Ask the Expert: What Is New in TJC's Pain Management Requirements?

May 2018 - Vol.15 No. 5 - Page #8

On January 1, 2018, The Joint Commission implemented new and revised pain assessment and management standards for its accredited hospitals. These requirements include the following new and revised components:

  • Establish a clinical leadership team
  • Actively engage medical staff and hospital leadership in improving pain assessment and management, including strategies for safe opioid prescribing and minimizing risks associated with opioid use
  • Provide non-pharmacological pain treatment modalities
  • Facilitate access to prescription drug monitoring programs (PDMPs)
  • Continue to promote the use of evidence-based practices in the development of pain treatment plans
  • Engage patients in treatment decisions about their pain management
  • Address patient education and engagement, including storage and disposal of opioids to prevent these medications from being stolen or misused by others
  • Facilitate referral of patients to treatment programs, when needed

Pharmacists should read and understand the new pain management requirements, which are available in their entirety on The Joint Commission website. Like all accreditation standards, they are directed to inform the accredited organization’s policies and procedures to improve patient care and safety. They do not recommend or direct specific assessment methods or clinical treatment strategies; these should be determined by the licensed practitioner.

Identify Pain Management Leaders

The concept of engaging leadership in the oversight of pain assessment, management, and safe opioid prescribing may be new for many organizations. Hospitals must determine the need for either a leader or leadership team that is responsible for pain management and safe opioid prescribing. An interdisciplinary/interprofessional team is recommended to discuss the approach that best supports the hospital’s processes and practices. The hospital must be able to articulate its strategies for identifying pain and ensuring safe opioid prescribing as organizational priorities.

The Joint Commission permits hospitals to establish their own policies and procedures. Before making a determination about what to include, the hospital may want to convene a group of clinicians who are involved in pain assessment, management, and safe opioid prescribing to discuss and revisit the organization’s approach to pain assessment and management. These clinicians may include members of the medical staff, nursing, pharmacists, and other clinical disciplines.

Pharmacists, as well as other clinicians who are involved in caring for the patient, should play a key role in these initiatives. Pharmacists can assist in determining drug efficacy, monitor interactions of multiple medications and their side effects, provide input to prescribers of opioid and non-opioid medications, and use their expertise to guide development of opioid safety practices and guidelines.

Multimodal Approach to Pain

The Joint Commission’s standards support a multimodal approach to pain and allow hospitals to determine what pharmacologic and non-pharmacologic treatment strategies they may offer. These may include the use of physical therapy, transcutaneous electrical nerve stimulation (TENS), cold therapy, localized heat, etc. If a specific treatment is not available, a patient may be referred to the outpatient setting.

Involve Patients in Treatment

Involving patients in decisions about their care has been a longstanding requirement of The Joint Commission. Together with the patient, physicians should discuss specific goals and establish realistic expectations related to pain reduction and functional improvement.

Identify and Monitor High-Risk Patients

The screening, assessment, treatment, and monitoring of at-risk patients begins with the physician’s assessment. Decisions regarding monitoring strategies should be made by the treating clinical team. High-risk patients include those with sleep apnea, as well as those receiving continuous intravenous opioids or on supplemental oxygen, among others. Be especially aware of the most dangerous adverse effects of opioid analgesics and respiratory depression.

Consider PDMPs

PDMPs, which aggregate prescribing and dispensing data submitted by pharmacies and dispensing practitioners, can be an effective tool for reducing prescription drug abuse and diversion. The Joint Commission does not mandate that organizations use PDMPs prior to prescribing an opioid due to the limitations of using current databases in many locations.

There is considerable variation among states in regard to administration, funding, software, substances monitored, notices to consumers, data collection intervals, and reporting structures.1,2 The success of these programs depends largely upon physicians’ awareness and use of them. Nonetheless, some states require querying the PDMP prior to opioid prescribing. It is important to note that hospitals are surveyed to assess compliance with their state’s law.

Performance-Improvement Activities

Facilities can begin to identify gaps by reviewing their current pain assessment and management practices (including both pharmacologic and non-pharmacologic approaches) and compare them against the current evidence-based guidelines.


The Joint Commission recommends that organizations review the American Pain Society Guideline on Management of Postoperative Pain,3 as well as other evidence-based guidelines of their choosing.

Clearly, it is critical to measure the effectiveness of any new standard. As such, The Joint Commission conducts an evaluation of the effectiveness of a standard by tracking and trending the types and numbers of received inquiries regarding the standard. The volume of inquiries that come into the Standards Interpretation Group for assistance with standards compliance is monitored. Note that standards-related questions may be submitted online by completing the submission form at


  1. Marco CA, et al. Ann Emerg Med. 2016;68(5):589-598.
  3. Chou R, et al. J Pain. 2016;17(2):131-157.

Phavinee Thongkhong-Park, PhD, RN, is an associate director in the Department of Standards and Survey Methods in the Division of Healthcare Quality Evaluation for The Joint Commission.


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