The Joint Commission’s new and revised pain assessment and management standards went into effect in 2019, covering all Joint Commission-accredited ambulatory care, including surgery centers and office-based surgery organizations. Natalya Rosenberg, PhD, RN, project director, standards and survey methods for The Joint Commission, answered Same-Day Surgery’s questions about the revised standards.

SDS: The updated standards require organizations to maintain a leadership team that is responsible for pain management and opioid prescribing and developing and monitoring performance improvement activities. In an ambulatory surgery center (ASC), which leader(s) might be best suited to take on this role? What would be an example of how ASCs could monitor performance improvement activities?

Rosenberg: Each organization will need to determine whether an individual leader will be assigned this responsibility or if a team model is used. The scope of organization services and patient populations served will help determine which model would be most appropriate and who will best fulfill this role (e.g., a nurse, a physician leader, etc.). The role of leader is to ensure there is an alignment in the organization’s approach to safe pain management and oversee implementation of this approach. The ASC setting has evolved and serves an increasingly complex patient population. Evidence and guidance on postoperative pain management are emerging. Having a leader or several leaders is necessary to help organizations rise to these challenges.

Regarding performance improvement metrics, organizations should choose the ones that are more meaningful or practical for them. Generally, in existing guidelines, there is support for monitoring adherence to an organization’s post-procedural pain management guidelines, monitoring duration of opioid prescriptions at discharge, and ensuring that patient and family receive education on safe storage and disposal of opioids to prevent misuse and diversion. Some organizations track naloxone administration as a safety indicator to identify patients who may have been prescribed too high a dose of opioids or who may have comorbid conditions that were not recognized or addressed.

SDS: How might surgery centers fulfill the requirement (LD.04.03.13, EP 3) to provide staff and physicians with educational resources on improving pain management and safe use of opioids?

Rosenberg: Organizations have flexibility in determining the methods for education, as well as content and frequency. Topics for education should be guided by the identified needs of the patient populations. A relevant topic may be perioperative pain management for patients with complex needs (i.e., receiving long-term opioid therapy or presenting with a history of substance use disorder). Providers also may benefit from education on recommended nonpharmacologic, pharmacologic, multimodal pain management strategies.

SDS: For small surgery centers, what type of consultation services would be feasible to provide staff for patients with complex pain management needs?

Rosenberg: Consultation or referral to a specialist (e.g., pharmacists and pain management specialists) is advised when it is necessary to develop a perioperative pain management plan for the patient with a history of substance abuse or for the patient on long-term opioid therapy ... Making sure access to internal or external resources for consultation is available and utilized to support safe practice could be one of the priority areas that pain management leaders could focus on.

SDS: How can surgery centers use the prescription drug monitoring program (PDMP) database to improve patient safety related to opioid prescriptions?

Rosenberg: ASCs are not required to facilitate access to the PDMP databases, and The Joint Commission does not mandate PDMP use, but will survey to the local state law and regulations that govern PDMP use. PDMP is an important tool that allows a clinician to assess pre-existing controlled substance use. This information could impact post-discharge management or could indicate the need to educate the patient and family on proper disposal of opioids.

SDS: Could you name resources surgery centers could use to find a tool or criteria that would help them screen, assess, and reassess patients’ pain?

Rosenberg: The Joint Commission has published an R3 report, which lists several publications with evidence-based tools that an organization can consider using. (Editor’s Note: This report is available to view online at: http://bit.ly/2W4JP6f.)

In addition, the Ambulatory Surgery Center Association (ASCA) offers an Opioid Resource Center (http://bit.ly/2XDWihM), [but] The Joint Commission does not endorse any of the materials on the ASCA website.

SDS: To fulfill the pain treatment plan requirement, which members of staff and outside expertise might be employed to assess evidence-based practices, the patient’s condition, and the patient’s history to develop a pain treatment plan?

Rosenberg: In the vast majority of cases, decisions should be up to the treating physician; additional staff and outside expertise are not required. However, in cases where patients have a history of addiction or for patients who want to avoid all narcotics, consultation with pharmacists or pain management specialists might be appropriate.

SDS: The standards include a requirement to involve patients in pain management treatment. Why is this standard important?

Rosenberg: It is important to include the patient as part of the development of a treatment plan so that realistic expectations of pain relief can be discussed and agreed upon. In addition, it provides an opportunity for the patient and the care team to have transparent discussions regarding available treatment options and realistic expectations of those treatments.