Report 4 of the Council on Scientific Affairs (A-02)
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Resolution 814, introduced at the 2001 Annual Meeting by the Georgia Delegation and referred to the Board of Trustees, asks:

That the American Medical Association (AMA), with or without partnership with other Joint Commission on Accreditation of Healthcare Organizations (JCAHO) corporate members, appoint a committee or task force of regularly practicing health care professionals, including a multi-specialty panel of physicians, nurses and other mid-level practitioners, and administrators to objectively study and evaluate the efficacy to date of the new JCAHO Standard as it is currently being applied and identify who is responsible for its origins; and

That this task force be urged to report back to the AMA Board of Trustees at an early date so that the Board can formulate recommendations to the Joint Commission.

Resolution 819, introduced at the 2001 Interim Meeting by the Arkansas Delegation and referred to the Board of Trustees, asks:

That the AMA emphatically deny the implied ability to practice medicine by any entity other than physicians; and that the JCAHO be implored to evaluate the manner in which its Pain Standards for 2001 are being implemented; and that the AMA continue its work to preserve the sanctity of the physician-patient relationship.

Introduction

The JCAHO introduced pain management standards in July 2000, effective for accreditation surveys conducted after January 1, 2001. While the release of these standards generated much support in the professional literature, concern has been expressed by some physicians and other health care professionals regarding the appropriateness of the standards and the burdens of implementing new pain assessment and management procedures.

This report summarizes the JCAHO pain management standards and physician reactions to them; describes efforts that have been initiated to clarify the standards, to develop appropriate, evidence-based physician performance measures on pain management, and to improve physician education in pain management techniques; and addresses the issue of whether it is appropriate for the AMA to attempt to convene a special task force at this time.

The Council on Scientific Affairs (CSA) previously examined issues related to pain management in two reports; one of these focused on barriers to appropriate pain management in adults and the other evaluated the use of opioid analgesics in patients with chronic noncancer pain.^1,2

Methods

Literature searches were conducted in the PubMed/MEDLINE database for articles published between 2000 and 2002 using the search terms joint commission, pain, and standards. A search of JAMA and the AMA Archives journals was conducted using the terms joint commission and pain management. Articles were selected that provided physician and organizational perspectives on the JCAHO pain management standards. The JCAHO World Wide Web site and the National Guideline Clearinghouse^TM were also searched for relevant information. Personal correspondence and other communications between the AMA and JCAHO staff, AMA members, and constituent medical societies were consulted.

Background

The relief of suffering is universally acknowledged as a cardinal goal of the ethical and compassionate practice of medicine. Pain is a complex phenomenon for both the patient and caregiver, influenced by physiological and psychosocial factors. The challenges of clinical management are heightened by pain since it influences the interpersonal relationship between the patient and the physician. Physicians have an obligation to relieve pain and suffering and to promote the dignity and autonomy of patients in their care. This includes providing effective palliative treatment for dying patients even though it may foreseeably hasten death (Opinion E-2.20--Withholding or Withdrawing Life-Sustaining Medical Treatment, AMA Policy Database).

In July 2000, the JCAHO introduced pain management standards, to be integrated into the JCAHO accreditation standards for hospitals and other health care organizations (providing ambulatory care, behavioral health care, home health care, hospice, and long-term care) and effective January 1, 2001.^3,4 The new standards were added to six chapters (of a total of eleven chapters of required functions or activities) in each accreditation manual as follows:

Accompanying the pain management standards, the JCAHO also provided "examples of implementation" from organizations that had demonstrated successful pain assessment and management approaches, with the following cautionary note: "The Examples of Implementation provided are NOT standards nor are they required ways to meet a standard. They are only examples of how other organizations have successfully demonstrated compliance with a standard."¹ Joint Commission Resources, Inc., a subsidiary of the JCAHO, also separately published an overview of the pain management standards, along with the examples of implementation.

Results

Reaction in the professional literature to the release of the JCAHO pain management standards from physicians and other health care professionals has been varied. Among articles in the literature that critiqued the appropriateness and impact of the new standards, many have been highly supportive, hailing the new JCAHO standards as a valuable step toward broader implementation of guidelines and sustainable improvements in pain assessment and management.^5-8 Others express concerns related to challenges in implementation and JCAHO motives in introducing these standards.^9-10

Hansen¹¹ labels the pain management standards "flawed," expressing concern that mandating treatment of chronic nonmalignant pain may create pressure on physicians to prescribe opiates inappropriately, thereby putting patients with chronic pain at substantial risk for drug abuse and addiction. A JCAHO reply notes that the standards do not, in fact, recommend any specific pharmacologic or nonpharmacologic treatment for pain and do not advocate the use of any particular categories of drugs, including opioids.¹¹

Physician correspondence directed to the JCAHO Board of Commissioners in June 2001 and copied to the AMA Board of Trustees charges the JCAHO with the creation of a policy on pain management that inappropriately removes responsibility for aspects of patient care from the physician and grants it to the hospital.¹² This physician further suggests that the JCAHO Board of Commissioners is "practicing medicine without a license," to the detriment of the profession and the benefit of pharmaceutical companies, patients seeking to abuse prescription drugs, and others.

AMA staff has corresponded with JCAHO staff since July 2001 to ensure that physician concerns regarding the pain management standards, including the concerns described above and those articulated in Resolution 814 (A-01), are adequately communicated. In a series of written responses received since November 2001,¹³ the JCAHO offered the following observations and potential remedies:

• Much of the concern related to the pain management standards reflects a perception of burdensome requirements of compliance and related paperwork. Many of these perceptions stem from a misunderstanding of the actual requirements of the standards. Some portion of this misunderstanding results from the manner in which the JCAHO presented the standards.

• Although the standards themselves are straightforward, the "examples of implementation" that were intended to support the standards are often confused as representing actual requirements. The examples are offered for use at the discretion of the accredited organization, but they are often viewed as the exact means of implementation expected by the JCAHO. Although the JCAHO has attempted to dispel this misconception, many organizations continue to prepare for their accreditation visits by implementing the examples themselves.

• The JCAHO Standards Review Task Force, which systematically reviews standards and survey processes for all hospital standards, has suggested that the examples of implementation be removed from the JCAHO accreditation manuals to reduce the chances of misinterpretation.

• The JCAHO needs to clarify the actual requirements of the pain management standards and better inform hospitals and other accredited organizations of how the standards are being surveyed.
  
• Regarding the suggestion that the JCAHO is "practicing medicine," the JCAHO general counsel has reviewed the concerns expressed and has concluded that no language in any of the JCAHO pain management standards (nor in any other JCAHO standard) could support a charge that the JCAHO is practicing medicine under any state’s medical practice act.

• At the JCAHO annual Surveyor Conference held in January 2002, surveyors were instructed on acceptable means of implementing the pain management standards. Surveyors were also instructed to provide consultation to an organization if it was ascertained that a robust "pain management" program had been developed solely for JCAHO accreditation and was above and beyond the level thought adequate by the organization. Surveyors are expected to educate organizations about the intent of the pain standards and to advise them of the level of expectation set forth by these standards.
  
• Additional communications regarding the pain management standards are currently under discussion.

Subsequent to the correspondence described above, the AMA learned that Joint Commission Resources is offering a series of educational programs to provide physicians with a review of the JCAHO pain management standards and instruction in interpretation and implementation of the standards.

Given the clarifications noted above, and the initiatives and potential remedies proposed and implemented by the JCAHO, the CSA does not believe that the AMA should attempt to appoint a multidisciplinary committee or task force at this time. Rather, available resources may be better directed at improving physician education in pain management and developing a core set of evidence-based performance measures.

Education. Following the 2001 Annual Meeting, the AMA Board of Trustees received correspondence from the American Academy of Pain Medicine (AAPM), offering to work with the AMA in addressing concerns related to the JCAHO standards.¹⁴ The AAPM suggested that Resolution 814 (A-01) reflected not only misinterpretation of the pain management standards but also a pervasive lack of physician understanding of the appropriate management of pain disorders. The AAPM noted that it had already developed objectives and frameworks for pain management curricula for medical schools and residency programs and that it was working with the JCAHO to clarify the standards and to provide educational seminars for physicians.

In subsequent correspondence, the AAPM offered to work collaboratively with the CSA and provided a position statement on the importance of undergraduate medical education in pain management.¹⁵ The position statement proposes that pain medicine, end-of-life care, and palliative care be required elements of the core medical school curriculum, preferably taught in integrated multidisciplinary courses by designated faculty with training and experience in these disciplines. AMA Medical Education staff responded with an invitation to the AAPM to share materials related to its proposed medical school curricula,¹⁶ anticipating that the AMA Council on Medical Education will report on this topic at the 2002 Interim Meeting. The AAPM indicated that copies of the proposed curricula would be provided in the spring of 2002.

Performance Measures. In its consideration of Resolution 814 (A-01), Reference Committee H heard testimony on the ongoing collaboration between the AMA, the JCAHO, and the National Committee for Quality Assurance (NCQA) on development of integrated performance measurement sets for physicians, hospitals, and health plans. As noted in Board of Trustees Report 11 (A-01), the collaborating organizations had released the product of their first condition-specific project, Coordinated Performance Measurement for the Management of Adult Diabetes, in April 2001. Measures coordination work was also ongoing on two other clinical topics, cardiac care and pregnancy and neonatal care, with a tentative plan to also initiate work on measures for pain management.

In August 2001, the AMA, JCAHO, and NCQA signed an agreement to accept external, unrestricted funding for joint development of a core set of evidence-based performance measures for pain management. The performance measures will be validated through field testing in multiple settings of care. The funds for this project are being provided by Purdue Pharma, L.P. However, as reported in Board of Trustees Report 14 (I-01), control and responsibility for the design and content of the pain management project and ownership of all project results belong solely to the AMA, JCAHO, and NCQA. A subsequent announcement from the JCAHO,¹⁷ which is functioning as administrative center for this project, identifies cancer, back pain, and arthritis as the specific conditions for which pain management measures will be developed.

As of March 2002, the AMA, JCAHO, and NCQA have completed selection of members of the Pain Management Clinical Expert Panel that will lead the measures development process. AMA representation on the Clinical Expert Panel includes members of the AAPM as well as members of other relevant medical specialty societies, including the American Academy of Orthopaedic Surgeons and the American Academy of Family Physicians. A first meeting of the Clinical Expert Panel in April 2002 will include a review of pain management guidelines and an initial consideration of opportunities for measurement.

From the National Guidelines Clearinghouse and other sources, JCAHO staff is compiling a bibliography of clinical practice guidelines for initial review by the Pain Management Clinical Expert Panel. Sources for guidelines that are under consideration for the derivation of performance measures include:

• For cancer pain management: American Society of Anesthesiologists (ASA), Agency for Healthcare Research and Quality (AHRQ), National Comprehensive Cancer Network/American Cancer Society, and others ^18-22
• For management of low back problems/pain: American Academy of Orthopaedic Surgeons/North American Spine Society and AHRQ ^23,24
• For the management of rheumatoid arthritis and osteoarthritis: American College of Rheumatology ^25,26

Additionally, several guidelines on chronic pain, from the ASA, the American Geriatrics Society, and others, may be considered, although these guidelines do not pertain specifically to cancer, back pain, or arthritis.^27-30

Conclusions

Concerns about the interpretation and implementation of the JCAHO pain management standards have been appropriately communicated to the JCAHO. The CSA believes that the AMA should continue to monitor physicians’ concerns and perceptions and, through the JCAHO Board of Commissioners and staff liaisons, continue to relay this information to the JCAHO. The JCAHO has taken steps and is considering additional communications to clarify the pain standards; the AMA must encourage these efforts and offer assistance where appropriate. The JCAHO should be encouraged to either disseminate substantial additional clarification for the "examples of implementation" or eliminate them from the accreditation manuals and other publications that are creating confusion about their use.

The CSA does not believe that it is necessary for the AMA to appoint or convene a special committee or task force to evaluate the efficacy of the new JCAHO pain management standards. However, the JCAHO does need to continue to clarify, educate, and advise organizations, as necessary, about acceptable means of implementing the pain management standards.

Continued improvement is needed in undergraduate medical education on pain management. The AMA Council on Medical Education should collaborate with relevant medical specialty organizations, including the American Academy of Pain Medicine and other specialty organizations with pain management curricula, to improve undergraduate, graduate, and continuing education in pain management.

The AMA-JCAHO-NCQA project to develop evidence-based performance measures for pain management will reinforce the value of pain management education, will provide a means for physicians and organizations to assess and improve their pain management programs, and may facilitate understanding and implementation of the JCAHO pain management standards. The AMA should continue its support for this collaborative initiative.

RECOMMENDATIONS

The following statements, recommended by the Council on Scientific Affairs, were adopted by the AMA House of Delegates as AMA directives at the 2002 AMA Annual Meeting:

1. The AMA will continue to work with the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and encourage continued collaborative efforts between the JCAHO and relevant medical specialty organizations to clarify the JCAHO pain management standards and to identify and clarify sources of information that are contributing to misinterpretation of the standards.
2. The AMA, through the Council on Medical Education, will continue to work with relevant medical specialty organizations to improve education in pain management in medical schools, residency programs, and continuing medical education programs.
3. The AMA, with or without partnership with other Joint Commission on Accreditation of Healthcare Organizations (JCAHO) corporate members, will appoint a committee or task force of regularly practicing health care professionals, including a multi-specialty panel of physicians, nurses and other mid-level practitioners, and administrators to objectively study and evaluate the efficacy to date of the new JCAHO Standard as it is currently being applied and identify who is responsible for its origins; and that this task force be urged to report back to the AMA Board of Trustees at an early date so that the Board can formulate recommendations to the Joint Commission.
4. JCAHO should be encouraged to disseminate substantial additional clarification for the "examples of implementation" and eliminate them from the accreditation manuals and other publications.

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References

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