1. Improving Pain Management An Introduction to Continuous Quality Improvement Gwendolen Buhr, MD May 30, 2003

2. Quality Improvement Process Three fundamental questions –What are we trying to accomplish? –How will we know that change is an improvement? –What changes can we make that will result in improvement?

3. Quality Improvement Process What are we trying to accomplish? –Set aims Facility rate of pain Desire to decrease to a lower level –Form a team (5-8 members) Leadership, technical expert, day to day champion Nursing, direct care workers, rehab, medicine, pharmacy, administration

4. Team Functioning Meet regularly Assign members specific tasks and responsibilities between meetings Make the work of the team visible Use posters about the project Display the data collected

5. Quality Improvement Process How will we know that change is an improvement? –Establishing measures – necessary to assess progress on your aim After 1 month there will be 5% more complete pain assessments 25% more patients will indicate that their pain is adequately addressed

6. Conduct an Audit MDS indicators – rate of pain and persistent pain Chart documentation Family and patient perceptions of the adequacy of pain treatment Staff knowledge Plot data on the key measures each month over time

7. Quality Improvement Process What changes can we make that will result in improvement? –Identify changes Staff education Pain assessment pocket cards Comprehensive admission and quarterly pain assessment forms Nurse initiated nonpharmacologic treatments –Be clear about your population of focus

8. Brainstorming Facilitator Ground rules –No bad ideas –Encourage participants to “think outside the box” –But not a “free for all” or “gripe session”

9. Describing the Process Cause & Effect/ Fishbone diagramming Flowcharting –To allow participants to identify the flow or sequence of events in a process –Identifies areas for data collection and analysis –Shows where simplification and standardization may be possible –Helps to identify improvement opportunities

10. Fishbone Diagram Persistent Pain Patient Nurse Treatment MD not reached to get order Incorrect treat- ment Incorrect dose Incorrect route Staffing Does not recognize Does not see as an urgent problem Does not follow-up Etiology Cancer Osteoarthritis Osteoporosis Does not want to report Afraid of opiates $$

11. Flow Diagram Patient reports pain or someone recognizes pain RN or LPN completes assessment & reviews meds Is the patient in pain? Is there a PRN pain med? Has pain improved? Pain under control Gives pain med Reassess in proper time period Call MD yes no yes no Patient judged not in pain Call MD Continue to monitor no yes

12. Changes Identify the changes to your system necessary to reach your aims –Today work on assessment, tomorrow on knowledge of pain management Set priorities based on the aim Avoid low impact changes

13. Quality Improvement Process Testing changes with the Plan-Do- Study- Act (PDSA) cycle as a guide

14. PDSA Cycle DocumentPlan Objective Describe current process Measure and analyze Focus on an improvement opportunity Carry out the plan Study Evaluate the results Draw conclusionsAct Standardize the change Monitor; hold the gains Do Identify root causes Generate and choose solutions problems and unexpected observations

15. Performance Improvement Measures Benchmarking –State or National quality indicators –Corporate benchmarks –Literature Aggregating data over time to show trends Targets

16. Test the Change Predict how much improvement can be expected Learn how to adapt the change to your environment Evaluate costs and side-effects of the change Minimize resistance

17. Make the First Test Small Make the change side-by-side with the existing system Encourage comments

18. Quality Improvement Process Do multiple PDSA cycles each time answering the questions: –What are we trying to accomplish? –How will we know that a change is an improvement? –What change can we make that will result in an improvement?

19. Example Initial Audit Results From Croasdaile Village

20. Methods for Assessment Test to determine staff knowledge The Minimum Data Set (MDS) to provide rates of pain and persistent pain The charts of 20 patients receiving analgesics reviewed to assess pain documentation 20 patients and 20 family members interviewed to glean their satisfaction

21. Staff Test on Pain Related Knowledge RN = Registered Nurse, LPN = Licensed Practical Nurse, CNA = Certified Nursing Assistant  = mean

22. Staff Test Continued More than half of the staff missed questions concerning: –Nonspecific signs and symptoms of pain –Recognition of pain in the cognitively impaired –Complementary (nonpharmacologic) therapies –The difference between acute and chronic pain

23. Patient and Family Responses

24. Mean = 3.6 Mean = 3.6 stronglyagree agree unsure stronglydisagree disagree Patients Response on a 5-point Scale to “ My Pain Is Adequately Addressed ”

25. Chart Review Residents With Pain Medication on Their MAR

26. Was Pain Documented? Number N=29% Residents with a pain intensity scale used to monitor pain 13.4 Documented No Pain 1344.8 Not Documented 26.9 Documented Pain 1448.3

27. Completeness of Documentation Number N=14% Location 964.3 Intensity 17.1 What made it worse 17.1 What made it better 214.3 Pain description 17.1 Response to treatments 17.1

28. Chart Review Continued No residents had effect of pain on sleep, mood, or ADLs documented No documentation of side effects of analgesics 1/15 (6.7%) cognitively impaired residents had behavioral signs or symptoms documented 16/29 (55.1%) had a diagnosis recorded for pain

29. Aims Improve management of chronic pain in the nursing home Begin with assessment –50% increase in complete pain documentation –50% increase in use of pain intensity scales Increase the use of non-pharmacologic treatments for pain

30. Changes Modify existing policies & procedures –Assessment plan: assess residents with pain at each MDS, when there is evidence of pain, with vital signs, and after each intervention –Assessment tool: comprehensive pain assessment and pain intensity rating scales –Implement nurse initiated non-pharmacologic treatments for pain (i.e., patient education, positioning, exercise, spiritual counseling, heat/cold or massage)

31. Next Steps Initiate staff educational program targeting deficiencies uncovered in staff testing Evaluate the results with a repeat audit