Table 2.
Extent of direct support from references for actionable standards
| Actionable standards | No of distinct components | Extent of support from references |
|---|---|---|
| PI.02.01.01, EP 19: The organization monitors the use of opioids to determine if they are being prescribed safely | 1 | Directly supported |
| PI.01.01.01, EP 40: The critical access hospital collects data on pain assessment and pain management, including types of interventions and effectiveness | 2 | Directly supported |
| PC.01.02.07, EP 7: Based on the patient’s condition, the organization reassesses and responds to the patient’s pain through the following: evaluation and documentation of responses to pain interventions; progress toward pain management goals, including functional ability | 7 | Directly supported |
| PC.01.02.07, EP 2: The critical access hospital screens patients for pain during emergency department visits and at the time of admission | 2 | Directly supported |
| LD.04.03.13, EP 6: The organization facilitates practitioner and pharmacist access to the Prescription Drug Monitoring Program databases | 2 | Directly supported |
| LD.04.03.13, EP 2: The critical access hospital provides non-drug pain treatment modalities | 1 | Directly supported |
| PC.01.02.07, EP 5: The organization involves patients in the pain management treatment planning process through the following: developing realistic expectations and measurable goals that are understood by the patient for the degree, duration, and reduction of pain; discussing the objectives used to evaluate treatment progress; providing education on pain management, treatment options, and safe use of opioid and non-opioid drugs when prescribed | 10 | Partly supported |
| PC.01.02.07, EP 4: The organization develops a pain treatment plan based on evidence based practices and the patient’s clinical condition, medical history, and pain management goals | 4 | Partly supported |
| MS.05.01.01, EP 18: The medical staff is actively involved in pain assessment, pain management, and safe opioid prescribing through the following: participating in the establishment of protocols and quality metrics; reviewing performance improvement data | 6 | Partly supported |
| LD.04.03.13, EP 4: The organization provides information to staff and licensed independent practitioners on available services for consultation and referral of patients with complex pain management needs | 4 | Partly supported |
| LD.04.03.13, EP 3: The organization provides staff and licensed independent practitioners with educational resources to improve pain assessment, pain management, and the safe use of opioid drugs based on the identified needs of its patient population | 5 | Partly supported |
| LD.04.03.13, EP 1: The organization has a leader or leadership team that is responsible for pain management and opioid prescribing and developing and monitoring performance improvement activities | 4 | Partly supported |
| PC.01.02.07, EP 8: The organization educates the patient and family on discharge plans related to pain management, including the following: pain management plan of care; side effects of pain management treatment; if applicable, activities of daily living, including the home environment, that might exacerbate pain or reduce effectiveness of the pain management plan of care, as well as strategies to address these issues; safe use, storage, and disposal of opioids when prescribed | 11 | Not supported |
| PC.01.02.07, EP 3: The organization treats the patient’s pain or refers the patient for treatment | 2 | Not supported |
| PC.01.02.07, EP 1: The organization has defined criteria to screen, assess, and reassess pain that are consistent with the patient’s age, condition, and ability to understand | 5 | Not supported |
| NPSG.01.01.01, EP 3: For newborn patients: Use distinct methods of identification for newborn patients | 1 | Not supported |
| PC.01.02.01, New EP 16: For critical access hospitals that provide obstetric services: if the mother tests positive for HIV, hepatitis B, group B streptococcus, or syphilis when tested in labor and during delivery, that information is also documented in the newborn’s medical record after delivery | 4 | Not supported |
| LD.04.03.13, EP 7: Critical access hospital leadership works with its clinical staff to identify and acquire the equipment needed to monitor patients who are at high risk for adverse outcomes from opioid treatment | 2 | Not supported |
| LD.04.03.13, EP 5: The critical access hospital identifies opioid treatment programs that can be used for patient referrals | 1 | Not supported |
| PI.02.01.01, EP 18: The critical access hospital analyzes data collected on pain assessment and pain management to identify areas that need change to increase safety and quality for patients | 2 | Not supported |
EP=element of performance.