PAIN MANAGEMENT is a basic human

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1 J Nurs Care Qual Vol. 31, No. 2, pp Copyright c 2016 Wolters Kluwer Health, Inc. All rights reserved. Quality Improvement Project to Improve Patient Satisfaction With Pain Management Using Human-Centered Design Tracy Trail-Mahan, MS, RN-BC; Scott Heisler, MBA, RN; Mary Katica, BFA In this quality improvement project, our health system developed a comprehensive, patientcentered approach to improving inpatient pain management and assessed its impact on patient satisfaction across 21 medical centers. Using human-centered design principles, a bundle of 6 individual and team nursing practices was developed. Patient satisfaction with pain management, as measured by the Hospital Consumer Assessment of Healthcare Providers and Systems pain composite score, increased from the 25th to just under the 75th national percentile. Key words: human-centered design, nursing, painmanagement, patient-centered care, patientsatisfaction PAIN MANAGEMENT is a basic human right, and The Joint Commission standards first implemented in 2001 sought to ensure uniform pain management and assessment. 1-3 However, pain management continues to offer important quality improvement (QI) opportunities. Recent Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) data indicate that only 71% of US composite pain management scores reflected optimal pain management. 4 Author Affiliations: Kaiser Permanente Santa Clara Medical Center, Santa Clara, California (Ms Trail-Mahan); and Kaiser Permanente Innovation Consultancy, Oakland, California (Mr Heisler and Ms Katica). All funding was provided by Kaiser Permanente. The authors declare no conflict of interest. Correspondence: Tracy Trail-Mahan, MS, RN-BC, Kaiser Permanente Santa Clara Medical Center, 710 Lawrence Expressway, Santa Clara, CA (Tracy.X.Trail-Mahan@kp.org). Accepted for publication: September 5, 2015 Published ahead of print: October 7, 2015 DOI: /NCQ Numerous barriers to effective pain management include cursory, inaccurate, or insufficiently frequent assessments; ineffective analgesic administration practices; and ineffective communication between nurses and patients and among nurses, particularly at shift change. 5,6 Misinformation among health care providers about appropriate dosing and route for opioid analgesics and unfounded concerns about dependence contribute to poor pain management. 7,8 Patients may not understand pain management scales or be able to self-report discomfort. 9,10 They may not request medication until pain is severe, which can occur on waking, and may do so because of unfounded concerns about dependency. 8,11-13 Thorough pain assessment, timely reassessment after an analgesic intervention, and documentation of both are all inconsistently performed among postoperative patients. 14 Equianalgesic dosing when transitioning patients from intravenous (IV) to oral routes of administration is pivotal. 15 Removing multiple barriers to effective pain management requires multimodal interventions that redesign nursing practice patterns

2 106 JOURNAL OF NURSING CARE QUALITY/APRIL-JUNE 2016 In 2009, Kaiser Permanente Northern California (KPNC) nurse leaders noted that scores for patient satisfaction with pain management in the first year of HCAHPS measurement were between the 25th and 50th national percentiles, indicating a substantial QI opportunity in inpatient pain management. The aims of the QI project reported here were to develop a multifaceted, patient-centered approach to improve inpatient pain management, implement it across 21 KPNC hospitals, and assess its impact on patient satisfaction, as measured by the HCAHPS pain management composite score. METHODS Setting Northern California is 1 of 7 regions of Kaiser Permanente, the largest not-for-profit integrated health care delivery system in the United States, serving 10.1 million members. KPNC provides the entire spectrum of health care for 3.3 million members in settings that include 21 medical centers, with a total average daily census exceeding KPNC has a robust improvement structure in place. 17 The experience of frontline nurses at routinely conducting plan-do-study-act (PDSA) rapid improvement cycles was a key organizational strength enabling the QI project. 17,18 Planning the intervention The core of the development process was human-centered design, which relies on a thorough understanding of what people want and need and has been used extensively to drive innovation in multiple industries, including health care Human design begins with an empathetic exploration of user (in this case, nurses and patients) experiences, which are synthesized into a deep understanding of those experiences and definition of the problem to be addressed. Solutions are explored in the ideation, prototyping, and testing phases. 23 Since 2003, the Kaiser Permanente Innovation Consultancy has used human-centered design methods and principles to help patients, frontline care providers, and managers design and implement new ways to improve the care experiences of patients and the work experiences of care providers. 24 Human-centered design begins with indepth observations and interviews that reveal the existing state of experiences. The authors conducted interviews, observations, and focus groups with approximately 50 nurses on 2 medical/surgical units at 2 hospitals to identify existing issues with pain management; it became clear that some nurses were more adept at pain management than others. In the next phase of observation, the nurse manager on a surgical unit identified 5 staff nurses perceived as pain management experts. Each identified nurse expert was observed and interviewed by the Innovation Consultancy staff over the course of a shift as they provided patient care. Human-centered design uses qualitative data analysis strategies to understand observations and interviews. Inductive category development in a narrative analysis framework identified 6 themes related to pain management. 25 Trust is key. Patients need reassurance that nurses are proactively partnering with them to manage their pain and are acutely aware of whether that is the case. Already behind. Even when instructed to call at the first sign of pain, patients often do not call for pain medication until their pain is poorly controlled. Miscommunication. Patients often do not understand what nurses want when asked to describe their pain on a 0- to 10 scale. Morning agony. Patients can easily sleep through their pain at night and find themselves in unnecessary pain in the morning. Remembering to reassess. In the rush of nursing shifts, it can be difficult for nurses to remember to reevaluate patients and document their reassessment. The pills do not work. Patients often lose faith in their oral pain medications because of perceived ineffectiveness.

3 Patient Satisfaction With Pain Management 107 This can happen when patients are transitioned off IV pain medication and not given equianalgesic oral pain medication or consistent dosing patterns. The Kaiser Permanente Innovation Consultancy team and a nursing pain management expert identified nursing practices that would address each theme. Discussion of these findings with approximately 50 nurses from 2 units at 2 medical centers over the course of a month enabled nursing staff to build a shared understanding of challenges in pain management and nursing practices that could mitigate them. These nurses subsequently conducted multiple PDSA cycles, refining the identified nursing practices related to pain management into a bundle of 6 best nursing practices. KP Painscape practices The best practices were collectively named KP Painscape. The goal is a coordinated team effort to help patients proactively manage pain. Prepare before entering patient room The objective of this practice is to assure patients that nurses know about their recent medications, nonpharmacologic interventions, and experiences with pain and are able to help them effectively manage pain. During a brief time-out before entering patient rooms, nurses evaluate the adequacy of pain management by reviewing pain scores, medications, and comfort measures. They identify opportunities to improve patient-centered pain management by understanding patient preferences; educating patients about the numerical pain scale, available medications, and nonpharmacologic interventions; and advocating for optimal pain management options. After entering patient rooms, nurses address pain management with proactive statements, such as, I noticed you grimacing, and we want to get your pain to your stated acceptable level of 3. Nurses remain authentically present with patients, focusing on verbal responses and nonverbal cues, such as facial expressions and posturing. Explore pain scale responses Nurses may not fully understand patients pain experiences, due, in part, to patients knowledge deficits about describing pain. For example, patients using a numerical rating scale may select numbers based on a carefully positioned resting state, although activity causes discomfort. The objective of this practice is to ensure that nurses fully understand patients experiences of pain. After soliciting numerical pain ratings, nurses ask additional questions about activities of daily living or functional goals: What is your pain level if you re trying to shift your position in bed or sit up? What is your pain level if you re walking to the bathroom? Similarly, nurses explore pain related to physical manipulation. For instance, a nurse may gently manipulate the leg of a patient who underwent a knee replacement. Integrating a probing pain scale response into each assessment, reassessment, and shift-change report and communicating results with physicians and other care providers help ensure a similar shared assessment of patients pain levels. Use appropriate dose when transitioning from IV to oral pain medications Inadequate dosing or infrequent redosing when patients transition from IV to oral administration routes can cause patients and nurses to doubt the efficacy of oral pain medications; patients may refuse them and nurses may revert to using IV medications. Inadequate dosing can also create additional work for nurses as they address patients poorly controlled pain. The objective of this practice is to ensure consistent transitions from IV to oral pain medications. Nurses use the highest equianalgesic dose of oral pain medications, rather than starting with a lower dose and increasing as needed. Every effort is made to successfully transition patients from IV to oral routes, taking into account the duration of efficacy so that patients experience no gaps in analgesic coverage. Nurses also offer nonpharmacologic comfort

4 108 JOURNAL OF NURSING CARE QUALITY/APRIL-JUNE 2016 measures, such as heat, ice, music therapy, therapeutic touch, distraction, repositioning, and guided imagery. Reassess on a timely basis Reassessing analgesia peak effect and duration is key to evaluating the adequacy of pain medication regimens. The objective is to ensure that nurses consistently reevaluate patients after administering pain medication and document reassessment results. Nurses adhere to organization- or unit-specific reassessment protocols; the Kaiser Permanente reassessment standard is 1 hour after oral pain medications or 30 minutes after IV pain medications. Nurses may use tools (eg, a worksheet to track assessments) as needed, aligning reassessments with purposeful hourly rounding when appropriate. Encourage around-the-clock dosing even when as-needed dosing is ordered Even when nurses and physicians ask patients to call for medication at the first sign of pain, some may not do so. The objective is to make it easier for nurses to help patients proactively manage continuous pain. Encouraging around-the-clock dosing helps ensure consistent analgesic levels and avoid extreme differences between pain levels and analgesic bioavailability; it also allows nurses to help patients stay ahead of pain, avoiding unnecessary as-needed (PRN) dosing, rescue medications, and reassessments. Instead of relying on patients to request pain medication, nurses proactively check with them before the next dose is available. During purposeful hourly visits, nurses assess pain and determine the need for additional medication. A last dose/next available entry on a white care board in the patient room helps track pain medication timing and schedule. Work as a team to keep pain medication regimens going at night Nurses may hesitate to awaken patients to assess the need for pain medication, and patients may not understand the need for brief sleep interruptions to ensure ongoing pain control. The objective is to maintain consistent bioavailability of analgesics around the clock. Patients and nurses discuss and agree on overnight pain medication regimens before bedtime. Nurses communicate the agreed-upon plan to the oncoming shift to ensure that patients receive requested medication. Even if pain medication is ordered on a PRN basis, the regimen may continue through the night. Support from physicians and pharmacists Physicians and pharmacists support KP Painscape. Physicians evaluate patients medication plans for completeness, including asindicated orders for opioids, adjuvant nonopioid medications, equianalgesic conversions from IV to oral medications, breakthrough analgesia, and around-the-clock dosing. They also support KP Painscape by asking probing questions about pain levels during daily rounds, evaluating the efficacy of current medication orders, and reinforcing the importance of hourly pain reassessments. Pharmacists support nurses and physicians in making appropriate pain medication decisions, such as IV-to-oral dose conversions and adjuvant medication. Pharmacists help determine the need to adjust medication regimens and are available for questions from on-call physicians about opioid conversions. Implementation of KP Painscape While KP Painscape was being finalized after the completion of the PDSA cycles on 2 nursing units, KPNC senior leaders selected it for inclusion in a portfolio of interventions for pilot testing at a third medical center in As pilot testing proceeded, a regional panel of pain management experts endorsed KP Painscape, and it became a regionally recommended practice in early A toolkit that included an implementation guide was distributed throughout the region, and regional pain summits and symposia in the fall of 2012 provided opportunities for multidisciplinary learning and input. KP

5 Patient Satisfaction With Pain Management 109 Painscape was implemented throughout KPNC in A change workbook facilitated spread; it remains available online. 26 The package includes detailed guidance on preparing to implement KP Painscape, kicking off the process, conducting PDSA cycles on a nursing unit, preparing for go-live implementation, and going live with KP Painscape; it also contains worksheets for nurse champions and unit managers to use throughout the process. In addition, patients were involved in implementation. Nursing managers talked with patients about the goal of improving pain management and gave them cards that listed the 6 KP Painscape nursing practices and a collection of small plastic clips; they asked patients to give a clip to a nurse when he or she engaged in one of the practices. Nurses displayed the clips on their name badges. Unit managers encouraged patients to ask questions about their pain management and medications; this prompted nurses to engage in patient-centered conversations. Unit managers and the authors also engaged in midmorning huddles with nursing staff, asking how many patients had experienced morning pain and needed PRN pain medications within the first hour of their shift. This activity provided feedback to nurses about the effectiveness of their implementation morning pain was a signal that something was not working and maintained KP Painscape as a priority. Finally, the authors invited nurses from units that were in the midst of implementing KP Painscape to an impromptu weekly coffee chat lasting 20 to 30 minutes that provided an opportunity for sharing successes, challenges, and solutions. Evaluation A pre/posttest design was used to assess the impact of KP Painscape on patient satisfaction with inpatient pain management, measured by the HCAHPS pain composite, a wellvalidated survey used nationally to assess patient satisfaction with inpatient care. 27 The pain composite consists of 2 questions: (1) During this hospital stay, how often was your pain well controlled? and (2) During this hospital stay, how often did the hospital staff do everything they could to help you with your pain?. Response options for both questions range from never to always. The composite score is calculated as the mean of the percentage of respondents responding always to both composite questions. 28 Changes over time in HCAHPS scores were assessed with linear regression analysis, with a P value of less than.05 representing statistical significance. This project was QI in nature and not subject to institutional review board oversight. RESULTS Surgical units in pilot medical centers demonstrated significant gains in the HCAHPS pain management composite score (Figure 1). Both medical centers were below or at the 50th national percentile in December 2008 but increased to above or near the 90th percentile by December Between 2008 and December 2013, KPNC as a whole demonstrated improvement from the 25th to just under the 75th national percentile (Figure 2), reflecting an increase in the annual average score from 63.9% to 72.7%. Changes in HCAHPS scores over time were statistically significant (P <.05) and sustained through November DISCUSSION This QI project used human-centered design to understand existing challenges with pain management and engage frontline nurses, nursing pain management experts, and nursing leaders in designing and testing solutions to address them. Challenges to pain management identified through observation and interviews corresponded to those documented in the literature, including inconsistent reassessment after pain medication, ineffective communication, inadequate dosing with oral medication when transitioning patients from IV pain medication,

6 110 JOURNAL OF NURSING CARE QUALITY/APRIL-JUNE 2016 Percent of patients selecting the most positive response category Development Year Pilot site 1 (SC) Pilot site 2 75th na onal percen le 50th na onal percen le 90th na onal percen le Figure 1. Changes in HCAHPS pain management composite scores over time on surgical units. HCAHPS indicates Hospital Consumer Assessment of Healthcare Providers and Systems. suboptimal patient understanding of pain rating scales and the need to report pain early to avoid severe discomfort, and inadequate overnight pain management. 5,6,9-11,13-15 The association of KP Painscape implementation with improvements in HCAHPS pain management composite scores is consistent with evidence that multifaceted interventions are required to address the complex issue of suboptimal pain management among inpatients. 16 In complex systems with multiple improvement initiatives, change fatigue can inhibit QI; motivating and engaging frontline care providers are essential. 29 Real-world observations and interviews resulted in themes that resonated for nursing staff, experts, and leaders, and nursing staff were empowered to conduct rapid tests of change that resulted in improved care processes and a sense of ownership of the initiative to improve pain management. Several limitations deserve mention. The project took place in an integrated health care delivery system with a comprehensive electronic health record (EHR); generalizability Figure 2. Changes in HCAHPS pain management composite scores over time at 21 hospitals. HCAHPS indicates Hospital Consumer Assessment of Healthcare Providers and Systems; KPNC, Kaiser Permanente Northern California; A, development phase; B, pilot at site 3; C, regional designation as recommended practice; and D, implementation throughout KPNC.

7 Patient Satisfaction With Pain Management 111 to other settings is unknown. However, KP Painscape nursing practices are possible in any inpatient setting; an integrated EHR does not directly contribute to their feasibility. Improved pain management was an organizational focus when implementation occurred, and other improvement efforts also likely affected HCAHPS scores. The bundled nature of KP Painscape does not allow assessment of the effectiveness of individual elements. Finally, implementation of KP Painscape practices likely varied across nursing units and medical centers. In our experience, KP Painscape was most effective when implementation occurred as part of a culture that evolved to embrace excellent pain management exemplified by, for instance, nurses committed to avoiding patients waking in morning pain. As practice changed, the culture evolved, further solidifying practice changes. Thus, the improvement reported here may underestimate the potential of KP Painscape to improve pain management. To assess sustainability, HCAHPS pain composite scores are included in a performance dashboard monitored by medical center and regional leaders. No process measures are tracked, presenting a challenge to sustainability. Although some practices, such as reassessment, around-the-clock pain management, and adequate dosing when transitioning from IV to oral medications, could potentially be monitored using the EHR, others cannot. Resource-intensive methods are required to monitor the practices of preparing before entering the patient s room and exploring pain scale responses. With pain composite scores sustained at 72%, these methods have not yet been explored. However, considerable room for improvement exists, and future QI projects may assess the uniformity of implementation of KP Painscape across all medical/surgical units. For many nurses, learning related to pain management has been primarily experiential, and some nurses may lack an understanding of multimodal and alternative pain management strategies. KP Painscape provides an evidence-based set of practices that help nurses both respond to patients empathetically and manage the pain management challenges of a full medical/surgical patient assignment. CONCLUSIONS Inpatient pain management is a complex area for QI, requiring multiple changes in nursing care processes. A multifaceted pain management approach reported here addresses challenges to effective pain management identified through interviews and observations with frontline nursing staff and validated in the literature. Implemented in 21 hospitals, KP Painscape is associated with sustained increases in HCAHPS composite pain management scores that also indicate the potential for further improvement. REFERENCES 1. Gordon RM, Corcoran JR, Bartley-Daniele P, Sklenar D, Sutton PR, Cartwright F. A transdisciplinary team approach to pain management in inpatient health care settings. Pain Manag Nurs. 2014;15(1): Lorenz KA, Sherbourne CD, Shugarman LR, et al. How reliable is pain as the fifth vital sign? JAmBoardFam Med. 2009;22(3): Berry PH, Dahl JL. The new JCAHO pain standards: implications for pain management nurses. Pain Manag Nurs. 2000;1(1): Centers for Medicare & Medicaid Services. Summary of HCAHPS survey results: April 2012 to March 2013 discharges. _13_discharges_states.pdf. Published Accessed August 3, Middleton C. Barriers to the provision of effective pain management. Nurs Times. 2004;100(3): Agency for Healthcare Research and Quality. Nurse bedside shift report (implementation handbook).

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