Quality Improvement Project to Improve Patient Satisfaction with Pain Management Using Human-Centered Design
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LWW/JNCQ JNCQ-D-15-00099 February 11, 2016 19:42 J Nurs Care Qual Vol. 31, No. 2, pp. 105–112 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, patient- centered 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 in- dividual 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, pain management, patient-centered care, patient satisfaction AIN MANAGEMENT is a basic human Numerous barriers to effective pain man- P right, and The Joint Commission stan- agement include cursory, inaccurate, or in- dards first implemented in 2001 sought sufficiently frequent assessments; ineffective to ensure uniform pain management and analgesic administration practices; and inef- assessment.1-3 However, pain management fective communication between nurses and continues to offer important quality im- patients and among nurses, particularly at provement (QI) opportunities. Recent Hos- shift change.5,6 Misinformation among health pital Consumer Assessment of Healthcare care providers about appropriate dosing and Providers and Systems (HCAHPS) data indi- route for opioid analgesics and unfounded cate that only 71% of US composite pain concerns about dependence contribute to management scores reflected optimal pain poor pain management.7,8 Patients may not management.4 understand pain management scales or be able to self-report discomfort.9,10 They may not request medication until pain is se- Author Affiliations: Kaiser Permanente Santa vere, which can occur on waking, and Clara Medical Center, Santa Clara, California may do so because of unfounded concerns (Ms Trail-Mahan); and Kaiser Permanente about dependency.8,11-13 Thorough pain as- Innovation Consultancy, Oakland, California (Mr Heisler and Ms Katica). sessment, timely reassessment after an anal- gesic intervention, and documentation of All funding was provided by Kaiser Permanente. both are all inconsistently performed among The authors declare no conflict of interest. postoperative patients.14 Equianalgesic dos- Correspondence: Tracy Trail-Mahan, MS, RN-BC, ing when transitioning patients from intra- Kaiser Permanente Santa Clara Medical Center, 710 Lawrence Expressway, Santa Clara, CA 95051 venous (IV) to oral routes of administration 15 ([email protected]). is pivotal. Removing multiple barriers to ef- Accepted for publication: September 5, 2015 fective pain management requires multimodal Published ahead of print: October 7, 2015 interventions that redesign nursing practice 16 DOI: 10.1097/NCQ.0000000000000161 patterns. 105 Copyright © 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. LWW/JNCQ JNCQ-D-15-00099 February 11, 2016 19:42 106 JOURNAL OF NURSING CARE QUALITY/APRIL-JUNE 2016 In 2009, Kaiser Permanente Northern and managers design and implement new California (KPNC) nurse leaders noted that ways to improve the care experiences of scores for patient satisfaction with pain man- patients and the work experiences of care agement in the first year of HCAHPS measure- providers.24 ment were between the 25th and 50th na- Human-centered design begins with in- tional percentiles, indicating a substantial QI depth observations and interviews that reveal opportunity in inpatient pain management. the existing state of experiences. The authors The aims of the QI project reported here were conducted interviews, observations, and fo- to develop a multifaceted, patient-centered cus groups with approximately 50 nurses on approach to improve inpatient pain manage- 2 medical/surgical units at 2 hospitals to iden- ment, implement it across 21 KPNC hospitals, tify existing issues with pain management; it and assess its impact on patient satisfaction, as became clear that some nurses were more measured by the HCAHPS pain management adept at pain management than others. In composite score. the next phase of observation, the nurse man- ager on a surgical unit identified 5 staff nurses METHODS perceived as pain management experts. Each identified nurse expert was observed and in- Setting terviewed by the Innovation Consultancy staff Northern California is 1 of 7 regions of over the course of a shift as they provided Kaiser Permanente, the largest not-for-profit patient care. integrated health care delivery system in the Human-centered design uses qualitative United States, serving 10.1 million members. data analysis strategies to understand obser- KPNC provides the entire spectrum of health vations and interviews. Inductive category care for 3.3 million members in settings that development in a narrative analysis frame- include 21 medical centers, with a total aver- work identified 6 themes related to pain age daily census exceeding 2200. KPNC has a management.25 r robust improvement structure in place.17 The Trust is key. Patients need reassurance experience of frontline nurses at routinely that nurses are proactively partnering conducting plan-do-study-act (PDSA) rapid im- with them to manage their pain and are provement cycles was a key organizational acutely aware of whether that is the case. r strength enabling the QI project.17,18 Already behind. Even when instructed to call at the first sign of pain, patients often Planning the intervention do not call for pain medication until their The core of the development process was pain is poorly controlled. human-centered design, which relies on a r Miscommunication. Patients often do thorough understanding of what people want not understand what nurses want when and need and has been used extensively to asked to describe their pain on a 0- to drive innovation in multiple industries, in- 10 scale. cluding health care.19-22 Human design begins r Morning agony. Patients can easily sleep with an empathetic exploration of user (in through their pain at night and find this case, nurses and patients) experiences, themselves in unnecessary pain in the which are synthesized into a deep understand- morning. ing of those experiences and definition of r Remembering to reassess. In the rush of the problem to be addressed. Solutions are nursing shifts, it can be difficult for nurses explored in the ideation, prototyping, and to remember to reevaluate patients and testing phases.23 Since 2003, the Kaiser Per- document their reassessment. manente Innovation Consultancy has used r The pills do not work. Patients often human-centered design methods and princi- lose faith in their oral pain medications ples to help patients, frontline care providers, because of perceived ineffectiveness. Copyright © 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. LWW/JNCQ JNCQ-D-15-00099 February 11, 2016 19:42 Patient Satisfaction With Pain Management 107 This can happen when patients are tran- Explore pain scale responses sitioned off IV pain medication and not Nurses may not fully understand patients’ given equianalgesic oral pain medication pain experiences, due, in part, to patients’ or consistent dosing patterns. knowledge deficits about describing pain. For The Kaiser Permanente Innovation Con- example, patients using a numerical rating sultancy team and a nursing pain manage- scale may select numbers based on a care- ment expert identified nursing practices that fully positioned resting state, although activity would address each theme. Discussion of causes discomfort. The objective of this prac- these findings with approximately 50 nurses tice is to ensure that nurses fully understand from 2 units at 2 medical centers over the patients’ experiences of pain. course of a month enabled nursing staff to After soliciting numerical pain ratings, build a shared understanding of challenges nurses ask additional questions about activi- in pain management and nursing practices ties of daily living or functional goals: What is that could mitigate them. These nurses subse- your pain level if you’re trying to shift your po- quently conducted multiple PDSA cycles, re- sition in bed or sit up? What is your pain level fining the identified nursing practices related if you’re walking to the bathroom? Similarly, to pain management into a bundle of 6 best nurses explore pain related to physical manip- nursing practices. ulation. For instance, a nurse may gently ma- nipulate the leg of a patient who underwent a KP Painscape practices knee replacement. Integrating a probing pain The best practices were collectively named scale response into each assessment, reassess- KP Painscape. The goal is a coordinated team ment, and shift-change report and communi- effort to help patients proactively manage cating results with physicians and other care pain. providers help ensure a similar shared assess- Prepare before entering patient room ment of patients’ pain levels. The objective of this practice is to as- sure patients that nurses know about their Use appropriate dose when recent medications, nonpharmacologic inter- transitioning from IV to oral pain ventions, and experiences with pain and medications