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Cultivating Collaboration

2. Give Patients a Voice, Not a Number

Pain Management

Changing the conversation: Quality Improvement Specialist Brenda Gulliver asks pointed, specific questions to get to the heart of each patient’s pain experience.

Creating a multidisciplinary, patient-centered conversation about pain management

Margaret Pearce, our CNO, had a single and clear request: Bring patient satisfaction pain-care scores up by at least two percent. To make it happen, she gave three suggestions: involve all stakeholders on the team, conduct a thorough assessment of the problem and be creative with the solution. What she didn’t tell us was how to do it. And this gave us the freedom to reimagine and reinvent everything—most significantly, the 0–10 pain scale. “Bringing the whole pain experience to one number wasn’t accurate or meaningful,” says Brenda Gulliver, quality improvement specialist. “We didn’t completely value the pain scale, and we weren’t using it in our daily practice.” The question was what would be better?

To begin grappling with this question, we assembled a team of nurses, pharmacists, physicians, educators, advanced practice nurses and physical therapists from our hospital. At the same time, on the other side of our campus, two investigators at the Pain Research Center had been asking very similar questions. “When we learned about their work, we knew we wanted them on board with us right away,” says Brenda.

92nd percentile for pain care satisfaction

Did the staff do everything they could to help manage my pain? Prior to our pain management pilot, our hospital scored in the 45th percentile in Press Ganey on this question. One quarter later, after implementing our new assessment tool, our scores in the pilot units went up to the 92nd percentile in Press Ganey.

Take a multidimensional perspective

Gary Donaldson, director of our university’s Pain Research Center, was eager to join the project. Along with colleague Richard Chapman, he’d been working for years on the problem of how to advance the measurement of pain, both in theory and in practice. “By joining forces with the hospital project, we had an opportunity to put some of our thinking to the test in a meaningful context,” says Gary.  

“We created a community centered around a common goal. It was the perfect union of collaborative thoughts and ideas.”—Brenda Gulliver, Quality Improvement Specialist

While Gary and Richard brought years of research and knowledge of pain care literature to the project, our nurses, physicians, APRNs, educators and physical therapists brought the practical, hands-on expertise. Meanwhile, our pharmacists brought their comprehensive medication insight.

“We fearlessly put ourselves out there, made connections and found people who could help,” says Shantel Mullin, our clinical pharmacy manager and one of the pain management project leads. “There’s already a culture of collaboration in place here at the University of Utah, so it felt natural to open new lines of communication between departments, to benefit from each others’ expertise and to focus on shared wins for our patients.”

Create meaningful conversations

The team developed a series of pain-care questions designed to replace the 0–10 pain scale in the pilot project. The questions focused on getting a description of the pain and an understanding of the patient’s ability to function throughout the day. “The beauty of the project was that better communication about pain permitted objectively superior measurement, and better measurement led to improved pain management,” says Gary.

To make the most of the new model, nurses were instructed to ask the new pain care questions in a casual and natural manner, rather than using a strict checklist format. “Everything we did was an effort to move away from the drive-by pain assessment,” says Brenda.

Deborah Watkins, one of our clinical nurse educators, participated in the pilot and immediately reported excellent results. “Asking for a pain number is a closed question,” she says. “Asking a patient to describe their experience opens up a dialog, so that a therapeutic relationship can form. Patients thanked me for listening and caring, but I don’t think I was suddenly caring more. I just had the tools to communicate more effectively.”

Don’t just discuss, document

While the pain discussion with patients was purposefully casual, the documentation of their responses needed to be highly structured—so that pharmacists, physical therapists, physicians and anyone else involved in the patient’s pain care could access our latest pain assessments and use them to make better decisions about medications, treatments and interventions.

To make this possible, we brought IT experts into the project early, so they had time to think through our documentation needs. This allowed them to become true team players in our process, so they could create a fully realized, easy-to-use tool that integrated seamlessly with the hospital’s regular documentation workflow. “We couldn’t have done it without early and ongoing collaboration with our IT people,” says Brenda. “They were just as invested as our clinicians.”

Spark a revolution with us

Patients on all our pilot units can see how much we care about helping them heal and getting them home. And they are sharing the love with us too. In one quarter after starting the pain management pilot, our patient satisfaction pain care scores  leapt from the 45 percentile to the 92 percentile on the pilot units. Now the new pain management tool is in place throughout our system, and we’re just getting started.

After thoroughly working through the new pain management protocol at our own hospital, we believe that patients everywhere deserve to have their pain recognized sympathetically, evaluated thoughtfully and treated carefully. Brenda confidently asserts that our pain management initiative will have a ripple effect far beyond our own hospital walls, with nurses everywhere tossing out numbers in favor of conversations. “We hope this will be revolutionary on a national scale.”

Tell us how you are improving the conversation about pain at your hospital.