New Pain Management Standards FAQs

Recently, the Joint Commission posted 10 FAQ’s addressing the new pain management standards that take effect January 2018. These are hot topics discussed by many organizations that we visit as they plan their implementation steps.

New Pain Management Standards

On the whole, the responses addressed here are unusual. In fact, they don’t address any questions we actually hear clients ask. In addition the questions each appear to ask; “what is the minimum requirement to remain compliant?”

So when reviewing each of the new pain management standards FAQs, keep this in mind:

• Seven are from the leadership standards associated with the pain management standards
• One is from performance improvement
• Two are from provision of care

FAQ LD.04.03.13, EP 3

Question: How should you handle staff and LIP education and resources. Are specific resources required and should information delivery take place?

Answer: No, you decide the options based on your services and needs. For content, you may choose online resources or clinical practice guidelines on safe opioid prescribing, modalities of treatment, multi-modal pain management, and assessment criteria.

LD.04.03.13, EP 1

Question: The new requirement states developing, implementing and monitoring performance improvement activities specific to pain management is a leadership responsibility. Is having a policy sufficient?

Answer: No, they expect active leadership, sustainable improvements and accountability across disciplines.

LD.04.03.13, EP 4

Question: Regarding consultation available to staff and LIP’s, does that mean internal or external consultation?

Answer: Use either or both as needed to meet staff and LIP needs. They advise that staff and LIP’s should know about available services and resources for continuing care upon discharge. In addition Joint Commission indicates they will assess compliance through interviews of staff and LIP’s.

LD.04.03.13, EP 2

Question: The new pain management standards require organizations to provide non-pharmacologic pain treatment modalities. What exactly is TJC talking about? And, is there any evidenced based literature to support the efficacy of these non-pharmacologic modalities?

Answer: Here the Joint Commission responds to the first portion of the question. But, they are silent on the second part concerning efficacy. TJC does identify options such as:
Transcutaneous electrical stimulation Acupuncture Chiropractic therapy Osteopathic manipulative treatment Massage therapy Relaxation therapy Music therapy Aromatherapy, Cognitive behavioral therapy And more.

LD.04.03.13, EP 6

Question: What does the requirement for the hospital to facilitate practitioner and pharmacist access to Prescription Drug Monitoring Programs actually mean? Is the organization required to access the PDMP for every patient receiving opioids?

Answer: Facilitating access simply means facilitating access. For example,

• Shortcuts to the PDMP database on hospital computers
• Links from the EMR, education of staff and LIP’s on how to access
• Demonstration/return demonstration competency and periodic monitoring of compliance as defined
• Compliance with state law or regulation that may mandate accessing the database prior to discharge with a narcotic prescription

Most importantly here, TJC states that the requirement does NOT apply to patients receiving short term opioids during their hospital encounter. Lastly, if your state does not have a PDMP, the requirement does not apply.

LD.04.03.13, EP 5

Question: How does the organization demonstrate compliance with the requirement to identify opioid treatment programs used for patient referrals?

Answer: This may be difficult for individual clinicians to do. So the hospital should create a list or database. TJC suggests reviewing the SAMHSA directory of opioid treatment programs.

LD.04.03.13, EP 7

Question: Does TJC have any specific recommendations or standards for monitoring postoperative patients on opiates? Plus, are there specific details about pulse oximetry?

Answer: Here the Joint Commission discusses risk assessment to help identify those patients at greatest risk. In addition they identify 6 references to help develop policies, protocols and quality indicators. We suggest one that is not on their list, the CMS Survey and Certification memo 14-15, issued March 14, 2014. This memo does an excellent job of describing risk assessment methods and measures hospitals can take to reduce risk from opiate administration.

PI.01.01.01, EP 18

Question: Since one of the HCAHPS measures does ask about pain management, does the use of this measure suffice for the new performance improvement standard?

Answer: No. TJC points out that HCAHPS only evaluates inpatient discharges. They want this PI standard to address both inpatient and outpatient populations. In addition, they call for the measurement activity to be broader in scope. For example they suggest use of Naloxone, incidents of respiratory depression, and practitioner prescribing practices.

PC.01.02.07, EP 8

Question: Who is responsible for providing the patient education required by this standard?

Answer: TJC does not specify who is responsible. But, they do make it clear that documentation of the education must appear in the medical record. Hospitals will need to think this through in the context of their EMR capabilities. Many will easily permit documentation in a care plan tab. Others can document in an education log.

Indeed, we encourage readers to identify the specific location to place this documentation. Do not allow placement in several different locations because you want to find the documentation upon request. The fact is, knowing where to look is essential.

PC.01.02.07, EP 1

Question: What is the difference between screening and assessment?

Answer: The answer is basic, important and a core concept spread throughout the Joint Commission standards in several performance areas. Screening looks for the potential presence of a problem. Meanwhile, assessment is the more in-depth evaluation of that problem. In addition, TJC reminds the industry to use different assessment tools for pain assessment, for the very young, elderly, and those without the ability to respond directly to questions.

These new pain management standards go into effect in January 2018. So, now is the time to take the necessary steps to maintain compliance.

Patton Healthcare Consulting

Patton Healthcare Consulting provides Joint Commission and CMS Compliance Assistance and a full range of pre-survey and post survey services.

We serve more than 200 hospitals, behavioral health care organizations, ambulatory clinics and home care companies nationwide—hospitals ranging from critical access hospitals to the largest health systems. Contact us at (888) PHC-INC1 for more information.