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Spring 2013
Improving Pain Management – Strategies that Work Karen Snow Kaiser, PhD, RN, Clinical Practice Coordinator, Division of Quality and Safety
Consumer satisfaction ratings are used nationally as one method to stimulate healthcare quality improvements. The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey is one of the tools developed to support this initiative. Randomly selected discharged patients are asked to respond to standardized HCAHPS questions about their hospital experience by a nonpartisan group. Survey results are then reported nationally, so patients can compare hospitals (see Hospital Compare website www.hospitalcompare.hhs.gov). UMMC has identified a goal to perform better than the 55th percentile on the nationally reported HCAHPS pain subscale in the FY’13 annual operating plan. This goal is important because our HCAHPS pain survey items consistently show moderate to strong relationships between patients’ overall satisfaction ratings of UMMC and their likeliness to recommend UMMC to others. Performance on the HCAHPS pain subscale is also an important measure of improvement for our Magnet redesignation. For that measure, we must demonstrate higher than average performance (greater than the 50th percentile) for five out of the previous eight quarters. Currently our HCAPHS pain subscale is at 74.4%, slightly greater than the 55th percentile. However, we have only exceeded the 50th percentile, which is currently 73.8%, three times over the last eight quarters, resulting in an opportunity for improvement. To improve the HCAHPS pain subscale, we need to improve the scores on the two survey items that comprise the subscale. These items assess how often staff did all that they could to manage pain and whether or not pain was well controlled. The UMMC Pain Committee and Pain Task Force have been looking at ways to improve our performance on these measures. They identified our high-performing units (units with HCAHPS pain subscale scores higher than the 50th percentile). These units demonstrate at least two of the following characteristics. ◗◗ Pain Task Force members routinely attend meetings. ◗◗ Nursing leadership and/or a pain champion is highly engaged and ensures pain is a priority at the unit level. ◗◗ A unit level improvement group is focused on improving satisfaction, including special efforts targeted at improving pain management. A variety of activities have been used by the high-performing units to improve their HCAHPS pain satisfaction scores. Since pain is a complex interdisciplinary issue, most have deployed more than one strategy. Some of the frequently used strategies are: ◗◗ An enhanced focus on pain during hourly rounds and/or handoffs. ◗◗ Noting ‘prn’ analgesic medication administration times on patient white boards. ◗◗ Using patient huddles to modify the pain management plan for patients with high pain scores. ◗◗ Encouraging pain patient education video use. ◗◗ Advocating for patients with other health care professionals. ◗◗ Sharing HCAHPS pain data and patient reported pain experiences (HCAHPS’s Voice of the Patient or patient letters) weekly or bi-weekly.
The Medical Center’s HCAHPS data support using many of these strategies. There are several relationships between other non-pain HCAHPS survey items and the pain HCAHPS items. For example, nurses listening carefully, clear communication by nurses, courtesy and respect by nurses, patient advocacy, teamwork, and perceptions about receiving the proper care all have moderate to strong relationships to the HCAHPS pain survey items. This suggests that focusing on related survey items, many of which are part of our rounding and handoff initiatives, may also improve the HCAHPS pain items. Specifically, the following may improve the HCAHPS pain survey item scores and the management of our patient’s pain by paying special attention to the following: ◗◗ Being courteous and respectful of a patient’s reports of pain. ◗◗ Listening carefully about a patient’s pain concerns. ◗◗ Acting as a patient advocate for pain issues. ◗◗ Encouraging teamwork when developing or modifying a pain management plan. ◗◗ Clearly communicating the pain management plan to the patient. The high-performing units note that constant vigilance is required for them to continue to outperform the national scores on the HCAHPS pain items. There tends to be little variability in HCAHPS scores for those with scores in the “middle of the pack.” Small changes in scores may result in large shifts in percentile rank between quarters. We know that changes in clinical processes improvement take time to become routine, so we can be lulled into thinking that short term gains are permanent and slip back into old practices. Since hospitals are striving to improve their nationally reported HCAHPS scores, the target keeps shifting, with this year’s pain subscale 50th percentile increasing almost a full point over last year’s score. Therefore, becoming and staying a top performer requires constant attention to pain and the strategies used to improve its management. Another issue is that fluctuation in scores occurs by chance. The small amount of variability in the “middle of the pack” means that even by “doing nothing” we may appear to improve. These misleading gains are short lived and scores slip backwards. The “bouncing up and down” improvement in some quarters and declining in others can point to unstable variable clinical processes. Bouncing can lead to a false sense of security and a belief that we don’t need to address the issue. This is a reason why Magnet requires several quarters of demonstrating higher than average performance on several HCAHPS subscales. This helps delineate better performers, and those who are actively striving to improve performance. Based on the experiences of high performing units and an informal assessment of barriers to providing effective pain management, the Nursing Process Improvement Council and Pain Task Force members are working together to make pain management more visible and actionable on the units. They are leading the effort to incorporate the following into their unit activities: ◗◗ Increasing the focus on pain during hourly, shift change, and multi-disciplinary rounds. ◗◗ Incorporating the patient’s pain goal, time the last ‘prn’ analgesic was administered and/or time next dose is available into the pain care plan, the kardex, the plan of care or the white board. ◗◗ Using huddles to plan a modification of the patient’s pain management plan for patients with uncontrolled pain. ◗◗ Using the kardex, the plan of care, and end of shift reports to share “what works” for individual patients. continued on page 18.