Here’s what surveyors want to know

Although new pain management standards won’t be scored until 2001, surveyors are already asking about them and want to see that your ED has a plan in place to comply, reports Stuart Shikora, MD, FACEP, a surveyor with the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL, and an ED physician at Mount Diablo Medical Center in Concord, CA.

"They want to see that there is thought being given to the new standards and that some model of pain assessment is being followed," says Shikora.

Surveyors are asking about both your current pain management and plans for changes, says Susie McBeth, associate director of the Joint Commission’s department of standards. "We are asking about what you have implemented and what you plan to implement to comply with the new standards."

Most EDs are already treating pain, says McBeth. "The trouble is the consistency with which they do it. You need to re-examine the processes you have now and be sure that pain is assessed and managed for every single patient," she explains.

Surveyors may ask to see the following, according to McBeth:

• protocols and practice guidelines for use of pain management;

• the educational materials about pain management given to patients;

• how pain assessment and interventions are documented in the patient’s medical record. This doesn’t need to be a special documentation form and can just be part of the comprehensive nursing assessment tool, says McBeth. "Some EDs have special forms if they have a pain management team, but surveyors won’t expect to see that."

4 questions to answer now

Surveyors are currently using a four-question survey to ask about the new pain management standards, says McBeth. The results will be taken to the board on Jan. 2, 2001, so they can decide whether the standards will be implemented immediately or in the second quarter of 2001, she explains.

Here are the questions surveyors are currently asking:

1. Do you use a standardized method for documenting pain assessment? If so, how long have you been using it?

Most organizations don’t use a standardized tool to measure pain, says McBeth. "The standards have forced them to go back and reassess how they managing pain across the entire organization, not just each unit."

2. How do you document the measurement of pain?

Most respondents document pain assessment in progress notes and not with a separate form. "There are different ways of doing this. We’re not looking for a separate pain assessment form. For example, a pain scale might be printed on the form used for the initial assessment," says McBeth.

3. Have you done any special projects on pain management using a performance improvement process?

About one-fourth of organizations are currently doing this, says McBeth. "One hospital had a large number of psychiatric patients, so they undertook a major effort to educate their staff on how agitated behavior may be caused by pain. Now they evaluate for pain before ordering a psychotropic medication," she reports.

4. Have the new pain standards changed the way you handle pain treatment?

Most respondents are reassessing the way they currently manage pain but haven’t implemented planned changes yet, notes McBeth.

Time line for scoring

The new pain management standards and examples of compliance will be included in the 2000-2001 standards manuals for affected Joint Commission accreditation programs, and they will be first scored in 2001, according to Shikora.

However, when the standards are first scored, there will be a cap system used for a year or two, Shikora reports. "Although scoring ranges from 1 to 5, 5 being no compliance at all, there will be a cap used. So even if you got a score of 5, its effect on the grid would be negligible, because it will be capped at a score of 1 or 2. This will give you a chance to get up to speed on the new standards."

In 2001, compliance will be determined by the presence of a functioning system to manage patients’ pain, protocols that direct staff to use the system, and chart review that shows the system is being used, says Shikora.

Surveyors will not ask about whether you gave the right medication or the right amount, Shikora says. "A lot of people worry that we’re going to be looking at whether or not they are using enough dilaudid, or if they are giving a weight-appropriate dose of Demerol, but it’s not going to be that detailed at this point. Those practices will be looked at when we fine-tune the system, approximately three years from now."

In 2001, surveyors will do random chart reviews of patients with specific diagnoses to see how well they were assessed, says Shikora. "We will pull the charts of patients with certain target discharge diagnosis or chief complaints which are unequivocally painful and would call for the use of analgesics. Those include kidney stones, renal colic, earaches in children, and fractures."

For more information on the new pain management standards, contact:

Regina Fink, RN, PhD, AOCN, Research Nurse Scientist, Patient Services, University of Colorado Hospital, 4200 E. Ninth Ave., Box A021-255, Denver, CO 80262. Telephone: (303) 372-5580. Fax: (303) 372-5559. E-mail:

Ann Kobs, MS, RN, President/CEO, Type 1 Solutions, 8695 College Parkway, Suite 307, Fort Myers, FL 33919. Telephone: (941) 415-4454. Fax: (941) 415-4450. E-mail:

Anne Llewellyn, RNC, BPSHSA, CCM, CRRN, CEAC, Professional Resources In Management Education, 1820 S.W. 100th Ave., Miramar, FL 33025. Telephone: (954) 436-6300, ext. 15. Fax: (954) 436-0161. E-mail:

Emory Petrack, MD, MPH, Chief, Division of Pediatric Emergency Medicine, Rainbow Babies and Children’s Hospital, 11100 Euclid Ave., Mail Stop MATH6097, Cleveland, OH 44106-6019. Telephone: (216) 844-8716. Fax: (216) 844-8233. E-mail:

Stuart Shikora, MD, Mount Diablo Medical Center, Emergency Department, 2540 East St., Concord, CA 94520. Telephone: (925) 258-0013. Fax: (925) 258-0014. E-mail: