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TJC’s new pain management standards are effective January 1, 2018, for all hospitals including psychiatric hospitals. As the 2018 surveys unfold, we expect to see significant emphasis on these new requirements. The following is a summary of key provisions of the new JCAHO pain management standards.

Leadership Chapter

LD.04.03.13: Pain assessment and management standards for hospitals, including safe opioid prescribing, is identified as an organizational priority for the hospital. Specific requirements:

  • Identify a leader or leadership team responsible for pain management and safe opioid prescribing as well as PI activities.
  • Provide non-pharmacologic pain treatment modalities.
  • Provide staff/LIPs with educational resources to improve pain management and safe use of opioid medications.
  • Provide staff/LIPs with information re consultation and referral for patients with complex pain management needs.
  • Identify opioid treatment programs to be used for patient referrals.
  • Facilitate access to the Prescription Drug Monitoring Program database if available in your state.
  • Acquire the equipment needed to monitor patients at high risk for adverse outcomes from opioid treatment.

Medical Staff Chapter

MS.05.01.01 (New EP 18): The medical staff is actively involved in pain assessment, pain management, and safe opioid prescribing through the following:

  • Participating in the establishment of protocols and quality metrics
  • Reviewing PI data.

Provision of Care Chapter

PC.01.02.07: The hospital assesses and manages the patient’s pain and minimizes the risks associated with treatment. Specific requirments:

  • Define criteria to screen, assess, and reassess pain that are consistent with the patient’s age, condition, and ability to understand.
  • Screen patients for pain during ER visits and at time of admission.
  • Treat the patient’s pain or refer the patient for treatment.
  • Develop a pain treatment plan for the patient.
  • Involve patients in the pain management treatment planning process through the following:
    • Develop measurable goals (understood by the patient) for the reduction of pain.
    • Discuss how progress will be evaluated.
    • Provide education on pain management and safe use of opioid medications
  • Monitor patients at high risk for adverse outcomes related to opioid treatment.
  • Reassess and respond to the patient’s pain by documenting the following:
    • Response to pain interventions
    • Progress toward goals including functional ability
    • Side effects of treatment
    • Risk factors for adverse events.
  • Educate patient/family on discharge plans related to pain management including:
    • Pain management plan of care
    • Side effects
    • Activities of daily living that might exacerbate pain
    • Safe storage and disposal of opioids

Performance Improvement Chapter

PI.01.01.01 (New EP 56): The hospital collects data on pain assessment and management including types of interventions and effectiveness.

PI.02.01.01 (new EP 18): The hospital analyzes the data collected on pain assessment and management to identify areas that change to increase safety and quality for patients.

PI.02.01.01 (new EP 19): The hospital monitors the use of opioids to determine if they are being used safely (e.g. tracking adverse events such as respiratory depression, naloxone use, duration and does of opioid prescribing.)

TJC has indicated that surveyors will be evaluating compliance with these new JCAHO pain management standards via tracers, document review, staff interviews, and the Data Use system tracer. So, make sure your leadership team has developed a plan to address each of the new requirments and educate staff on these important pain assessment and management standards for hospitals.