In June of this year, The Joint Commission (TJC) released new and revised pain assessment and management standards for all TJC-accredited ambulatory care facilities, critical access hospitals and office-based surgery organizations. These standards are part of TJC's efforts to address disparities between the pain management standards the organization published in 2001 and current thinking and guidance regarding the use and overuse of opioids.
The standards for the settings mentioned above go into effect in January of 2019. Although many healthcare organizations may already have departmental policies and procedures that are largely consistent with these requirements, those that haven't already done so should review and modify their current policies and procedures to ensure compliance.
TJC has received criticism for its initial pain standards, which some within the medical and healthcare communities claim contributed to a misguided view of pain as a "fifth vital sign" and the over-zealous use of opioids that fueled the current opioid crisis.
Also playing a role, according to many, were the questions about pain management on the Centers for Medicare and Medicaid Services' (CMS's) Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, which many believed pressured physicians to over-prescribe opioids in an attempt to achieve more favorable HCAHPS scores. Those questions have since been removed and replaced with questions about "pain communication." (However, in its proposed rule for the Outpatient Prospective Payment System and Ambulatory Surgery Center Payment System for 2019, CMS has suggested removing these pain communication questions, effective in 2022.)
Although TJC noted in a detailed statement published on its website that its previous standards did not require the use of drugs to manage a patient's pain nor specify which drug should be prescribed, the organization embarked in 2016 on a project to develop and revise the standards to zero in on the safe and judicious use of opioids in response to the opioid crisis that remains in full force. The first product of that initiative, the new and revised pain assessment and management standards for TJC-accredited hospitals, went into effect in January 2018.
Development of this latest set of standards began with an extensive literature and field review, followed by the creation of a technical advisory panel of representatives of leading healthcare organizations, including academic medical centers, associations, payers and health technology groups; a primary care panel of experts in chronic non-cancer pain management in primary care settings and safe prescribing and provider education programs; and a standards review panel to evaluate standard drafts.
Designed to strengthen organizations' pain assessment, treating, education and monitoring practices, the new requirements appear in the following chapters of the accreditation manual:
- Leadership (LD.04.03.13)
- Provision of Care, Treatment and Services (PC.01.02.07)
- Performance Improvement (PI.01.01.01; PI.02.01.01)
- Medical Staff (MS.05.01.01, applicable to critical access hospitals only)
The ambulatory care standards call for facilities to, among other things:
- Designate a leader or team responsible for pain management, opioid prescribing and performance improvement activities in these areas.
- Educate staff and practitioners on pain assessment and management, and the safe use of opioids, based on the needs of its patient population.
- Inform staff and practitioners about available consultations and referrals for patients with complex pain management needs.
- Facilitate access to databases of the prescription drug monitoring program, which have been shown to help prevent misuse and diversion of controlled substances.
- Define criteria to screen, assess and reassess pain that are appropriate for the patient's age, condition and ability to understand.
- Treat the patient's pain or refer the patient for treatment, using nonpharmacologic, pharmacologic or a combination of strategies. (This can include patients with complex requirements and pediatric patients with non-cancer pain, among others.)
- Monitor the use of opioids to ensure they are being safely prescribed. This can include defining metrics related to the use of opioids to identify priority areas for improvement and resource allocation.
TJC has published reports detailing the new requirements, as well as the rationales and references used in developing them, for ambulatory care, critical access hospitals and office-based surgery organizations. Also available is an ambulatory care applicability grid indicating which standards apply to which types of ambulatory facilities.