- Email: [email protected]
Quality improvement challenges in pain management
Pain 107 (2004) 1–4 www.elsevier.com/locate/pain
Editorial
Quality improvement challenges in pain management
1. Introduction A great deal of attention has been paid to the quality of pain management in the last decade, with growing recognition that the under treatment of pain is a major, yet avoidable, public health problem. Studies have consistently shown poor pain control for postoperative and trauma pain, cancer pain and for many chronic pain problems not related to cancer. Major barriers to effective pain management have been identified including the inadequate knowledge of health care professionals, patients and the public; lack of institutional commitment; regulatory concerns; and limited access to and reimbursement for interdisciplinary care. Despite efforts to address these barriers and continued advances in our understanding of pain, the quality of pain management remains inconsistent at best. The need to measure and improve the quality of care is increasingly recognized by consumers, payors and health care professionals alike. Serious and widespread quality problems exist throughout American medicine. The Institute of Medicine’s (IOM) report, A New Health System for the 21st Century, highlighted the disturbing absence of real progress toward restructuring health care systems to address both quality and cost concerns or toward applying advances in information technology to improve administrative and clinical processes (Richardson et al., 2001). The report also cited the lack of careful analysis and alignment of payment incentives with quality improvement. Some have expressed concern that market forces, not good science, are driving current pain management practices (Harden, 2002). The pain community must become engaged in quality improvement efforts and act upon its responsibility to define, measure, and improve the quality of pain management.
2. Efforts to improve the quality of pain management The question of how one changes practice behaviors to improve the quality of care has been a topic of great debate and experimentation in recent years. Changes in practice in some areas of healthcare are rapid and dramatic, e.g.
adoption of a novel drug delivery system or surgical technique. Unfortunately, change remains elusive in many critical areas. Numerous educational strategies have been used to improve pain management: textbooks, literature reviews, role model programs (Weissman et al., 1993, 1997) clinical preceptorships (Pasero et al., 1999), professional resource training programs (Ferrell et al., 1993), curriculum outlines (IASP, http://www.iasp-pain.org) and clinical practice guidelines (AHCPR, 1992, 1994; APS 1995, 2002; ASA, 1995, 1996, 1997; AGS, 2002). Although there have been improvements in knowledge and attitudes, there is little evidence that these guidelines result in improvements in clinical practice. In 1990, Mitchell Max, the chair of the Quality of Care Committee of the American Pain Society (APS), asserted that if there were to be improvement in the quality of pain care, it would be necessary to move beyond traditional educational and advocacy efforts and focus on systems of care to establish processes to support, reinforce and reward good pain management (Max, 1990). Suggestions for action included routinely monitoring and displaying patients’ pain ratings, designing bedside tools to assist optimal drug ordering, encouraging patients to communicate about unrelieved pain and initiating review mechanisms that improve systems and encourage creative design by the clinicians involved. During the last decade, many initiatives have used a QI approach to implement these recommendations. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) adopted a QI philosophy in the late 1980s and approved pain assessment and management accreditation standards in 1999. The JCAHO standards reiterate and build on the work of the Agency for Healthcare Research and Quality (AHRQ) and the American Pain Society (APS) to outline a specific set of institutional responsibilities aimed at improving outcomes of pain management. In late 2002, the United States Centers for Medicare and Medicaid Services (CMS) launched a national nursing home quality improvement initiative. CMS is working in partnership with the Quality Improvement Organizations (QIOs) in each
0304-3959/$20.00 q 2003 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved. doi:10.1016/S0304-3959(03)00267-7
2
D.B. Gordon, J.L. Dahl / Pain 107 (2004) 1–4
state to focus on specific quality measures to improve care. Almost all QIOs have elected to focus improvement activities on pain management (http://www.cms.hhs.gov/ providers/nursinghomes/nhi/).
3. Impact of pain QI efforts The experiences of some institutions that have adopted a quality improvement approach to pain management have been encouraging. In a state-based pain management initiative focused on post-operative pain, 15 participating hospitals achieved significant improvements in five of six quality indicators (Gold et al., 1996). Gordon et al. (2002) analyzed data obtained from 20 studies performed at eight large US hospitals from 1992 to 2001. Positive changes were observed in staff knowledge and attitudes, documentation of pain assessment, and there were reductions in routine use of intramuscular injections and meperidine. Similarly, a national QI project involving more than 200 hospitals resulted in changes in structures and practices critical to improving acute post-operative pain management (Dahl et al., 2003), but no changes in pain severity, interference, and satisfaction ratings provided by patients. These results are consistent with previous studies that have been unable to link improvements in processes of care, such as improved pain assessment, with reduced pain severity. However, when QI initiatives have included more treatment-focused strategies such as designated acute pain services and ward protocols to optimize use of regional techniques and systemic analgesics, significant reductions in pain intensity have been observed (Stromberg et al., 2003).
4. The challenge of improving quality The experiences of the last decade point to certain limitations of QI efforts: the paradox of patient satisfaction with inadequate pain control, the lack of focus on strategies likely to result in treatment improvements, and the limited periods of observation. Yet, there are several larger challenges that must be addressed if quality improvement efforts are to succeed: the failure to define quality pain management, the lack of deference for and funding of quality improvement research, inadequate implementation of QI activities, and the absence of physician leadership. 4.1. The failure to define quality pain management Quality implies specific measurable attributes that can, in many instances, be captured with the same degree of accuracy as measures used in traditional scientific studies. However, measurable attributes of quality pain management have not yet been clearly defined. Quality of care is multidimensional and can be evaluated on the basis of
structure, process and outcome (Donabedian, 1968). Structure refers to enduring characteristics of the clinical setting, including policies, procedures, standards of care and organizational resources. Process refers to actions that take place during clinical care. In the context of pain management, processes include clinician actions such as assessing and treating pain. Outcome refers to the endpoint of care or patients’ responses to care. Pain outcomes can include severity and duration of pain, the extent to which pain interferes with life activities, or patients’ satisfaction with the care they receive. Quality pain management depends on a host of complex relationships and processes including: appropriate assessment and reassessment; interdisciplinary, collaborative care planning that includes patient input; appropriate treatment that is effective, cost conscious, culturally and developmentally appropriate, and safe; and access to specialty care as needed. Little is known about the relationships among these processes and how they impact patient outcomes. Although much is known about the validity and reliability of a number of outcome measures (e.g. pain intensity ratings, functional interference), less is known about measurement of the structures and processes that constitute quality pain management. Success of pain QI efforts is dependent on development of these measures in order to generate data to document the success (or failure) of improvement efforts. To date, pain QI initiatives have focused on processes and structures that support improved assessment and documentation, not on pain management strategies. It is essential that the field move beyond merely improving pain assessment and documentation and into increased implementation of newer and likely more effective treatment regimens. Numerous rigorous clinical trials have documented the superiority of multi-modal therapy. There is growing evidence that post-operative pain in the hospital setting is best managed with a combination of methods including regional anesthetic techniques (e.g. nerve blocks, local wound infiltration, and epidural catheters to deliver local anesthetics and/or opioids), along with systemic nonsteroidal anti-inflammatory drugs, opioids, and non-pharmacologic techniques (Kehlet, 1997; Jin and Chung, 2001). To this end, it is critical to operationalize such concepts as multi-modal therapy. There is an old saying that you’ll never know if you’ve gotten to where you are going if you don’t know where you’re going in the first place. Not only have we not clearly defined the desired endpoint, we still do not really know what it is possible to achieve. Numerous studies document inadequate pain control, but what is optimal control of acute pain? Certainly, elimination of pain is unrealistic in the majority of situations. Is high quality reflected if 60% of patients report 30% relief when treated? What is an acceptable rate of adverse outcomes from specific treatment regimens? Although these are clearly not easy questions to answer, we must address them in an organized and concerted manner.
D.B. Gordon, J.L. Dahl / Pain 107 (2004) 1–4
4.2. The lack of deference for and funding of quality improvement research A criticism of QI has been the lack of rigor in the methodologies used to generate data with resultant doubts about the validity and reliability of the data. This criticism is in part a result of a lack of understanding of the differences between measurement for QI, research, and performance (external accountability). QI data are collected to provide a better understanding of the extent and nature of the problem, motivation for change, and points for comparison after change has been made. Measures chosen for QI must be few and easy to collect because there are few resources and time to collect them. Measurements should be made over a short period of time so that data can be collected periodically and most importantly be available to provide insight into a problem. Measurement for research purposes requires control of all possible variables and is intended to produce new knowledge of widely generalizable or universal value. Research findings though important, have very little direct practical application in the clinical setting. Research results can only be applied to those patients who fit strict research criteria. Data for accountability are used for performance comparisons by purchasers of healthcare and do not illuminate how the outcomes were achieved or how processes might be changed to improve the outcome. Publication of QI data does nothing to bring improvement; if the data show deficiencies, they may lead to fear and blame and may even poison the improvement effort. Another criticism of QI data relates to the apprehension that variations in processes of care may not be linked to outcome. Bridges must be built between clinicians charged with practice changes, funding sources, and researchers who can design large scale studies to examine the relationships of these factors and the cost-effectiveness and appropriateness of QI for different types of improvement. Long-term surveillance studies are needed in order to capture the point at which changes in structure and process translate into improved patient outcomes. QI studies should not be evaluated for funding or for publication with the same scrutiny as research trials. More QI studies need to be conducted by persons with experience in designing procedures for data collection and interpretation. System weaknesses and failures need to be part of a candid selfexamination in the pain literature. 4.3. Inadequate implementation of QI activities Neither the type or number of strategies used within healthcare QI initiatives have been helpful for distinguishing successful from unsuccessful programs. Success of hospital based QI initiatives has been linked instead to six broad cultural attributes of the clinical setting: clearly constructed goals, administrative support, clinician support, design and implementation of improvement initiatives, use
3
of data, and modifying variables (Bradley et al., 2001). Administrative support must go beyond organizational philosophy and provide the resources necessary to collect and analyze data and implement change. Few settings have really had the opportunity to fully implement the QI process. A host of factors such as organizational turbulence, staff turnover, degree of competition for care, and health system affiliation can limit the interdisciplinary participation necessary for successful implementation of a QI approach to quality problems. 4.4. Lack of physician involvement and leadership Physician leadership has been notably absent in pain QI efforts. One explanation may be that physicians are trained and updated regularly on the basis of research and thus believe that all data must be as complex and precise as that necessary to produce new knowledge. Physicians may fail to see the benefit of collecting data to understand a process of care. Physician leadership (not just involvement) has been shown to be critical to the success of QI initiatives in other areas of health care (Bradley et al., 2001). Physicians’ effectiveness is enhanced if they are highly respected clinicians, themselves committed to practice change and have consensus building skills. Expertise and previous QI training are not essential. Physicians may see little difference between new QI efforts and the previous quality assurance paradigm that focused on finding errors, imposing punishments, and was generally regarded as harassment. While physicians may have many legitimate questions about QI, it is time for them to embrace this collaborative approach because QI efforts will never be successful without them.
5. Conclusions The IOM described present efforts to improve the quality of healthcare as analogous to a team of engineers trying to break the sound barrier by tinkering with a model T Ford (Chassin and Galvin, 1998). Given the complexity of the issue, it is unrealistic to think that one approach can solve the problem of poor quality pain management. Radical new vehicles are needed. Integrating new knowledge and behaviors into day-to-day practice is a complicated but necessary process to improve quality. Our ability to modify the behaviors of patients, purchasers, and providers of care is dependent on evidenced-based standards of care and the collection of valid performance data. Yet, the field of pain management is just beginning to define quality and measure the relationships between pain management practices and outcomes of care. A comprehensive evaluation of the quality of pain management involves measurement of both practice patterns and patient outcomes. Much work is needed to develop and test valid and reliable measures of quality pain
4
D.B. Gordon, J.L. Dahl / Pain 107 (2004) 1–4
management. Pain management clinicians must work in collaboration with accrediting bodies, quality researchers, and policy makers (in this decade of pain control and research) to better define and measure the quality and benefits of effective pain management. Sweeping changes in the processes and tools being used to deliver and monitor care are required.
Acknowledgement We are grateful to Dr Mitchell Max for his thoughtful review of this editorial.
References Agency for Healthcare Policy and Research (AHCPR). Acute Pain Management: Operative or Medical Procedures and Trauma: Clinical Practice Guideline No. 1. Rockville, MD US Public Health Service, Agency for Health Care Policy and Research 1992; AHCPR publication 92-0032. Agency for Healthcare Policy and Research (AHCPR). Management of Cancer Pain: Adults: Clinical Practice Guideline No. 9. Rockville, MD US Public Health Service, Agency for Health Care Policy and Research 1994; AHCPR publication 94-0592. American Geriatric Society Panel on Persistent Pain in Older Persons, The management of persistent pain in older persons. J Am Geriatr Soc 2002; 50:S205– S24. American Pain Society Quality of Care Committee, Quality improvement guidelines for the treatment of acute pain and cancer pain. J Am Med Assoc 1995;23:1874 –80. American Pain Society. Guideline for the management of pain in osteoarthritis, Rheumatoid Arthritis and Juvenile Chronic Arthritis, 2nd Edition, American Pain Society, 2002. American Society of Anesthesiologists Task Force on Pain Management, Acute Pain Section, Practice Guidelines for acute pain management in the perioperative setting. Anesthesiology 1995;82:1071 –81. American Society of Anesthesiologists Task force on Pain Management, Cancer Pain Section, Practice guidelines for cancer pain management. Anesthesiology 1996;84(5):1243 –57. American Society of Anesthesiologists, Practice guidelines for chronic pain management. Anesthesiology 1997;86:995–1004. Bradley EH, Holmboe ES, Mattera JA, Roumanis SA, Radford MJ, Krumholz HM. A qualitative study of increasing b-blocker use after myocardial infarction. Why do some hospitals succeed? J Am Med Assoc 2001;285:2604–11. Chassin MR, Galvin RW. and the National Roundtable on Health Care Quality. The urgent need to improve health care quality. J Am Med Assoc 1998;280:1000–5.
Dahl JL, Gordon DB, Ward S, Skemp M, Wochos S, Schurr M. Institutionalizing pain management: the Post-Operative Pain (POP) management project. J Pain 2003 (in press). Donabedian A. Promoting quality through evaluation of the process of patient care. Med Care 1968;6:181 –202. Ferrell BR, Grant M, Ritchey KJ. The pain resource nurse training program: a unique approach to pain management. J Pain Symptom Manage 1993; 8:549–56. Gold JA, Dahl JL, Tavris DR. Word from WIPRO. Hospitals take steps to improve pain management. Wis Med J 1996;95:183 –5. Gordon DB, Pellino TA, Miaskowski C, McNeill JA, Paice JA, Laferriere D, Bookbinder M. A ten year review of quality improvement monitoring in pain management and recommendations for standardized measures. Pain Manage Nurs 2002;3(4):116–30. Harden RN. Pain management: where is the evidence? APS Bull 2002; 12(6):5. International Association for the Study of Pain (IASP). Curricula on pain for medical schools and schools of nursing and pharmacy. http:/www. iasp-pain.org. Jin F, Chung F. Multimodal analgesia for postoperative pain control. J Clin Anesth 2001;13:524– 39. Kehlet H. Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth 1997;78:606–17. Max M. Improving outcomes of analgesic treatment: is education enough? Ann Intern Med 1990;113:885– 9. Pasero C, Gordon DB, McCaffery M, Ferrell BR. In: McCaffery M, Pasero C, editors. Pain: clinical manual.; 1999. p. 711–44. Richardson W, Berwick D, Bisgard J. Crossing the quality chasm: A new health system for the 21st century. Washington, DC: Institute of Medicine; 2001. Stromberg MW, Wickstrom K, Joelsson H, Sjostrom B. Haljamae. Postoperative pain management on surgical wards—do quality assurance strategies result in long-term effects on staff member attitudes and clinical outcomes? Pain Manage Nurs 2003;1:11-22. Weissman DE, Dahl JL, Beasley JW. The cancer pain role model program of the Wisconsin Cancer Pain Initiative. J Pain Symptom Manage 1993; 8:29–35. Weissman DE, Griffie J, Gordon DB. Role model program to promote institutional changes for pain management of acute and cancer pain. J Pain Symptom Manage 1997;14:274–9.
Debra B. Gordon University of Wisconsin Hospital and Clinics, Madison, WI, USA June L. Dahl* University of Wisconsin Medical School, 4735 Medical Sciences Center, 1300 University Avenue, Madison, WI, USA E-mail address: [email protected]
* Corresponding author. Tel.: þ1-608-265-4012.
Editorial
Quality improvement challenges in pain management
1. Introduction A great deal of attention has been paid to the quality of pain management in the last decade, with growing recognition that the under treatment of pain is a major, yet avoidable, public health problem. Studies have consistently shown poor pain control for postoperative and trauma pain, cancer pain and for many chronic pain problems not related to cancer. Major barriers to effective pain management have been identified including the inadequate knowledge of health care professionals, patients and the public; lack of institutional commitment; regulatory concerns; and limited access to and reimbursement for interdisciplinary care. Despite efforts to address these barriers and continued advances in our understanding of pain, the quality of pain management remains inconsistent at best. The need to measure and improve the quality of care is increasingly recognized by consumers, payors and health care professionals alike. Serious and widespread quality problems exist throughout American medicine. The Institute of Medicine’s (IOM) report, A New Health System for the 21st Century, highlighted the disturbing absence of real progress toward restructuring health care systems to address both quality and cost concerns or toward applying advances in information technology to improve administrative and clinical processes (Richardson et al., 2001). The report also cited the lack of careful analysis and alignment of payment incentives with quality improvement. Some have expressed concern that market forces, not good science, are driving current pain management practices (Harden, 2002). The pain community must become engaged in quality improvement efforts and act upon its responsibility to define, measure, and improve the quality of pain management.
2. Efforts to improve the quality of pain management The question of how one changes practice behaviors to improve the quality of care has been a topic of great debate and experimentation in recent years. Changes in practice in some areas of healthcare are rapid and dramatic, e.g.
adoption of a novel drug delivery system or surgical technique. Unfortunately, change remains elusive in many critical areas. Numerous educational strategies have been used to improve pain management: textbooks, literature reviews, role model programs (Weissman et al., 1993, 1997) clinical preceptorships (Pasero et al., 1999), professional resource training programs (Ferrell et al., 1993), curriculum outlines (IASP, http://www.iasp-pain.org) and clinical practice guidelines (AHCPR, 1992, 1994; APS 1995, 2002; ASA, 1995, 1996, 1997; AGS, 2002). Although there have been improvements in knowledge and attitudes, there is little evidence that these guidelines result in improvements in clinical practice. In 1990, Mitchell Max, the chair of the Quality of Care Committee of the American Pain Society (APS), asserted that if there were to be improvement in the quality of pain care, it would be necessary to move beyond traditional educational and advocacy efforts and focus on systems of care to establish processes to support, reinforce and reward good pain management (Max, 1990). Suggestions for action included routinely monitoring and displaying patients’ pain ratings, designing bedside tools to assist optimal drug ordering, encouraging patients to communicate about unrelieved pain and initiating review mechanisms that improve systems and encourage creative design by the clinicians involved. During the last decade, many initiatives have used a QI approach to implement these recommendations. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) adopted a QI philosophy in the late 1980s and approved pain assessment and management accreditation standards in 1999. The JCAHO standards reiterate and build on the work of the Agency for Healthcare Research and Quality (AHRQ) and the American Pain Society (APS) to outline a specific set of institutional responsibilities aimed at improving outcomes of pain management. In late 2002, the United States Centers for Medicare and Medicaid Services (CMS) launched a national nursing home quality improvement initiative. CMS is working in partnership with the Quality Improvement Organizations (QIOs) in each
0304-3959/$20.00 q 2003 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved. doi:10.1016/S0304-3959(03)00267-7
2
D.B. Gordon, J.L. Dahl / Pain 107 (2004) 1–4
state to focus on specific quality measures to improve care. Almost all QIOs have elected to focus improvement activities on pain management (http://www.cms.hhs.gov/ providers/nursinghomes/nhi/).
3. Impact of pain QI efforts The experiences of some institutions that have adopted a quality improvement approach to pain management have been encouraging. In a state-based pain management initiative focused on post-operative pain, 15 participating hospitals achieved significant improvements in five of six quality indicators (Gold et al., 1996). Gordon et al. (2002) analyzed data obtained from 20 studies performed at eight large US hospitals from 1992 to 2001. Positive changes were observed in staff knowledge and attitudes, documentation of pain assessment, and there were reductions in routine use of intramuscular injections and meperidine. Similarly, a national QI project involving more than 200 hospitals resulted in changes in structures and practices critical to improving acute post-operative pain management (Dahl et al., 2003), but no changes in pain severity, interference, and satisfaction ratings provided by patients. These results are consistent with previous studies that have been unable to link improvements in processes of care, such as improved pain assessment, with reduced pain severity. However, when QI initiatives have included more treatment-focused strategies such as designated acute pain services and ward protocols to optimize use of regional techniques and systemic analgesics, significant reductions in pain intensity have been observed (Stromberg et al., 2003).
4. The challenge of improving quality The experiences of the last decade point to certain limitations of QI efforts: the paradox of patient satisfaction with inadequate pain control, the lack of focus on strategies likely to result in treatment improvements, and the limited periods of observation. Yet, there are several larger challenges that must be addressed if quality improvement efforts are to succeed: the failure to define quality pain management, the lack of deference for and funding of quality improvement research, inadequate implementation of QI activities, and the absence of physician leadership. 4.1. The failure to define quality pain management Quality implies specific measurable attributes that can, in many instances, be captured with the same degree of accuracy as measures used in traditional scientific studies. However, measurable attributes of quality pain management have not yet been clearly defined. Quality of care is multidimensional and can be evaluated on the basis of
structure, process and outcome (Donabedian, 1968). Structure refers to enduring characteristics of the clinical setting, including policies, procedures, standards of care and organizational resources. Process refers to actions that take place during clinical care. In the context of pain management, processes include clinician actions such as assessing and treating pain. Outcome refers to the endpoint of care or patients’ responses to care. Pain outcomes can include severity and duration of pain, the extent to which pain interferes with life activities, or patients’ satisfaction with the care they receive. Quality pain management depends on a host of complex relationships and processes including: appropriate assessment and reassessment; interdisciplinary, collaborative care planning that includes patient input; appropriate treatment that is effective, cost conscious, culturally and developmentally appropriate, and safe; and access to specialty care as needed. Little is known about the relationships among these processes and how they impact patient outcomes. Although much is known about the validity and reliability of a number of outcome measures (e.g. pain intensity ratings, functional interference), less is known about measurement of the structures and processes that constitute quality pain management. Success of pain QI efforts is dependent on development of these measures in order to generate data to document the success (or failure) of improvement efforts. To date, pain QI initiatives have focused on processes and structures that support improved assessment and documentation, not on pain management strategies. It is essential that the field move beyond merely improving pain assessment and documentation and into increased implementation of newer and likely more effective treatment regimens. Numerous rigorous clinical trials have documented the superiority of multi-modal therapy. There is growing evidence that post-operative pain in the hospital setting is best managed with a combination of methods including regional anesthetic techniques (e.g. nerve blocks, local wound infiltration, and epidural catheters to deliver local anesthetics and/or opioids), along with systemic nonsteroidal anti-inflammatory drugs, opioids, and non-pharmacologic techniques (Kehlet, 1997; Jin and Chung, 2001). To this end, it is critical to operationalize such concepts as multi-modal therapy. There is an old saying that you’ll never know if you’ve gotten to where you are going if you don’t know where you’re going in the first place. Not only have we not clearly defined the desired endpoint, we still do not really know what it is possible to achieve. Numerous studies document inadequate pain control, but what is optimal control of acute pain? Certainly, elimination of pain is unrealistic in the majority of situations. Is high quality reflected if 60% of patients report 30% relief when treated? What is an acceptable rate of adverse outcomes from specific treatment regimens? Although these are clearly not easy questions to answer, we must address them in an organized and concerted manner.
D.B. Gordon, J.L. Dahl / Pain 107 (2004) 1–4
4.2. The lack of deference for and funding of quality improvement research A criticism of QI has been the lack of rigor in the methodologies used to generate data with resultant doubts about the validity and reliability of the data. This criticism is in part a result of a lack of understanding of the differences between measurement for QI, research, and performance (external accountability). QI data are collected to provide a better understanding of the extent and nature of the problem, motivation for change, and points for comparison after change has been made. Measures chosen for QI must be few and easy to collect because there are few resources and time to collect them. Measurements should be made over a short period of time so that data can be collected periodically and most importantly be available to provide insight into a problem. Measurement for research purposes requires control of all possible variables and is intended to produce new knowledge of widely generalizable or universal value. Research findings though important, have very little direct practical application in the clinical setting. Research results can only be applied to those patients who fit strict research criteria. Data for accountability are used for performance comparisons by purchasers of healthcare and do not illuminate how the outcomes were achieved or how processes might be changed to improve the outcome. Publication of QI data does nothing to bring improvement; if the data show deficiencies, they may lead to fear and blame and may even poison the improvement effort. Another criticism of QI data relates to the apprehension that variations in processes of care may not be linked to outcome. Bridges must be built between clinicians charged with practice changes, funding sources, and researchers who can design large scale studies to examine the relationships of these factors and the cost-effectiveness and appropriateness of QI for different types of improvement. Long-term surveillance studies are needed in order to capture the point at which changes in structure and process translate into improved patient outcomes. QI studies should not be evaluated for funding or for publication with the same scrutiny as research trials. More QI studies need to be conducted by persons with experience in designing procedures for data collection and interpretation. System weaknesses and failures need to be part of a candid selfexamination in the pain literature. 4.3. Inadequate implementation of QI activities Neither the type or number of strategies used within healthcare QI initiatives have been helpful for distinguishing successful from unsuccessful programs. Success of hospital based QI initiatives has been linked instead to six broad cultural attributes of the clinical setting: clearly constructed goals, administrative support, clinician support, design and implementation of improvement initiatives, use
3
of data, and modifying variables (Bradley et al., 2001). Administrative support must go beyond organizational philosophy and provide the resources necessary to collect and analyze data and implement change. Few settings have really had the opportunity to fully implement the QI process. A host of factors such as organizational turbulence, staff turnover, degree of competition for care, and health system affiliation can limit the interdisciplinary participation necessary for successful implementation of a QI approach to quality problems. 4.4. Lack of physician involvement and leadership Physician leadership has been notably absent in pain QI efforts. One explanation may be that physicians are trained and updated regularly on the basis of research and thus believe that all data must be as complex and precise as that necessary to produce new knowledge. Physicians may fail to see the benefit of collecting data to understand a process of care. Physician leadership (not just involvement) has been shown to be critical to the success of QI initiatives in other areas of health care (Bradley et al., 2001). Physicians’ effectiveness is enhanced if they are highly respected clinicians, themselves committed to practice change and have consensus building skills. Expertise and previous QI training are not essential. Physicians may see little difference between new QI efforts and the previous quality assurance paradigm that focused on finding errors, imposing punishments, and was generally regarded as harassment. While physicians may have many legitimate questions about QI, it is time for them to embrace this collaborative approach because QI efforts will never be successful without them.
5. Conclusions The IOM described present efforts to improve the quality of healthcare as analogous to a team of engineers trying to break the sound barrier by tinkering with a model T Ford (Chassin and Galvin, 1998). Given the complexity of the issue, it is unrealistic to think that one approach can solve the problem of poor quality pain management. Radical new vehicles are needed. Integrating new knowledge and behaviors into day-to-day practice is a complicated but necessary process to improve quality. Our ability to modify the behaviors of patients, purchasers, and providers of care is dependent on evidenced-based standards of care and the collection of valid performance data. Yet, the field of pain management is just beginning to define quality and measure the relationships between pain management practices and outcomes of care. A comprehensive evaluation of the quality of pain management involves measurement of both practice patterns and patient outcomes. Much work is needed to develop and test valid and reliable measures of quality pain
4
D.B. Gordon, J.L. Dahl / Pain 107 (2004) 1–4
management. Pain management clinicians must work in collaboration with accrediting bodies, quality researchers, and policy makers (in this decade of pain control and research) to better define and measure the quality and benefits of effective pain management. Sweeping changes in the processes and tools being used to deliver and monitor care are required.
Acknowledgement We are grateful to Dr Mitchell Max for his thoughtful review of this editorial.
References Agency for Healthcare Policy and Research (AHCPR). Acute Pain Management: Operative or Medical Procedures and Trauma: Clinical Practice Guideline No. 1. Rockville, MD US Public Health Service, Agency for Health Care Policy and Research 1992; AHCPR publication 92-0032. Agency for Healthcare Policy and Research (AHCPR). Management of Cancer Pain: Adults: Clinical Practice Guideline No. 9. Rockville, MD US Public Health Service, Agency for Health Care Policy and Research 1994; AHCPR publication 94-0592. American Geriatric Society Panel on Persistent Pain in Older Persons, The management of persistent pain in older persons. J Am Geriatr Soc 2002; 50:S205– S24. American Pain Society Quality of Care Committee, Quality improvement guidelines for the treatment of acute pain and cancer pain. J Am Med Assoc 1995;23:1874 –80. American Pain Society. Guideline for the management of pain in osteoarthritis, Rheumatoid Arthritis and Juvenile Chronic Arthritis, 2nd Edition, American Pain Society, 2002. American Society of Anesthesiologists Task Force on Pain Management, Acute Pain Section, Practice Guidelines for acute pain management in the perioperative setting. Anesthesiology 1995;82:1071 –81. American Society of Anesthesiologists Task force on Pain Management, Cancer Pain Section, Practice guidelines for cancer pain management. Anesthesiology 1996;84(5):1243 –57. American Society of Anesthesiologists, Practice guidelines for chronic pain management. Anesthesiology 1997;86:995–1004. Bradley EH, Holmboe ES, Mattera JA, Roumanis SA, Radford MJ, Krumholz HM. A qualitative study of increasing b-blocker use after myocardial infarction. Why do some hospitals succeed? J Am Med Assoc 2001;285:2604–11. Chassin MR, Galvin RW. and the National Roundtable on Health Care Quality. The urgent need to improve health care quality. J Am Med Assoc 1998;280:1000–5.
Dahl JL, Gordon DB, Ward S, Skemp M, Wochos S, Schurr M. Institutionalizing pain management: the Post-Operative Pain (POP) management project. J Pain 2003 (in press). Donabedian A. Promoting quality through evaluation of the process of patient care. Med Care 1968;6:181 –202. Ferrell BR, Grant M, Ritchey KJ. The pain resource nurse training program: a unique approach to pain management. J Pain Symptom Manage 1993; 8:549–56. Gold JA, Dahl JL, Tavris DR. Word from WIPRO. Hospitals take steps to improve pain management. Wis Med J 1996;95:183 –5. Gordon DB, Pellino TA, Miaskowski C, McNeill JA, Paice JA, Laferriere D, Bookbinder M. A ten year review of quality improvement monitoring in pain management and recommendations for standardized measures. Pain Manage Nurs 2002;3(4):116–30. Harden RN. Pain management: where is the evidence? APS Bull 2002; 12(6):5. International Association for the Study of Pain (IASP). Curricula on pain for medical schools and schools of nursing and pharmacy. http:/www. iasp-pain.org. Jin F, Chung F. Multimodal analgesia for postoperative pain control. J Clin Anesth 2001;13:524– 39. Kehlet H. Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth 1997;78:606–17. Max M. Improving outcomes of analgesic treatment: is education enough? Ann Intern Med 1990;113:885– 9. Pasero C, Gordon DB, McCaffery M, Ferrell BR. In: McCaffery M, Pasero C, editors. Pain: clinical manual.; 1999. p. 711–44. Richardson W, Berwick D, Bisgard J. Crossing the quality chasm: A new health system for the 21st century. Washington, DC: Institute of Medicine; 2001. Stromberg MW, Wickstrom K, Joelsson H, Sjostrom B. Haljamae. Postoperative pain management on surgical wards—do quality assurance strategies result in long-term effects on staff member attitudes and clinical outcomes? Pain Manage Nurs 2003;1:11-22. Weissman DE, Dahl JL, Beasley JW. The cancer pain role model program of the Wisconsin Cancer Pain Initiative. J Pain Symptom Manage 1993; 8:29–35. Weissman DE, Griffie J, Gordon DB. Role model program to promote institutional changes for pain management of acute and cancer pain. J Pain Symptom Manage 1997;14:274–9.
Debra B. Gordon University of Wisconsin Hospital and Clinics, Madison, WI, USA June L. Dahl* University of Wisconsin Medical School, 4735 Medical Sciences Center, 1300 University Avenue, Madison, WI, USA E-mail address: [email protected]
* Corresponding author. Tel.: þ1-608-265-4012.