Specifications Manual for Joint Commission National Quality Measures (v2020A2)
Posted: 10/30/2019

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Measure Information Form
Version 2020A2

Measure Information Form

Measure Set: Palliative Care (PAL)

Set Measure ID: PAL-02

Performance Measure Name: Pain Assessment

Description: Proportion of palliative care patients who screened positive for pain during the palliative care initial encounter and received a clinical assessment of pain, which included at least five of seven components, within one (1) day of screening.

Rationale: As described from the University of Chapel Hill PEACE Measure Set project, pain is prevalent and undertreated for many populations of seriously ill patients, including those patients nearing the end of life. Poor screening, assessment, and undertreatment of pain is more common for patients with serious illness who are also of minority race ethnicity. Use of the Pain Screening and Pain Assessment quality measures will increase reporting and efforts to improve awareness of the presence of pain (screening) and assessment of severity, etiology and effect on function (assessment) which are the essential first steps required for quality pain management and treatment. The prevalence of pain ranges from 40-80% in seriously ill patient populations. As detailed in a systematic review from AHRQ and the American Pain Society Quality of Care guidelines, pain screening and assessment are the essential steps required to ensure that pain is detected by clinicians and appropriate treatment implemented. (Wells et al., 2008; Gordon et al. 2005; as cited by PEACE) Failure to screen, assess, and treat pain results in functional limitations, physiologic stress, and psychological harms such as social withdrawal and depression. The current quality of pain screening, assessment, and treatment is poor, as documented in systematic pain prevalence and treatment studies from hospital, outpatient, cancer and nursing home settings. (Reynolds et al., 2002; Deandria et al., 2008; Mularski et al., 2006; Erdek et al., 2004; as cited by PEACE) In a systematic review of quality of pain care for diverse patient populations, Gordon reported high average pain severity (6.17-8.37 on 10 point scale) and moderate rates of pain severity screening or other assessment (47%-96%). These findings did not vary by underlying diagnosis. (Gordon et al., 2002) (PEACE, 2015)

The National Consensus Project for Quality Palliative Care (2013) guidelines recommend that the interdisciplinary team assesses and manages pain in a safe and timely manner to a level acceptable to the patient or surrogate and that symptom assessment, treatment, side effect and treatment outcome information should be recorded in the medical record.

Type Of Measure: Process

Improvement Noted As: Increase in the rate

Numerator Statement: Patients who received a comprehensive clinical assessment, which included at least five of seven components, within one (1) day of screening positive for pain.
Included Populations: Not applicable

Excluded Populations: None

Data Elements:

Denominator Statement: Patients receiving specialty palliative care in an acute hospital setting who report pain when pain screening is done on the initial palliative care encounter.
Included Populations:

Excluded Populations:
  • Palliative care program length of stay less than 1 day

Data Elements:

Risk Adjustment: No.

Data Collection Approach: Retrospective data sources for required data elements include administrative/billing data and medical records. Some hospitals may prefer to gather data concurrently by identifying patients in the population of interest. This approach provides opportunities for improvement at the point of care/service. However, complete documentation includes the principal or other ICD-10CM/PCS diagnosis and procedure codes, which require retrospective data entry.

Data Accuracy: Variation may exist in the assignment of ICD-10CM/PCS codes; therefore, coding practices may require evaluation to ensure consistency.

Measure Analysis Suggestions: None

Sampling: Yes. Please refer to the measure set specific sampling requirements and for additional information see the Population and Sampling Specifications Section.

Data Reported As: Aggregate rate generated from count data reported as a proportion.

Selected References:
  • CMS Hospice Item Set, http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting/Hospice-Item-Set-HIS.html
  • Deandria S, Montanri M, Moja L et al. Prevalence of undertreatment of cancer pain: a review of published literature. Ann Oncol 2008; 19:1985-91.
  • Erdek MA, Pronovost PA. Improving assessment and treatment of pain in the critically ill. Int J Qual Health Care 2004; 16:59-64.
  • Gordon DB, Dahl JL, Miaskowski C et al. American Pain Society recommendations for improving the quality of acute and cancer pain management. Arch Intern Med 2005; 165:1574-1580.
  • Gordon DB, Pelliano TA, Miaskowski C et al. A 10-year review of quality improvement monitoring in pain management: recommendations for standardized outcome measures. Pain Manage Nurs 2002; 4:116-130.
  • Measuring What Matters, http://aahpm.org/quality/measuring-what-matters
  • Mularski R, White-Chu F, Overbay D et al. Measuring pain as the 5th vital sign does not improve quality of pain management. J Gen Intern Med 2006; 6:607-612.
  • National Consensus Project for Quality Palliative Care. Clinical Practice Guidelines for Quality Palliative Care. 3rd ed. Pittsburgh, PA: Author; 2013. http://www.nationalconsensusproject.org/NCP_Clinical_Practice_Guidelines_3rd_Edition.pdf
  • PEACE Hospice and Palliative Care Quality Measures, http://www.med.unc.edu/pcare/resources/PEACE-Quality-Measures
  • Reynolds K, Henderson M, Schulman A, Hanson LC. Needs of the dying in nursing homes. J Pall Med 2002; 5:895-901.
  • Wells N, Pasero C, McCaffery M. Improving the Quality of Care through Pain Assessment and Management. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Chapter 17.

Original Performance Measure Source / Developer:
American Academy of Hospice and Palliative Care (AAHPM) and Hospice and Palliative Nurses Association (HPNA) Measuring What Matters Project Top Ten Measures That Matter List
CMS Hospice Item Set
PEACE Hospice and Palliative Care Quality Measures Set

Measure Algorithm:

Measure Information Form PAL-02
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Specifications Manual for Joint Commission National Quality Measures (v2020A2)
Discharges 01-01-20 (1Q20) through 6-30-20 (2Q20)


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