Pain Management - Performance Improvement: Data Collection, Analysis and Implementing Change PI.02.01.01

One of the new pain management standards requires organizations to analyze data collected on pain assessment and pain management to identify areas that need change to increase safety and quality for patients. Would the results of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) used by CMS be sufficient to meet this requirement?

Any examples are for illustrative purposes only.

No, HCAHPS alone would not be sufficient to meet this requirement. The hospital and medical staff together determine what quality metrics are collected, giving consideration to the patient population served and pain management challenges that may be unique to each hospital. HCAHPS data is limited to patients discharged from an inpatient encounter. Organizations should include data from outpatient programs involved in pain management as well. Examples may include interventional pain management and chronic pain management programs. Depending on the analysis of data, organizations may need to modify or add quality metrics in order to keep them current as changes in patient demographics and/or services provided by the organization change.
Examples of data may include monitoring the duration and dose of opioid(s) being prescribed, use of Naloxone, patterns and trends of opioid-induced respiratory depression, practitioner ordering practice patterns, etc. A recommended article is Frederickson TW, et al.  Reducing Adverse Drug Events elated to Opioids Implementation Guide. Philadelphia: Society of Hospital Medicine, 2015.

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 April 28, 2020
Manual: Hospital and Hospital Clinics
Chapter: Performance Improvement PI

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