Pain Quality Improvement Overview Process

How to Initiate a Pain Quality Improvement Project Using Geriatric Pain Tools

This section has all the tools you need to initiate a quality improvement program at your nursing home. This document provides an overview of how to use the tools in this section.

The tools consist of:

There are six steps to get the program started:

  1. The first step is to use the Steps to QI Worksheets to establish the QI committee and committee processes. Follow the worksheets in alphabetical order and by the time you have filled in the last worksheet, you will have completed your first quality improvement project.
  2. Use the Facility Assessment Checklists to assess the status of your current pain management program in your facility. The checklists address the most important processes in a comprehensive pain management program including:
    * Assessment upon Admission/Readmission/Change of Condition
    * Care Plan that includes Older adult/Family Goals for Pain
    * Pain Treatment and Monitoring
    * Pain Reassessment
    * Pain Management
  3. Use one of the Recommended Pain QI Questions for your first few projects. In fact, the questions can be used sequentially to build a comprehensive program. The six questions listed also correspond to the six Pain Audit Checklists and the six data points in the Pain Data Tracking Tool.
    * Start with the first question, “Was an appropriate, comprehensive, and timely pain assessment for the older adult completed within 24 hours of admission?”
    * Complete the corresponding audit checklist.
    * Enter the data into the Pain Data Tracking Tool under the corresponding question for your baseline measurement.
    * The instructions to use the Pain Data Tracking Tool are on the first tab of the spreadsheet.
    * These three steps can be repeated with each of the Recommended Pain QI Questions.
  4. Use the Steps to Quality Improvement as needed as part of the overall performance improvement project. Share audit information resulting from the Pain Data Tracking Tool with staff and reinforce/reward achievements in improving pain practices.
  5. Make sure to implement an educational program (follow the Steps to Quality Improvement Worksheets) so that your staff understands the policy and procedures and the new/improved process related to the specific Pain QI Questions. For example: If the requirement is to complete a comprehensive pain assessment within 24 hours of admission, you want to audit if that is being done. If it is not, you should go through the Steps to QI worksheets to help determine “why” it is not being done and then educate the staff as you implement the revised program or process on pain assessments.
  6. Once you have implemented the QI program for timely admission pain assessments, continue weekly audits until the desired improvement is accomplished.



  • If you do not show improvement within 4-6 weeks, go back to the Steps to QI worksheets to determine “why” the goal was not met. You may need to revise another part of the process.
  • You should continue weekly audits until there is a predetermined level of sustainment (e.g. 95% of charts indicate compliance with the standard established by the committee). In other words, the staff should have integrated the new process into their daily work and should not miss completing a timely assessment.
  • At this point you might reduce the auditing to once a month and if sustainment is continued, further reduce the audits to quarterly and eventually to every six months.
  • Once you feel comfortable that the admission assessment is sustained, it is time to go on to the next QI question. Repeat the above steps for the next questions and so on until you have completed all six QI questions.
  • If your nursing home can sustain all six processes, you will have a good basic pain management program and can go on to some higher level performance improvement QI questions.

QI Pain Overview Process - PDF Version