meeting minutes, discussions with leadership, practitioners, governing body members, performance improvement data, etc.

Note: This requirement is not applicable to all settings in the ambulatory care program. Refer to an applicability grid in the E-dition or standards manual for details.

Resources:
R3 Report: Pain assessment and management standards for Ambulatory Care
R3 Report: Pain assessment and management standards for Office-based Surgery
Sentinel Event Alert Issue 49: Safe use of opioids in hospitals
 

 
Last updated on May 04, 2020
Manual: Ambulatory
Chapter: Leadership LD

If no, please comment on how we could improve this response.

If you have additional standards-related questions regarding this topic, please use the Standards Online Submission Form