Quality Improvement in Pain Management
Submitted by Kaitlin Graye, BSN, RN
Healthcare providers hold an ethical responsibility to provide reasonable relief from pain and suffering. Pain management has improved with medical advances research shows that as many as 60% of long term care (LTC) residents report a persistent presence of moderate-to-severe pain (Shen, Zuckerman, Palmer, & Stuart, 2015). Effective pain management cannot be achieved without evaluating pain. Among the substantial number of elderly individuals suffering from pain, 32% receive inadequate treatment (Hunnicutt, Ulbricht, Tjia, & Lapane, 2017). The geriatric population faces numerous obstacles to receiving adequate pain control, often suffering from multiple co-morbidities, degenerative changes, and cognitive barriers limiting their ability to communicate. Effective pain management cannot occur without an accurate representation of the problem. The purpose of this paper is to discuss a qualitive improvement project aimed at enhancing pain assessments at University Hills Health and Rehabilitation (UHHR) Center.
Studies estimate over 18 million elderly Americans regularly experience pain (Patel, Guralnik, Dansie, & Turk, 2013). Effective health care strives to provide care that benefits patients while avoiding underuse and misuse (Institute of Medicine (U.S.) Committee on Quality of Health Care in America, 2001). Improving the effectiveness of care involves balancing potential side effects of pain medications with insurmountable damage that can result from unrelieved pain. The LTC facility is targeted in this quality initiative because it has no policy mandating method or frequency for documenting pain assessments. Over eight percent of residents at UHHR report moderate to severe pain, more than twice as high as the state average (Centers for Medicare and Medicare Services, 2018). The facility’s quality scores indicate an extreme need for process changes to improve care.
Patient-centered care considers the resident’s treatment preferences and individualized needs (Institute of Medicine (U.S.) Committee on Quality of Health Care in America, 2001). The geriatric population is vulnerable to undertreated pain because they have an increased pain tolerance and decreased pain threshold (Booker & Haedtke, 2016). Pain is inconsistently assessed after admission to this facility. More than 40% of older adults do not feel it is necessary to report pain, making them unlikely to report pain unless asked (Schreir, Stering, Pitzer, & Schmerz, 2015). Patients unable to communicate are frequently excluded from pain scores because the facility has no non-verbal assessment tool in place. The numerical rating scale is unreliable for evaluating patients with cognitive impairments, which accounts for more than half of all long-term care residents (Malara et al., 2016).
System Level of Focus
This quality improvement initiative will be implemented at the microsystem level because assessing pain must begin where the point of patient care occurs. Clinical microsystems have been described as the building blocks of the entire healthcare system, and without their success, effective patient-centered care cannot be delivered (Nelson et al., 2008). Implementation will occur in a nursing unit with forty residents within the LTC facility. The microsystem is an ideal level of focus for quality improvement because this environment is where care is delivered, and changes are ultimately enacted (Silver et al., 2016). Improvements at the microsystem level have positive implications for the macrosystem and mesosystem (Geary & Roussel, 2017).
Leadership will use the education and communication approach and the participation and involvement approach to implement the change initiative. Since the practice issue does not require immediate intervention, leaders can utilize strategies that require a slower approach, which minimizes resistance and offers economic and social advantages through increased involvement from employees (Kotter & Schlesinger, 1979). Training on how to properly use the pain assessment tools will be provided to lessen staff anxiety. Implementing policies for assessment accompanied by providing education on pain has been proven effective in improving the treatment of persistent pain in long-term care settings (Long, 2013). Informational materials will be periodically distributed to staff to explain the importance properly assessing pain and the negative effects unrelieved pain impose on residents. Studies show increasing pain awareness results in improved pain management in long-term care (Mamhidir et al., 2017).
Tying the pain assessment initiative to the microsystem’s purpose of providing quality care will increase the staff’s commitment to change. Employees will be invited to engage in open discussions to voice concerns and to introduce possibly unknown factors that should considered in program development. Staff participation in the program’s development fosters a sense of empowerment and ownership, leading to higher sustainability of practice changes (Cranely et al., 2018). Leadership will form an implementation committee composed of staff and management.
A simple cause and effect diagram can be used to easily communicate the need for process improvement. This model can display the many detrimental effects unrelieved pain has on quality of life. Chronic unrelieved pain is linked to lower quality of life and higher mortality rates (Smith et al., 2018). Stress on staff is heightened when patients with cognitive impairment have increased episodes of abhorrent behaviors resulting from pain. Agitation, psychosis, irritability, aggression, and combativeness occur more frequently in cognitively impaired patients who receive no interventions for pain (Habiger, Flo, Achterberg, & Husebo, 2016). This facility’s number of residents exhibiting symptoms of depression is triple the state average and the number who received medication for anxiety, insomnia, or psychosis is higher than state and national averages (Centers for Medicare and Medicaid Services, 2018). Pain contributes to a loss of appetite resulting in unintentional weight loss and impaired immunity in the elderly (Pilgrim & Robinson, 2015). Persistent pain is strongly linked to reduced physical activity, depression, and withdrawal from social activities (Wilkie et al., 2016). Further strain is placed on staff when pain increases the need for assistance required to complete activities of daily living and leads to sleep disturbances (Molton & Terrill, 2014).
Quality Improvement Model
The project implementation will follow the plan-do-study-act, or PDSA, model. The PDSA model is effective for short-term change initiatives within microsystems (Bollegala et al., 2016). The planning phase will occur over four months. Management will collect data on current assessment patterns from chart audits. The prevalence of pain experienced by residents will be extracted from information within the most recent MDS review. Education and training will also be completed in the planning phase. Leadership will disperse informational materials and hold training sessions on new assessment tools. Cognitively intact residents are to be assessed using the numerical rating scale (NRS). Residents with cognitive impairment should be assessed using the pain assessment in advanced dementia (PAINAD) tool.
The second phase will consist of implementing the pain assessment policies. Staff will have a clear understanding of expectations regarding completion of pain assessments and how to select the appropriate pain assessment for each individual resident. Management will be available for support and guidance. A policy outline will be posted for quick referencing. The evaluation begins at the time of implementation of the new policy to provide continuous feedback. The committee will perform weekly random chart audits to record the number of appropriate and completed pain assessments. The implementation and evaluation period will last for six months to capture data from two quarterly MDS reports. Data from MDS assessments is submitted to a national database and contributes to scores reflected in Medicare’s Nursing Home Compare tool (Centers for Medicare and Medicaid Services, 2018). Following project completion, leadership will assess effectiveness through data comparison to determine if any concepts should be modified or adjusted.
The structural resources required for this system change will include adopting a new pain assessment policy and introducing a pain assessment scale for non-verbal patients. Employees will receive education on pain in the geriatric population and using the PAINAD scale. Health care worker’s estimations of pain are significantly lower than self-reported pain among residents, indicating a need for further pain related education (Takai et al., 2015). Observational assessment tools, such as the PAINAD scale, have been proven to increase the accuracy of pain assessment among individuals with cognitive impairments (Lukas, Barber, Johnson, & Gibson, 2013). The new policy mandates documentation of pain assessments once per shift with an appropriate tool. Human resource requirements include an implementation team consisting of the director of nursing, unit manager, and six nurses. Financial resources will be required to cover the wages for training costs, meetings, and evaluation of compliance and effectiveness.
Quantitative measurements to determine effectiveness will include the percentages of pain assessments completed, appropriate tools used, and patients reporting moderate to severe pain. For this initiative, moderate to severe pain was defined as a score above six on the NRS or PAINAD scale. Pain prevalence will be compared with data collected from chart audits and MDS assessments. Qualitative methods to determine effectiveness will consist of in-depth interviews with residents related to pain prevalence, pain management and quality of care. Interviews with residents will be conducted to reveal trends in the perceptions held regarding quality of care and current practices. Qualitative information will be collected from monthly focus groups with staff to gain feedback relating to the initiative’s impact and the perspectives following implementation. Improving pain treatment in long-term care settings has been shown to decrease stress among employees (Aasmul, Husebo, & Flo, 2016).
The facility’s quality scores directly impact its image within the community. Performance measures will be evaluated by comparing data collected pre and post implementation. Effectively enhancing quality care involves improving the duration and quality of life (Donabedian, 1978). Persistent pain causes significant harm to one’s physical and mental wellbeing. Outcome measures will be evaluated by the percentage of residents who self-report consistent or recurrent pain that is moderate to severe. Percentages will be calculated separately for data extracted from MDS reports and chart audits to improve the reliability of findings. Effectiveness of the project will be determined by the initiative’s ability to reduce pain prevalence and intensity.
Healthcare systems must ensure essential tools are available for use, are mandated within the policies, and are used by competent healthcare professionals. The percentage of appropriate pain assessments documented by staff as indicated by the policy defined within the initiative will be assessed as a structural measure to capture the staff’s ability to properly assess pain. Donabedian (1985) explains that evaluating processes closely relies on documentation within medical records. For this reason, the percentage of residents who had completed pain assessments charted every shift as will be evaluated as a process measure.
Displays for Outcome Reporting
A run chart is particularly useful in monitoring the effectiveness of process changes because it shows chronologically plotted data patterns on a line graph. The numerical performance measure data can be plotted in the run chart to demonstrate the initiative’s effects over time and assist viewers with recognizing improvements. A second tool that is helpful in displaying outcome measures is a pie chart. Pie charts can be constructed to show the percentages of patients reporting moderate to severe pain within the facility and percentages of completed pain assessments. Visualizing pie charts before and after the change initiative can display a reduction in the problem.
Quality Initiative Contributions
Findings from the quality improvement initiative will assist leadership with making informed decisions on practice improvements. Improvements in clinical documentation relating to pain will aid clinicians with modifying treatment plans to enhance pain management. Pain management cannot be effective without proper pain assessment. Evaluating the findings from this quality improvement initiative can assist with identifying areas in need of improvement to address the prevalence of persistent pain in long-term care.
Quality improvement is essential for the growth and survival of complex adaptive systems. Microsystems are a prime setting for implementing change initiatives without excessive strain on resources. Optimizing healthcare delivery involves improving performance measures that contribute to clinical excellence. A consistent effort must be made to evaluate and sustain quality improvement. Creating standards for appropriate pain assessment is the first step toward to better pain management, which benefits residents, staff, and the community.
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