Pain Management f

1. Pain Managementf July 17, 2013 Carrie Brady, JD, MA cbradyconsulting@gmail.com Ashka Dave adave@aha.org David Schulke dschulke@aha.org

2. AHRQ/HRET Patient Safety Learning Network (PSLN) Project • This program is supported by the U.S. Agency for Healthcare Research and Quality (AHRQ) through a contract with the Health Research and Educational Trust (HRET). • HRET is a charitable and educational organization affiliated with the American Hospital Association, whose mission is to transform health care through research and education. • AHRQ is a federal agency whose mission is to improve the quality, safety, efficiency, and effectiveness of health care for all Americans.

3. The Patient Experience of Care is Fundamental to Clinical Improvement • Understanding the patient experience of care is not an add-on activity: it should be used as a fundamental element in your other improvement efforts. • For those working on the HRET Partnership for Patients Hospital Engagement Network (HEN) or another HEN, your work will benefit directly from your efforts to improve the patient experience of care (e.g., readmissions, ADEs). • Lessons you learn in this HCAHPS Learning Network will help you succeed in the HEN project because— • Patient-centered care is a driver of clinical outcomes • Employee and patient engagement are 2 sides of one coin • HCAHPS assesses key factors in ADEs and readmissions

4. HCAHPS Technical Assistance Faculty • Carrie Brady, MA, JD • HRET’s primary HCAHPS faculty • Former senior Connecticut Hospital Association staffer • Previously a vice president at Planetree • Exemplary hospital peers • Hospital for Special Surgery, New York

5. HCAHPS Pain Management Domain During this hospital stay: • How often was your pain well controlled? • How often did the hospital staff do everything they could to help you with your pain? Source: CMS Summary of HCAHPS Survey Results and HCAHPS Percentiles April 2013 Public Report (July 2011 – June 2012 Discharges) www.hcahpsonline.org • 71% “Always” is the national average • Best performing hospitals in the country (95th percentile) get 80% or more “Always”

6. Pain Management is Important • Every patient in the focus groups AHRQ conducted while developing the HCAHPS survey indicated that staff doing everything they could to help with pain was important • Unmanaged pain has potential long-term effects • Direct clinical effects • Effects on healthcare relationships and future behavior

7. Improving Patient Perceptions • Patients’ experience of pain management is not entirely dependent on their level of pain • Pain management perceptions are affected by many factors, including: • Effective communication with physicians and nurses • Responsiveness • Empathy See e.g. DuPree E. et al., Improving Patient Satisfaction with Pain Management Using Six Sigma Tools, Joint Commission Journal on Quality and Safety, v. 35, no. 7 July 2009 Gupta A. et al., Patient Perception of Pain Care in Hospitals in the United States, Journal of Pain Research 2009:2 157-164.

8. Exploring Pain • Pain Created by Health Care • Avoid unnecessary pain (“first, do no harm”) • Don’t underestimate the impact of frequent “simple” procedures (e.g. phlebotomy) • Reduce anxiety • Pain Alleviated by Health Care • Remember pain management is a team sport • Establish patient and family partnerships • Build staff skills and tools

9. Patient and Family Partnerships • Set Reasonable Expectations • Be candid about the pain to be expected • Keep the patient informed • e.g., use the white board to keep the pain goal and plan visible, as well as next scheduled medication • Respect the Patient’s Expertise • Discuss options, tradeoffs, and preferences, including what has worked previously • Develop pain goals and a plan 9

10. Make Sense of the Pain Scale • Explain the purpose of the pain scale • Ask patients contextual questions • e.g., at what point on the scale would they take an over the counter medicine for pain • Track progress • e.g., white board or paper tool available during stay and after discharge

11. Engaging Staff in Pain Management • Provide tools and resources • Training in pain management • Develop protocols for pain • Formal or informal pain team • Recognize barriers, including attitudes • Consider experiential learning techniques (e.g., ice cube)

12. Tap Into Your Own Expertise Use “positive deviance” techniques to improve pain management Survey staff to identify the “go to” people in your organization for pain management Convene the identified staff members to discuss their practices and how they can be applied more broadly United Hospital: Employing Positive Deviance to Improve the Culture of Pain Management, in Robert Wood Johnson Foundation, Improving Patient Experience in the Inpatient Setting: A Case Study of Three Hospitals, April 2012 (available online at http://www.rwjf.org/en/research-publications/find-rwjf-research/2012/04/improving-patient-experience-in-the-inpatient-setting.html)

13. Expand the Timeline • Anticipate and proactively plan for pain management, rather than reacting to it • Consider ideal timing and variety of communication techniques (e.g. pain brochures or bill of rights for pain management) • Learn from experience before and after hospitalization • e.g., ask discharged patients what was most effective intervention to manage pain 13

14. Improving Pain Management with a Simple Communication Tool Comfort and Pain Relief Menu Exempla Saint Joseph Hospital • Menu highlights variety of strategies available to manage pain, including: • Comfort items and actions • Personal care items • Relaxation aids • Serves as communication resource for staff and ready reference for patients • Empowers additional staff members to respond to pain Available for free download as part of the Picker Institute Always Events® materials at http://alwaysevents.pickerinstitute.org/?p=1154 14

15. Hospital for Special Surgery

16. History of Hospital for Special Surgery (HSS) Founded in 1863 as The Hospital for the Relief of the Ruptured and Crippled; HSS is the oldest existing orthopedic hospital in the United States From a small rehabilitation-oriented facility to an internationally renowned center for the treatment of musculoskeletal diseases • Mission: Provide the highest quality patient care, improve mobility, and enhance the quality of life for all and to advance the science of orthopedic surgery, rheumatology, and their related disciplines through research and education • Vision: Lead the world as the most innovative source of medical care, the premier research institution, and the most trusted educator in the field of orthopedics, rheumatology, and their related disciplines

17. Specialization Allows for Unmatched Degree of Expertise Pathology & Lab Medicine Neurology HSS is singularly focused on Musculoskeletal Medicine Orthopedics Rheumatology • 95 Surgeons with Sub-Specialties in: • Centers of Excellence in: • Inflammatory Arthritis • Osteoarthritis • Lupus • Scleroderma, Vasculitis, Myositis • Osteoporosis • Pediatric Rheumatology • Adult Reconstruction & Joint Replacement • Foot and Ankle • Hand & Upper Extremity • Limb Lengthening & Complex Reconstruction • Metabolic Bone Disease • Pediatrics • Scoliosis • Spine • Sports Medicine & Shoulder • Trauma Related Disciplines All oriented towards Musculoskeletal Medicine Infectious Disease Pain Management Physiatry Rehabilitation • Motion Analysis • Pediatric Rehab • Sports Rehab • & Performance • Spine Disorders • Nerve Injuries • Arthritis • Peripheral Neuropathies • Complex Regional Pain • Syndrome (RSD) • Hand Therapy • Integrative Care • Joint Mobility Radiology & Imaging Anesthesiology

18. Imperatives for a Dynamic Pain Management Program Surgical Population Higher Consumer expectations Increased Regulatory Requirements Greater Need for Interdisciplinary Team Coordination Faster Pace in Healthcare Industry

19. History of Pain Program at Hospital for Special Surgery Inpatient Pain Services – Late 1980’s HSS –Multidisciplinary Planning Team- 1990 HSS APS Launch – March 1991 Started with 40 PCA Pumps First Hospital in NY to allow epidural infusions on the inpatient units

20. Current Status Acute Pain Service Chronic Pain Service Recuperative Pain Service

21. Patient Experience Regarding Pain • Dedicated Teams • Consultation and management from surgery to discharge • Providing different levels skills and knowledge: RN/MD • Acute Pain – handling routine pain problems • Chronic Pain – handling complicated pain problems • Recuperative Pain – handling transitional pain problems – both inpatient and outpatient • Individualized attention to the patient’s need • Accessibility – daily rounds – multiple visits – 24/7 availability • Consistency in clinical care

22. Patient Experience Regarding Pain • Comprehensive Medication Order Sets • Allows for an analgesic plan and side effect management • Patient Education • Revised discharge booklet • Help Line for patients needing a telephone intervention

23. Patient Experience Regarding Pain • Staff Education • Clinician’s Guide to Pain Service Handbook – distributed to all staff outlining pain services • Multiple in-services aimed at providing updated knowledge to the staff on pain issues which helps information translation to the patient • Staff orientation • Research • Multiple clinical research trials which have impacted on the pain management practice.

24. Acute Pain Service • Pain Management Plan • Use of Regional Analgesia Techniques • Epidurals • Peripheral Nerve Blocks and Catheters • Order sets allowing flexibility to adapt to patient needs. • Dedicated Core Team • Anesthesiologist – 24/7 Coverage • Nurses – Certified in Pain Management

25. The Recuperative Pain Medicine Service Team

26. Recuperative Pain Medicine Service Individual plans of care for each patient regarding pain management following surgery Patient seen multiple times during day by Nurse Practitioners ensuring effectiveness of treatment modalities Helpline to answer pain management questions after Discharge

27. Nursing Orientation on Regional Anesthesia: Managing the Pain from Orthopaedic Surgery Acute Pain Management Service Hospital for Special Surgery

28. Nursing Orientation Curriculum • Pain Goals • Pain Management Principles • Assessment • Listening Skills • Analgesic Approaches • Epidural • PCA • Peripheral Nerve Blocks • Spinal • Benefits of Regional Anesthesia

29. Nursing Orientation Curriculum Dosing and mixing of medications Local anesthetics Epidural Side Effects Multi Modal Approaches Coagulation Issues

32. HSS and Patient Satisfaction with Pain Control Note: Inpatient peer group are magnet hospitals nationwide and percentile rank are represented by pink line graph. Blue bars represent mean score for patient satisfaction with how well pain was controlled during their inpatient stay.

33. HSS and Patient Satisfaction with Care Note: Inpatient peer group are magnet hospitals nationwide and percentile rank are represented by pink line graph. Blue bars represent mean score for patient satisfaction with overall rating of care provided during their inpatient stay

34. Patients who reported that their pain was “Always” well controlled (HCAHPS Pain Domain) U.S. National Average: 71% NYS Average: 67%

35. Patient Satisfaction with Nursing and Personal Issues Nursing Section Personal Issues Section Note: Prink line graph represent patient satisfaction with Nursing Section that captures the following metrics: Friendliness & courtesy of nurses, promptness in response to call bell requests, Nurses’ attitude toward requests, Attention to special/personal needs, Nurses kept keeping patient informed and skill of nurses Blue line graph represent patient satisfaction with Personal Issues Section that captures the following metrics: Staff concerned for privacy, How well pain was controlled, Staff addressed emotional needs, Response to concerns/complaints and Staff include patients in decisions regarding treatment

36. HSS and Overall Patient Satisfaction Q2’13 Magnet Percentile Rank: 96th %ile

37. HCAHPS & Value Based Purchasing Program = Benchmark threshold required for full earn back under FY15 VBP Program HCAHPS data reflects rating from patients discharged during Q3’11 to Q2’12

38. Questions and Discussion

39. New AHRQ Resources • Guide to Patient and Family Engagement in Hospital Quality and Safety • Provides detailed implementation guides and tools for four interventions: • Working with Patient and Family Advisors • Communicating to Improve Quality • Nurse Bedside Shift Report • IDEAL Discharge Planning http://www.ahrq.gov/professionals/systems/hospital/engagingfamilies/index.html

40. HCAHPS Curriculum 2012-13All Web conferences are scheduled for 12-1pm EasternAll are archived at: http://www.psl-network.org/ • December 7, 2012: Fundamentals of HCAHPS • December 18/19, 2012: Using HCAHPS Data Effectively • January 16, 2013: Nurse Communication • February 13, 2013: Responsiveness • March 13, 2013: Medication Communication • April 24, 2013: Discharge Information • June 5, 2013: Physician Communication and Engagement • July 17, 2013: Pain Management • August 14, 2013: Clean and Quiet