Pain Management | Joint Commission

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Saturday 6:45 CST, May 26, 2018

Pain Management


On January 1, 2018, The Joint Commission implemented new and revised pain assessment and management standards for accredited hospitals.  

The new and revised pain assessment and management standards are reflected in the Leadership; Medical Staff; Provision of Care, Treatment, and Services; and Performance Improvement chapters of The Joint Commission hospital accreditation manual. 

The standards require a Joint Commission accredited hospital to establish policies and procedures that address comprehensive clinical assessment of pain; treatment or referral for treatment; and reassessment for patients as it designates, based on patient population and scope of services provided.

The additions and revisions require hospitals to:

  • Establish a clinical leadership team 
  • Actively engage medical staff and hospital leadership in improving pain assessment and management, including strategies to decrease opioid use and minimize risks associated with opioid use 
  • Provide at least one non-pharmacological pain treatment modality
  • Facilitate access to prescription drug monitoring programs
  • Improve pain assessment by concentrating more on how pain is affecting patients’ physical function
  • Engage patients in treatment decisions about their pain management
  • Address patient education and engagement, including storage and disposal of opioids to prevent these medications from being stolen or misused by others
  • Facilitate referral of patients addicted to opioids to treatment programs

Read more: Standards Development

The scope of the standards aligns with the purpose of all accreditation standards: to guide accredited health care organizations to develop policies and procedures to improve the quality of patient care and safety. They do not recommend specific assessment methods or clinical treatment strategies and do not interfere with the independent medical judgment of licensed practitioners who decide the appropriate care for their patients.

The updates are a revision to The Joint Commission’s original standards established in 2001 in an effort to address pain management. Both the original standards and the revisions effective January 1, 2018, state that:

  • Hospitals must have a process to address pain assessment when necessary.
  • Hospitals must have a process upon clinical determination to either treat patient pain or refer patients for pain treatment, which may include nonpharmacologic or pharmacologic approaches.
  • Hospitals must have a process for the clinician to reassess and respond to a patient's pain based on reassessment criteria.

Joint Commission accredited organizations are encouraged to consult with their Joint Commission account executive for clarification, implementation or compliance questions about standards. 

Read more: Facts about Joint Commission Accreditation Standards for Health Care Organizations: Pain Assessment and Management