Enhancing Pain Management to Meet Accreditation Standards in a Large Healthcare System

A large academic healthcare system within the Mountain West identified opportunities to improve pain management practices. To address these issues a multimodal pain relief approach emphasizing non-opioid alternatives was implemented. This paper outlines the methods, results, and conclusions of a pain project aimed at improving pain management practices within this healthcare system. Methods: The project implemented new pain assessment tools and documentation expectations across the system, developed order sets based on a pain escalation pathway, and evaluated the effectiveness of these interventions. The project involved multiple departments and stakeholders including Nursing Quality, Information Technology, and clinical staff. Results: Improvements were observed in the correct placement of order sets, with accuracy increasing within two months post-implementation. While data on opioid usage is pending, there were notable improvements in inpatient pain assessment and reassessment rates, with several units meeting or exceeding the 95% goal. Conclusions: The pain project demonstrated significant progress in addressing pain management challenges and promoting evidence-based practices. The sustainability of interventions was supported by ongoing monitoring and staff education initiatives. The project underscores the potential for broader adoption of similar strategies to improve patient outcomes and reduce opioid-related harms. Further research is needed to assess long-term outcomes and optimize intervention strategies.