A Standardized Quality Assessment System to Evaluate Pain Detection and Management in the Nursing Home Mary P. Cadogan, DrPH, RN, GNP, John F. Schnelle, PhD, Nahla R. Al-Sammarrai, MS, Noriko Yamamoto-Mitani, PhD, RN, GNP, Georgina Cabrera, MSG, Dan Osterweil, MD, and Sandra F. Simmons, PhD Context: Assessment and management of pain for nursing home residents is frequently reported to be inadequate, yet few studies have used objective crite- ria to measure the quality of care related to pain. Objective: Field test a standardized resident interview and medical record review protocol to assess and score quality indicators relevant to pain. Design: Descriptive. Setting: Thirty nursing homes (NHs). Participants: Seven hundred ninety-four residents met overall eligibility criteria. Quality indicators were scored for those residents who met specific eligibility requirements for each pain indicator. Measurements: Medical record reviews were com- pleted for 542 participants, and data were used to score 12 indicators related to pain assessment, man- agement, and response to treatment. A seven-item pain interview was attempted with all 794 participants and completed with 478 participants who were rated by NH staff as cognitively aware. Results: Quality indicators could be reliably scored. Physicians scored low on assessment of pain, perform- ing targeted history and physical examinations, docu- menting risk factors for use of analgesics, and docu- menting response to treatment. Forty-eight percent of participants (227/478) reported symptoms of chronic pain during the interview, and 81% of this group re- ported a preference for a pain medication. However, nearly half had no physician assessment of pain in the past year and only 42% were receiving pain medica- tion. Licensed nurse assessments of pain were docu- mented weekly; but, more than 50% of those report- ing symptoms of chronic pain on interview had nurse pain scores of 0 for 4 consecutive weeks prior to inter- view. Conclusions: Infrequent or incomplete physician pain assessment and treatment and inaccurate documenta- tion by licensed nurses limits evaluation of pain care quality based on medical record review alone. A brief resident interview identified participants reporting symptoms of chronic pain not documented in the medical record and those with a preference for medi- cation. Initial targeting of residents with self-reported pain maximizes the efficiency of the standardized scoring system described in this study. Focusing on ex- plicit process measures clearly identifies areas for im- provement and represents an important step in assess- ing the quality of pain care in the NH. (J Am Med Dir Assoc 2006; 7: S11–S19) Keywords: Pain management; nursing homes; quality improvement Pain is a common and treatable condition among nursing home (NH) residents even though there is evidence that pain is often undetected and untreated in this population. 1–8 In response to this crisis, there is a nationwide effort to improve pain management in NHs through implementation of quality indicators. 9 These indicators focus on outcomes but do not include explicit direction for successfully achieving them. The key assessment and treatment processes that should guide a pain management program in the NH setting have been articulated in several practice guidelines. 10 –12 In addi- tion, process-oriented quality indicators have recently been de- veloped and validated with expert consensus methodology. 13 However, there have been no standardized evaluations of performance on these quality indicators. Thus, a gap remains in our understanding of how to target interventions for im- provement of pain assessment and management. The purpose Los Angeles Jewish Home for the Aging, UCLA Borun Center for Gerontologi- cal Research, Los Angeles, CA (M.P.C., J.F.S., N.R.A-S., N.Y-M., G.C., D.O., S.F.S.); UCLA School of Nursing, Los Angeles, CA (M.P.C.); UCLA Department of Med- icine, Division of Geriatrics, Los Angeles, CA (J.F.S., N.R.A-S., D.O., S.F.S.); Veterans Administration Hospital, Sepulveda, CA (J.F.S.). Address correspondence to Mary P. Cadogan, DrPH, RN, CGNP, UCLA School of Nursing, Factor 5-952, Box 956919, Los Angeles, CA 90095-6919.E-mail: mcadogan@ucla.edu Copyright ©2005 American Medical Directors Association DOI: 10.1016/j.jamda.2005.12.011 SUPPLEMENT Cadogan et al. S11