NQF #0209 Pain Measure
Quality Indicator Data Collection, Recording and Calculation Protocol
Introduction:
Description of Quality Indicator
Outcome Measure:
Collection process:
How often reported:
Data Elements:
Benchmark or Target:
Pain Measure
Pain was brought to a comfortable level within 48 hours
of initial assessment after hospice admission
Percentage of patients whose pain was brought to a
comfortable level within 48 hours of initial hospice pain
assessment.
1. Every patient during the initial pain assessment
will be asked “Are you uncomfortable because
of pain?”
2. Each patient who answered “yes” to the above
question, will be contacted between 48 hours
and 72 hours (3rd day of admission) after initial
pain assessment to ensure accuracy of data
3. This contact can be by a clinician or nonclinician, in person or by telephone
4. RN completing the initial pain assessment and
the interviewer completing the follow-up
evaluation MUST determine that the patient is
able to understand the questions and reliably
self-report.
Data should be compiled monthly and reported
quarterly
1. Total number of patients admitted per
month/quarter
2. Numerator: patients who replied “yes” to the
question “was your pain brought to a comfortable
level (as defined by the patient) within 48 hours after
initial pain assessment.
3. Denominator
 Patients who replied “yes” when asked if
they are uncomfortable because of pain at
the initial pain assessment (after admission to
hospice)
No benchmarks available
Target to be determined based on first year data
Population included in the measure:
Inclusions:
Exclusions:
Patients able to self-report on service who are 18 years of age or older with length
of stay more than 2 days and with pain present on initial admission assessment.
All pediatric patients and adults with length of stay of 2 days or less and patients
without pain on initial admission assessment.
Data collection and recording procedures:
1. All admitting RN’s are responsible for obtaining the date on their admission pain
assessment.
2. All admitting RN’s are to report the initial positive screenings for pain to the
(determined by each agency) to ensure that the follow-up pain assessment is
completed 48 hours after the initial pain assessment.
3. The follow-up question must be asked no earlier than 48 hours after initial pain
assessment and no later than midnight of the third day after the initial pain
assessment.
4. Follow-up interviewer can be clinician or nonclinician. Contact can be in person or
by phone. (determined by each agency)
Data Variables – Categorical
Variable Name
1. Screened for pain (1)
Allowable values:
2. Date of first screening
Variable Question
Was patient screened for pain at any time during the initial
admission pain assessment?
Y
N
Unable to self report
Not documented
MM/DD/YYYY
3. Was patient uncomfortable or in pain?
Did the patient say yes to the question “Are you
uncomfortable because of pain?”
Allowable values:
Y
N
Unable to report
4. Pain Treatment
Allowable values:
If the patient screened positive, did the patient receive
pharmacological and/or nonpharmacological treatment
for pain?
Y
N
Not documented
5. Follow up assessment for patient’s responding yes to pain measure on initial assessment
Did the patient say “yes” to the question?
“Was your pain brought to a comfortable level within 48
hours?
Allowable values:
Y
N
Not documented—indicate reason; i.e.
 Discharged due to death
 Discharged alive
 Can no longer speak due to disease process
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6. Time frame for rescreening pain
Allowable values:
Was the patient contacted no earlier than 48 hours after
initial pain assessment and no later than midnight of the
third day after the initial pain assessment?
Y
N
Calculation of the quality indicators
Numerator: All patients who responded yes to the second question “Was your pain brought to a
comfortable level within 48 hours of the start of hospice care?
Denominator: Total number of patients who responded yes to the first question “Are you
uncomfortable because of pain?” on initial pain assessment after admission to hospice.
Formula: Numerator/Denominator x 100%
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