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The Greeley Company’s consulting model is intended to help hospitals and their affiliated Medical Staffs build and strengthen effective leadership and oversight processes. We teach and reinforce the Greeley Medical Staff Leadership Model and the Framework for Sustained Compliance to help hospitals attain and maintain lasting and value-driven improvements to safety, experience and efficiency.

We also recognize The Joint Commission’s role in establishing and reinforcing standards and improvement goals for issues that impact the lives of patients and providers. Therefore, it is understandable that the Commission would want to participate in a meaningful way to address the current opioid epidemic while assuring appropriate pain management for hospital patients. It is therefore with regret that we must strongly oppose the proposed revisions to Joint Commission standards related to pain assessment and management.

Our objections are on three levels:

  1. We believe that the Joint Commission should use tools other than standards to promote safe and effective practices that focus on narrow aspects of health care. New standards like these are not necessarily the way to make lasting change and improvement.
  2. Many of the proposed standards place an unrealistic burden on hospitals.
  3. If pain is in the spotlight today, which of the many other important challenges will be in the spotlight tomorrow?

Discussion: Standards vs. Aspirations

Healthcare organizations today have two tracks when it comes to certification and accreditation: 1. The staying in business track; and 2. The aspirations / goals track.

The “staying in business” track focuses on maintaining certification by the Centers for Medicare and Medicaid Services (“CMS”) as a hospital, critical access hospital or other provider / supplier. In other words, they must demonstrate continuous compliance with the Medicare Conditions of Participation. Joint Commission accreditation bestows deemed status, meaning that CMS judges that the survey and accreditation process yields Compliance with the CoPs. To maintain deeming authority the Joint Commission must assure that deviations from their core standards are promptly corrected: normally within 60 days of identification. Standards such as the proposed Pain Assessment and Management requirements are aspirational in nature, and hospitals will be very hard pressed to put a meaningful program in place within 60 days after a deficient program is identified. The proposed requirements instead will require a continued focus on pain management and opioid safety that spans more than a simple 60 cycle of correction. Addressing issues like this requires a marathon, not a sprint.

We encourage the Joint Commission to find other methods to address such issues. Perhaps an optional improvement award that can be added to the accreditation. This approach would align with the aspirations or goals track that is common across the industry. It is such tracks that stimulate improvements in the management of stroke, transplantation and congestive heart failure.

Discussion: Issues with Individual Proposed Elements of Performance

LD.04.04.01 EP.32

Improvement efforts should stem from internally-driven prioritization rather than external fiat. Such is the expectation of the Quality Assessment and Performance Improvement Standard in the Medicare Conditions of Participation. In the case of this proposed element of performance, the Joint Commission places itself in the position of the hospital governing body, assuming that this issue is among the most important the hospital faces. It is more likely that other challenges are of higher import and more appropriate for a formal improvement process; issues such as patient flow, falls reduction, continuity for patients with social needs, care of behavioral health care patients in locations without sufficient community resources, care of patients with diabetes, care of patients with S-T elongation myocardial infarctions, etc. Pain management and opioid management may rightfully be prominent on the list among these and other issues, but the selection of the most important issue must be left to the hospital, not an accreditation organization.

LD.04.05.17 EP.01

Like LD.04.04.01 EP.32, this requirement places the Joint Commission in the role of the governing body by making resource allocation decisions on its behalf. It also presumes that there are measurable and evidence based goals or data the hospital may use to serve as a goal for improvement, yet current literature suggests that this is not the case.

LD.04.05.17 EP.02

This standard is vague and eludes objective external evaluation. What is meant by “promote?” To some, it means grants for development, research, community-wide campaign and the like. To others it means posting a flyer of available resources in the lunch room.

LD.04.05.17 EP.03

Calling for additional resources for a particular topic again presumes that the Joint Commission is able to make difficult resource allocation decisions better than the governing body and leadership team. Furthermore, the subject matter (pain assessment, pain management and safe use of opiate medications) is vague and subject to interpretation. Although hospital nursing and other personnel are already required to be trained in pain assessment, trying to train or re-train licensed independent practitioners on the medical staff places the hospital in the role of a school of medicine. Likewise, instruction in pain management is teaching medicine rather than a hospital “competency.” Mechanisms such as the requirement for a pharmacist’s review of new orders are already in place to assure the safe use of opiates (and all other classes of medication).

LD.04.05.17 EP.04

This plan for measuring disparities in pain assessment and management is in conflict with the day to day reality of the healthcare industry. Few hospitals are capable of performing the type of research that would be required to detect such differences among subgroups in the population it serves. Data to detect these differences do not currently exist in hospital records and would need to be collected through extensive concurrent and retrospective studies. Even if such data were collected (at great expense) once, it is unlikely that ongoing studies would be feasible or suitable for objective improvement techniques.

LD.04.05.17 EP.05

This requirement already exists in the hospital standards related to discharge planning and patient / family education for all patients with ongoing healthcare needs. We see no justification for specifying one particular issue among the hundreds encountered in the routine care of hospital patients.

LD.04.05.17 EP.06

The hospital has an obligation to provide referral resources for all post-hospital medical needs, as do the individual practitioners on the medical staff who attend patients. This requirement does not add clarity or focus to these existing obligations.

LD.04.05.17 EP.07

We do not object to this requirement per se. However, we believe this to be an unwarranted highlight of these vs. other resources. What about other databases hospitals should be accessing? Why are these not called out specifically? The truth is that access to such data sources is already implied in Information Management and other standards.

LD.04.05.17 EP.08

Hospitals are required by CMS to monitor at-risk post-surgical patients who are receiving opioids. We do not object to the Joint Commission reflecting this requirement in their standards. However, the proposed requirement applies to any patient receiving opioids, and is broader than the CMS expectation. It is also vague as to which equipment is required. Pulse oximetry is typically available and frequently used. But perhaps the Joint Commission means to require equipment to monitor end-tidal carbon dioxide. The requirement is not clear. And, if the latter is intended, then much more data would be needed to justify placing such a burden of the healthcare industry.

MS.05.01.01 EP.18

We have no objection to requiring the medical staff to develop protocols and measure their effectiveness. However, the medical staff is an independent and self-governing entity … it is inappropriate (and technically impossible) for the hospital to impose requirements on physicians for one disease process over another. It would be different if the hospital had a choice to become “pain / opiate approved” or some similar designation. However, this proposal places pain ahead of any other disease process or treatment challenge by placing this as a requirement for core accreditation.

PC.01.02.07 Intent

Clinical practice guidelines, according to past Joint Commission standards and publications, are algorithms developed and approved by the medical staff. We are not aware of a guideline that is approved by a consensus within the medical community for pain management or opioid use. We are aware of opinions from various groups, but no consensus-based guidelines. If there is such a consensus, then we encourage the Joint Commission to point it out in the standard or other publications.

This is also a slippery slope: a slope the Joint Commission traversed more than a decade ago.

PC.01.02.07 EP.01

Having policies are fine requirements and common throughout the standards manual. However, we’re not aware of a consensus among the industry that is worthy of universal adoption. If there is such a standard, we encourage the Joint Commission to propose a “starred” requirement (a requirement that references another set of expectations, such a FGI or NFPA 101). It can then be better evaluated before adoption.

PC.01.02.07 EP.03

We support this requirement.

PC.01.02.07 EP.04

The requirement for an assessment of psychological factors that may pose a risk of opioid addiction is not supported by the literature; it is vague and un-implementable. We are not certain what the author means when it references psychological “risk factors.”

PC.01.02.07 EP.05

This requirement is subject to broad over-interpretation. Physicians typically try to discover the etiology of significant pain, especially if it’s among the things that brought the patient to the hospital. However, the proposed requirement does not establish a threshold and encroaches on the practice of medicine.

PC.01.02.07 EP.06

This requirement is vague and expansive. Does it apply to all pain? Scenario: a patient visits the emergency department and has a chronic pain in his left shoulder (self-report 3 of 10). This is not why the patient came to the ED. The emergency medicine physician is not concerned that it presents an emergency medical condition. Yet the standard would require the physician to develop a plan when none might be indicated.

PC.01.02.07 EP.07

Hospitals do not develop treatment plans. This falls under the practice of medicine and is the responsibility of privileged practitioners. The Joint Commission seems to be subjecting physicians to second guessing by surveyors and non-physician hospital personnel. “Was a given plan correct for a given patient based on available evidence and guidelines?” Although that might be a discussion for the peer review process in some instances, making a general requirement seems unjustified.

PC.01.02.07 EP.08

We do not object to this requirement, but also do not feel it is necessary since general care planning and patient education requirements already set these expectations.

PC.01.02.07 EP.09

We do not completely follow the intent of this requirement. Expectations already exist for documenting the results of pain interventions. Yet the Joint Commission seems to be requiring a specific set of new elements of routine documentation that are not always necessary (turning, deep breaths, etc.). Although such assessment documentation is appropriate in some instances, it is not called for in others (pain to left thumb). We also don’t know what is meant by risk factors for adverse events. If the Joint Commission intends to require enhanced monitoring for high-risk post-surgical patients receiving opioids, then the wording of that bullet should be improved.

In summary, this requirement should be at least clarified or, better, recognized as already covered by existing assessment and care planning expectations.

PC.01.02.07 EP.10

Some of the expectations in this EP are already required of outpatient pharmacies. Others (such as plan for pain management) are expansive and unclear.

PI.01.01.01 EP.56

Rather than specify the type of pain management data to be collected, we believe the Joint Commission would be better served to leave this up to the institution. Greeley deals with burdensome, non-communicative, “click based” nursing documentation systems on a daily basis. These systems can degrade communication among providers and obscure critical thinking. In our opinion this requirement would exacerbate this problem. It also places one more data collection and assessment task to quality departments that are already overburdened. Better would be to allow the hospital to allocate resources based on the prioritization of their own improvement imperatives.

PI.02.01.01 EP.18

Other than the emphasis of this issue over other equally-compelling data collection targets, we have no objection to this requirement.

PI.02.01.01 EP.19

We agree that the monitoring addressed in this EP is appropriate and useful. We are curious about including the duration of opiate prescriptions, however, since this again is the practice of medicine and typically outside episode of hospital care. Summary Thank you for the opportunity to comment. We agree that this is an important issue but urge the Joint Commission to deliberate further before imposing this particular set of requirements. We also urge that the Joint Commission develop methods other than additions to core accreditation standards to address issues of topical import: perhaps something like a “pain management approved” addition to a hospital’s accreditation.


We agree that this is an important issue but urge the Joint Commission to deliberate further before imposing this particular set of requirements. We also urge that the Joint Commission develop methods other than additions to core accreditation standards to address issues of topical import: perhaps something like a “pain management approved” addition to a hospital’s accreditation.

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