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The New JCAHO Pain

Standards: Implications
for Pain
Management Nurses
yyy Patricia H. Berry, PhD, RN, CRNH, CS, and
June L. Dahl, PhD

From the Pain Management

Improvement Group, Department of
Pharmacology, University of
Wisconsin-Madison Medical School,
Madison, WI.
Supported by a grant from the Robert
Wood Johnson Foundation (J.L.D.).
Address correspondence and reprint
requests to Patricia H. Berry, PhD, RN,
CRNH, CS, University of WisconsinMadison, 1300 University Ave, Room
4720, Madison, WI 53706.
2000 by the American Society of
Pain Management Nurses
doi: 10.1053/hm.2000.5833


The newly approved Joint Commission on Accreditation of Healthcare

Organizations (JCAHO) pain management standards present an important opportunity for widespread and sustainable improvement in
pain assessment and management. Unrelieved pain is a major, yet
avoidable, public health problem. Despite 20 years of work by educators, clinicians, and professional organizations and the publication of
clinical practice guidelines, there have been, at best, modest improvements in pain management practices. Multiple barriers found in the
health care system, and among health care professionals, patients,
and families, continue to impede progress. In August 1997 a collaborative project was initiated to integrate pain assessment and management into the standards, intent statements, and examples of implementation of JCAHOa rare opportunity to improve pain management in health care facilities throughout the country. After review by
multiple JCAHO committees and advisory groups and critique by an
expert panel, the JCAHO Board of Commissioners approved the revisions in May 1999. The revisions are published in the 2000 2001 standards manuals and will be effective January 1, 2001, for all patient
care organizations accredited by JCAHOambulatory care, behavioral
health, health care networks, home care, hospitals, long-term care,
and long-term care pharmacies. An evaluation of the impact of the
revisions is currently being completed, and education of the JCAHO
surveyors and health care professionals is underway. Nurses, especially those with expertise in pain management, are valuable resources as health care organizations change their pain assessment
and management processes to meet the new standards.
2000 by the American Society of Pain Management Nurses

The newly approved Joint Commission on Accreditation of Healthcare Organization (JCAHO) pain assessment and management standards present a rare and
important opportunity for widespread and sustainable improvement in how
pain is managed in the United States. Nurses, especially those with expertise in
Pain Management Nursing, Vol 1, No 1 (March), 2000: pp 3-12

Berry and Dahl

pain management, can be valuable assets in assisting

with improvements in an organizations pain assessment and management processes. This article provides
a review of the incidence and costs of uncontrolled
pain and the many reasons for its undertreatment, and
an explanation of the JCAHO standards development
process. In addition, implications for pain management nurses are discussed, including suggesting a process for building an institutional commitment to pain
management in any health care organization.


Unrelieved pain is a major, yet avoidable, public health
problem (Carr, Jacox, Chapman, Ferrell, Fields, Heidrich, Hester, Hill, Lipman, McGarvey, Miaskowski, Mulder, Payne, Schlecter, Shapiro, Smith, Tsou, & Vecchiarelli, 1992; Cleeland, Gonin, Hatfield, Edmondson,
Blum, Stewart, & Pandya, 1994; Jacox, Carr, Payne,
Berde, Breitbart, Cain, Chapman, Cleeland, Ferrell, Finley, Hester, Hill, Leak, Lipman, Logan, McCarvey, Mulder, Paice, Shapior, Siberstein, Smith, Stover, Tsou,
Vecchiarelli, & Weissman, 1994). Pain is the most
common reason people seek medical attention. Ironically, it continues to be undertreated despite the availability of effective drugs and other therapies. Several
studies document the incidence of uncontrolled pain.
Data from the Robert Wood Johnsonfunded SUPPORT study showed a high incidence of uncontrolled
pain (from 74% to 95%) in very ill and dying hospitalized adults despite planned interventions from nurses
to encourage physicians to attend to pain control
(SUPPORT Study Principle Investigators, 1995). Others have shown similar frequencies of uncontrolled
pain. Marks and Sachar (1973) first alerted health care
professionals to the undertreatment of pain. They
found a large discrepancy between the amount of
analgesic ordered and the amount actually administered to surgical patients, which resulted in significant
unrelieved pain. Other research documents a high
incidence of uncontrolled and severe pain in hospitals
(Donovan, Dillon, & McGuire, 1987; Oden, 1989; Sriwantanakul, Weis, Alloza, Kelvic, Weintraub, & Lasagna, 1983). Upward of 70% to 80% of people in longterm care facilities are estimated to have pain, with
75% reporting pain that interferes with day-to-day
functioning. Their pain is also often undertreated or
totally ignored in their treatment plans (Ferrell, Ferrell,
& Osterweil, 1990; Roy & Thomas, 1986; Sengstaken
& King, 1993; Bernabei, Gambassi, & Lapane, 1998).
Similarly, 50% to 80% of patients with cancer do not
receive adequate pain control, and many experience
severe pain that impacts their ability to perform the

basic activities of daily life (Bonica, 1985; Jacox et al,

1994). High levels of unrelieved pain also have been
documented in other health care settings, including
burn units (Atchison, Osgood, Carr, & Szyfelbein,
1991), outpatient clinics (Jacox et al, 1994; Foley,
1995), emergency departments (Todd, Samaroo, &
Hoffman, 1993), and pediatric units (Schlecter, 1989).
Although there are no studies documenting the incidence of unrelieved pain in home care settings, it is
reasonable to assume it is similar to that in other
settings (K.M. Stevenson, personal communication,
March 1999). Surprisingly, there is no research on the
adequacy of pain management in hospice patients
despite the fact that hospice is considered a leader in
end-of-life pain and symptom treatment.


Unrelieved pain has adverse physiological and psychological effects. Physiological consequences include
impaired gastrointestinal and pulmonary function
(Cousins, 1994; Sydow, 1988; Wattine, 1988); nausea
and dyspnea (Desbiens, Mueller-Rizner, Connors, &
Wenger, 1997); increased metabolic rate, including, in
the case of cancer, increased tumor growth and metastasis (Sklar & Anisman, 1979; Visintainer, Volpocelli, & Seligman, 1982); impaired immune response
(Keller, Weiss, Schliefer, Miller, & Stein, 1981); insomnia, delayed healing, increased blood clotting, loss of
appetite, and inability to walk or move about (Bendebba, Torgerson, & Long, 1997; Laudebslager, Ryan,
Drugan, Hyson, & Maier, 1983; Liebeskind, 1991; Liu,
Carpenter, & Neal, 1995; McCaffrey & Pasero, 1999;
Page, 1996). Indeed, impairment of upper extremity
joint function, because of pain, is a risk factor for
functional decline and increased dependency in older
adults (Hughs, Gibbs, Dunlop, Edelman, Singer, &
Chang, 1997). Psychological consequences of unrelieved pain include anxiety and depression (Casten,
Parmalee, Kleban, Lawton, & Katz, 1995; Heim & Oci,
1993), loss of enjoyment of life, inability to relate to
others, feelings of hopelessness and helplessness, and
even requests for physician-assisted suicide (Bendebba
et al, 1997; Foley, 1991; Liu et al, 1995; McCaffrey &
Pasero, 1999).
There is increasing and compelling evidence that
unrelieved acute pain is directly linked to subsequent
long-term pain problems, which further supports the
importance of and need for aggressive control of acute
pain (Dworkin, 1997; Katz, 1995). In one study, the
level of acute pain in elderly hospitalized adults was
strongly associated with later pain (Desbiens, MuellerRizner, Connors, Hamel, & Wenger, 1997). In addition, poor management of postthoracotomy pain was

New JCAHO Pain Standards

associated with long-term, chronic pain (Dworkin,

1997; Katz, Jackson, Kavanaugh, & Sandler, 1996).
Severe and uncontrolled acute pain is a risk factor for
phantom limb pain, postherpetic neuralgia, and
chronic back pain (Linton, 1997). In a study that examined risk factors for the development of chronic
pain in women after mastectomy for breast cancer, the
strongest predictor was the intensity of acute postoperative pain (Tasmuth, von Smitten, & Kalso, 1995).
Management of pain after a radical prostatectomy with
epidural analgesia decreased preoperative pain during
hospitalization and long after discharge, and was associated with increased activity levels after discharge
(Carr, 1998; Gottschalk, Smith, Jobes, Kennedy, Lally,
Noble, Grugan, Seifert, Cheung, Malkowicz, Gutsche,
& Wein, 1998). Although these findings call attention
to the importance of pain management during illness
and in the postoperative period, they also suggest that
appropriate and aggressive up front pain management would decrease the likelihood of future chronic
pain problems with attendant disability (Carr, 1998).
Pain also impacts markedly on family coping and
functioning, including increasing social isolation and
marital conflict, reducing sexual activity, and causing
feelings of anger, anxiety, resentment, and despondency among family members (Snelling, 1994). Differing perceptions about pain and its management among
patients and family members also can interfere with
optimal pain management (Taylor, Ferrell, Grant, &
Cheyney, 1993; Ferrell, Ferrell, Rhiner, & Grant,
1991). With health care increasingly administered on
an outpatient basis, the knowledge and support of
family and others are essential ingredients to optimal
pain management.
Inadequate management of pain and other symptoms not only decreases the quality of life; it also
creates a financial burden on the health care system
and on our society. Unrelieved pain costs millions of
dollars annually as a result of longer hospital stays,
rehospitalizations, and visits to outpatient clinics and
emergency rooms (Grant, Ferrell, Rivera, & Lee, 1995;
Sheehan, McKay, Ryan, Walsh, & OKeffe, 1996). Furthermore, patients who are unable to work because of
pain increase the cost of disability programs. Persons
with uncontrolled pain may not only lose income but
also access to insurance coverage (Latham & Davis,
There is evidence that adequate pain management will indeed save precious health care dollars and
resources. In addition to preventing the development
of chronic pain problems in some patients and reducing the number of readmissions for uncontrolled pain,
hospital stays can be shortened and pain can be suc-

cessfully managed at home (Ferrell, 1993; Ferrell &

Griffith, 1994).
Health care provider liability for undertreatment
and mismanagement of pain may emerge as an important future issue (Shapiro, 1996). A family of a nursing
home resident was awarded 15 million dollars in early
1991 because the nursing staff, despite appropriate
physician orders, refused to provide adequate pain
management, largely owing to a lack of knowledge
about pain treatment and erroneous perceptions regarding addiction (Pain Control: A Case of Negligence,
1991; Cushing, 1992). The Georgia Supreme Court
affirmed a patients right to refuse medical treatment
as well as the right to be provided adequate comfort
care, including pain management (State v. McAfee,


Multiple studies show that many health care professionals lack the knowledge and skills to manage pain
effectively (Brunier, Carson, & Harrison, 1995; Drayer,
Henderson, Reidenberg, 1999; Ferrell, McGuire, &
Donovan, 1993; Gibbs, 1995; Levin, Berry, & Leiter,
1997; McCaffrey & Thorpe, 1989). Health care professionals also have inaccurate and exaggerated concerns
about addiction, tolerance, respiratory depression, and
other opioid side effects, which lead them to be extremely cautious about the use of these drugs (Brunier
et al., 1995; McCaffrey, Ferrell, ONeil-Page, Lester, &
Ferrell, 1993; Von Roenn, Cleeland, Gonin, Hatfield, &
Pandya, 1993; Vortherms, Ryan, & Ward, 1992). Education, although important, has been insufficient to
effect practice change (Max, 1990; Greco & Eisenberg,
Patients and the general public share these concerns about opioids. Americans would rather bear pain
than take actions to relieve it, fearing addiction, side
effects of medications, and dependence on drugs.
Likewise, many persons fear tolerance and believe
strong medications should be saved until they are
really needed (Bostrom, 1997). Many people believe
pain is a necessary part of life (Fins, 1997). Patients
may be reluctant to challenge a health care provider
who says, There is nothing I can do about your pain,
because they view pain as an inevitable part of life.
Finally, many people believe good patients do not
complain (Levin, Cleeland, & Dar, 1985; Ward, Goldberg, Miller-McCauley, Mueller, Nolan, Pawlik-Plank,
Robbins, & Stormoen, 1993).
Although health care professionals as well as patients may create formidable impediments, traditional
patterns of professional practice may be the most
intractable barriers to effective pain management. The

FIGURE 1. y Also called a shbone diagram, an Ishikawa diagram is used as a tool to map out factors thought to affect
a problem or desired outcome. (Copyright, 2000, University of Wisconsin Board of Regents, used with permission.)

New JCAHO Pain Standards

failure of staff to routinely assess and document pain,

the lack of access to practical treatment protocols, and
the common view that pain is an expected and insignificant symptom continue to impede progress. Health
care organizations and institutions must address these
barriers in their practice settings to ensure that all
patients receive quality pain management. The resulting improvements in functional status and quality of
life can prevent needless suffering and reduce the
financial burden that unrelieved pain imposes on the
health care system and society as a whole. An Ishikawa
(fishbone) diagram (see Figure 1) provides a visual
summary of the barriers to adequate pain management.
Although at first glance improving pain management may require increased staff and time, we have
found otherwise from interacting with organizations
successful in this field. For example, St. Clare Hospital
and Health Services, in Baraboo, Wisconsin, with an
average census of 40 patients, initiated a pain management improvement program in the early 1990s as part
of their organizations performance improvement activities. Through interdisciplinary efforts, they have
documented improvements in the frequency and quality of pain assessment on admission and throughout
the hospital stay; the reduction of the use of meperidine and the use of the intramuscular route for pain;
and increased use of patient-controlled analgesia, intrathecal administration of medications for women in
labor, and dorsal blocks for circumcisions (P. Felland,
personal communication, September 1999). Other organizations report minimal financial outlay to effect
organization-wide change (J. Loeb, personal communication, 1999; P. Tanabe, personal communication,
October 1999). More research is ongoingand desperately neededto further show the cost effectiveness of quality pain assessment and management.


Undertreatment of pain persists despite nearly 3 decades of efforts to educate health care clinicians, patients, and the public about pain and its treatment. The
tools to relieve most, if not all, pain have been available for many years. During the past 20 years, many
educators, clinicians, and professional organizations
have dedicated themselves to improving the management of pain (American Pain Society Quality of Care
Committee, 1995; Fox, 1997). As the investigators in
the SUPPORT study concluded, more proactive and
forceful measures may be needed to improve care of
seriously ill and dying patients (SUPPORT Study Principle Investigators, 1995). A change in the JCAHO

The Institutionalizing Pain Management
Projects Other Pain Management
Improvement Initiatives
Implementation of a national quality improvement
program focused on acute postoperative pain
Development and implementation of pain quality
improvement programs with home health agencies in
Wisconsin. After completion of the Wisconsin
programs, the programs will be for national
A set of eight videotapes, directed primarily to home
health nurses, each 10 to 15 minutes in length,
focusing on pain assessment and management skills.
Copies of these tapes will be given to the agencies
participating in the home health care project and sold
at cost to others.

standards and other enforceable guidelines to include

pain assessment and treatment would indeed be the
measure needed.
In August 1997, the Robert Wood Johnson Foundation provided support for a 3-year project whose
overall goal is to make pain assessment and treatment
an integral part of the nations health care system. An
important part of this project was to integrate pain
assessment and management into the standards that
JCAHO uses to accredit health care facilities. The other
three project initiatives are summarized in Table 1.
The project presented a unique and rare opportunity
to effect sustainable systemwide change in pain management practices in all care settings. At the same
time, we entered into a collaborative project with the
JCAHO Department of Standards to integrate pain assessment and management for all patients into their
standards, intent statements, examples of implementation, and survey process questions.
Collaborating with the JCAHO seemed an efficient and logical way to impact on pain assessment
and management practices in the U.S. health care
system. The Joint Commissions mission is to improve
the quality of care provided to the public by offering
health care accreditation and related services that support performance improvement in health care organizations. According to JCAHO documents,
the Joint Commission has comprehensive quality review
programs for hospitals, health plans, home care agencies,
laboratories, behavioral health care settings, long term
care facilities, ambulatory care clinics, and networks of
services that can, and often do, serve as an alternative to
state and federal inspection of these organizations. In fact,
the Joint Commissions Hospital, Home Care, and Labora-

Berry and Dahl

tory Accreditation Programs are recognized by the federal

Health Care Financing Administration (HCFA) as meeting
or exceeding the federal quality standards for these organizations. Thus many of these organizations are able to use
their Joint Commission accreditation to obtain Medicare
certification through a process known as deemed status.
Similar reliance for licensure purposes exists for hospitals
and other types of provider organizations in most states
(Joint Commission on Accreditation of Healthcare Organizations, 1999).

After over 2 years of working with the Department of Standards staff in justifying the need, reviewing and summarizing the relevant literature, preparing
draft standards language, intent statements, and examples of implementation, and assisting in the presentations to the various advisory and decision making committees, the revisions received approval of the JCAHO
Board of Commissioners in May 1999. The standards
are published in the 2000 2001 manuals for ambulatory care, behavioral health, health care networks,
home care, hospitals, long-term care, and long-term
care pharmacies and will most likely be scored for
compliance beginning with the 2001 health care organization surveys.
The new standards require all organizations to:
Recognize the right of patients to appropriate assessment and management of their pain;
Identify patients with pain in an initial screening assessment;
Perform a more comprehensive pain assessment when
pain is identified;
Record the results of the assessment in a way that
facilitates regular reassessment and follow-up;
Educate relevant providers in pain assessment and management;
Determine and assure staff competency in pain assessment and management;
Address pain assessment and management in the orientation of all new staff;
Establish policies and procedures that support appropriate prescription or ordering of effective pain medications;
Ensure that pain does not interfere with participation in
Educate patients and their families about the importance of effective pain management;
Address patient needs for symptom management in the
discharge planning process; and
Collect data to monitor the appropriateness and effectiveness of pain management.

An example of the standards, intent statements,

and examples of implementation are found in Table 2.
All of the new standards are posted on the Joint Commissions Web site at, by selecting

pain assessment and management under the top

spots drop-down menu. Questions about the new
standards can be directed to JCAHOs Standards Interpretation Unit at (630)792-5900 (E-mail
We are now collaborating with the Department of
Education Programs and the Department of Publications
to educate surveyors, accredited health care organizations, and health care professionals from all disciplines
about pain and the new pain standards. In addition, these
educational programs and materials also describe how to
institutionalize pain assessment and management practices into an organizations daily care processes. Institutionalizing pain assessment and management into the
fabric of an organization is especially important because this is the intent of the new standards. Finally, we
will complete an evaluation of the impact of the standards revisions and summarize our project, a process we
estimate will take until August 2001.


Nurses, especially those with expertise in pain management, are often called on to become the champions
or lead the pain management improvement efforts in
an organization. Knowledge of pain management,
along with knowledge of the organization, excellent
oral and written communication skills, good interpersonal skills, patience and persistence, flexibility, and a
commitment to promoting pain management as part
of a generalist practice rather than solely as a specialist
skill are critical attributes (Gordon, Dahl, & Stevenson,
1996). Consider offering your expertise to your organization as they consider the new pain standards and
the organizational changes necessary to meet them.

Education alone does not change practice. Indeed,
traditional patterns of professional practice may be the
most intractable barriers to effective pain management, including the failure of staff to routinely assess
and document pain, the lack of access to practical
treatment protocols, and the common view that pain
is an expected and insignificant symptom. Health care
organizations and institutions must address these barriers in their practice settings to ensure that all patients receive quality pain management. One way to
approach these barriers is to institutionalize pain
management practices defined as incorporating basic
principles of pain assessment and treatment into pat-

New JCAHO Pain Standards

1999-2000 Comprehensive Accreditation Manual for Hospitals (CAMH) Assessment of
Patients Chapter

Table Unavailable.
Please See Print Journal.

terns of daily practice including documentation systems, policies and procedures, standards of practice,
orientation and continuing education programs, and
quality improvement programs; or, in other words,
weaving standards of pain management into the fabric of the organization.
Although the process of institutionalizing pain
management may vary from one setting to another,
the basic steps to ensure high quality, sustainable,
and cost-effective improvements in pain management for all patients, clients, and/or residents are
the same. Also keep in mind that changing institutional practices is a continuous, and often slow and

laborious process. Successful efforts, however, that

produce interdisciplinary collaboration, long-lasting
change, and most importantly, improvements in the
quality of pain management, are well worth the
The following eight steps to institutionalizing
pain management are listed below (Gordon et al.,
1996). They are patterned after the work of the American Pain Society Quality of Care Committee (1995)
Quality improvement guidelines for the treatment of
acute pain and cancer pain. Both served as a guide for
the development of the new JCAHO pain assessment
and management standards.


Berry and Dahl

1. Develop an interdisciplinary work group. An interdisciplinary approachand buy-inis essential to

change an organizations practice patterns. Invite members from all disciplines that have pain management in
their practice responsibilities, including nursing, medicine, pharmacy, as well as representatives from administration. Invite those people who may be the most
resistant to change. Consider also including patient and
family representation whenever possible.
2. Analyze current pain management practices in your
care setting. An individualized organizational analysis is essential to assure buy-in from all involved and
clearly differentiate between actual organizational
needs and individual interests. In addition, having
data relevant to only the organization brings the
issue and the problem close to home. Data related
to the cost of unrelieved pain to the organization is
especially powerful. Use Continuous Quality Improvement (CQI) principles, including root cause
analysis, to gather data to understand the process
and discover opportunities for improvement. Gather
data with the goal of using it in the future for comparison.
3. Articulate and implement a standard of practice. The
goal is to make pain visible in the organization. Establish a standard for the assessment of pain, including
guidelines to assist clinicians in making decisions about
how follow-up is performed. In addition, determine the
method of assessment in which pain assessment is
documented, and how and when it is communicated
among health care professionals and care settings. Finally, develop specific policies/resources to guide the
use of specialized techniques for drug administration
(e.g., the spinal and parenteral routes).
4. Establish accountability for quality pain management.
Keep in mind that lack of accountability for pain management is one of the major barriers to quality pain
management. Competency assessments regarding pain
assessment and management and inclusion in performance evaluations, practice standards, position descriptions, and policies and procedures assigns accountability and ensures that pain assessment and management is not just a specialty service, but rather
everyones responsibility who cares for patients in the
5. Provide information about pharmacological and nonpharmacological interventions to clinicians to facilitate
order writing, interpretation, and implementation of
orders. There are multiple resources available for cliniciansincluding the Agency for Healthcare Research
and Quality and Research Clinical Practice Guidelines
for acute and cancer pain, the American Pain Society
Sickle Cell Guidelines, and countless algorithms, pro-

tocols, pocket guides, and clinical pathways. Provide

information and education relevant to the bedside caregiverwhere clinicians need, and use it, the most.
6. Promise patients a quick response to their reports of
pain. As discussed earlier, patients and families have
low expectations regarding pain and pain relief. Including a commitment to pain management in an organization mission statement and the patient bill of rights
sends a strong message about the promise of adequate
pain management. In addition, educating patients and
families about why pain management is an important
part of their care, that their reporting pain is essential
to good pain management, how to use a pain rating
scale, and what are realistic and desirable pain relief
goals with attention to cultural and language variables
is also necessary.
7. Provide education for staff. Although education alone
does not change practice, it is still an essential part of
institutional change. Including pain assessment and
management in orientation and continuing education
programs, case presentations, pain rounds, and developing pain resource nurses are some ways to provide
education for staff. Education requires careful planning, including the use and incorporation of the principles of adult education, and should also support the
institutional change process.
8. Continually evaluate and work to improve the quality
of pain management. No improvement effort or change
is complete without an evaluation that then feeds back
into the organizations CQI process. There are multiple
ways to accomplish thisthrough use of the American
Pain Society Patient Survey (American Pain Society
Quality of Care Committee, 1995), medical record review, review of costs associated with pain management, and readmissions for uncontrolled pain, and
drug use reviews.

The costs of uncontrolled pain are momentousin
human, economic, and psychosocial terms. Everyone,
regardless of diagnosis, should expect and receive
appropriate pain management. The new JCAHO standards are an important first step in making this, until
now, unrealistic dream a reality.

The authors acknowledge the valuable contributions
of Debra B. Gordon, MS, RN, and the JCAHO Department Standards staff.

New JCAHO Pain Standards

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