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

Leadership is responsible for developing, implementing 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 performance improvement activities, e.g., on monitoring the use of opioids (See also PI.02.01.01, EP 19).  
 
Whether an individual 'leader' is assigned this responsibility, or a 'team' model is used, responsible leader(s):
1. participate in defining the goals and metrics for performance improvement activities, e.g., on monitoring the use of opioids;
2. allocate resources to conduct performance improvement activities;
3. review performance improvement data;
4. promote improvement in practices and accountability across disciplines and services involved in pain management and opioid prescribing. 

Survey activities may include:  staff interviews, review of applicable meeting minutes, discussions with leadership, practitioners, governing body members, Performance Improvement data, etc.

Resources:
R3 Report: Pain assessment and management standards for hospitals
R3 Report: Pain assessment and management standards for Critical Access Hospitals
Sentinel Event Alert Issue 49: Safe use of opioids in hospitals
 
Last updated on May 04, 2020
Manual: Hospital and Hospital Clinics
Chapter: Leadership LD

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