Background: Pain assessment is a crucial step and can be a key performance indicator (KPI) in healthcare
and effective pain management for patients. In this study, we investigated the effectiveness of a quality
improvement (QI) initiative using the Plan-Do-Check-Act (PDCA) model to enhance the rate and quality
of pain assessments in hospitalized patients after medication administration.
Method: In our study, the KPI of pain assessment was the percentage of hospitalized patients who had
a pain scale record within 30 minutes after receiving injectable analgesics as per physician orders (both
STAT and PRN). The percentage was very low (7.87%) during 2020.07–2021.06, and the pain care team
used the root cause analysis (RCA) to identify the major causes in low percentage. According to RCA, we
applied PDCA model into QI in pain assessment.
Results: The implementation of PDCA model led to signifi cant improvements in pain assessment rates,
increasing from an initial 7.87% to 48.74% after the fi rst phase and to 70.49% in the ongoing phase (P <
0.001). Different types of wards demonstrated a signifi cant improvement trend over time (P for trend <
0.001), with surgical wards exhibiting the most notable effectiveness among all ward types.
Conclusion: The application of the PDCA model effectively improved pain assessment rates. This QI
strategy is feasible for other healthcare indicators, aiming to improve overall hospital care quality.

Keywords: pain assessment, PDCA, quality improvement, RCA

Quality of medical care is one of the key performance indicators (KPIs) in healthcare management [1]. To provide patients with effective pain management, pain assessment is a crucial step [2]. Pain not only causes patients’ physical discomfort but also affects their psychological well-being. Improper pain management can lead to negative impacts on patients, their families, and even the hospital [2]. Hence, healthcare professionals need to regularly assess and document patients’ pain severities, and provide appropriate medical care after assessment. An increasing number of studies are utilizing electronic medical records (EMRs) to improve pain monitoring, management, and the quality of care [3]. However, effectively managing and maintaining good KPIs is a topic that healthcare teams need to deeply contemplate by properly using EMR.

The Plan-Do-Check-Act (PDCA) cycle is a tool for improving quality management. It operates based on four steps: P (Plan) —Identify the root causes of the problem and formulate improvement strategies. D (Do) —Take action based on the plan. C (Check) —Evaluate the results of plan execution, confirm the effectiveness of the actions taken, and identify any issues. A (Act) —Make adjustments and corrections for the identified issues in the checking phase. The PDCA cycle is widely applied in various fields for quality control, such as manufacturing and healthcare management [4-6]. While there have been few studies in the past that applied the PDCA model to quality management in pain assessment, many researchers have effectively used this model to continuously improve the quality of hospital care management [1,6]. Therefore, this study aimed to investigate whether the PDCA cycle can be applied to improve the quality management of pain assessment in hospitalized patients.

The pain assessment indicator as a KPI in this study referred to the percentage of hospitalized patients who had a pain scale record within 30 minutes after receiving injectable analgesics as per physician orders (both STAT and PRN). The numerator/denominator = the number of patients with pain assessment records within 30 minutes after medication within the denominator population/the number of hospitalized patients who received STAT and PRN injectable analgesics. From July 2020 to early 2021, it was discovered that the rate of pain assessments recorded within 30 minutes (inclusive) after medication rates was less than 10%. Subsequently, the pain care team initiated a quality improvement (QI) plan targeting the aforementioned indicator. Using a root cause analysis (RCA) diagram, root causes for the low rate were identified. After discussion, four main dimensions were concluded: processes, education and training, workload, and policy (Figure 1).

The blame was attributed to the heavy workload of nursing staff, irregular monitoring of pain assessment recording status, incomplete reporting process for pain assessment records, and lack of integration between medication administration and recording processes. Additionally, the system lacked a reminder mechanism for reporting after injectable analgesics are administered, often resulting in a failure to record the patient pain condition. In summary, these various factors could contribute to frequent lapses in documenting patients’ pain conditions, thereby lowering the rate of pain assessment records and subsequently affecting the quality of pain care.

Based on the aforementioned four identified causal factors from RCA, the PDCA model was applied to improve the quality management of pain assessment for hospitalized patients (Table 1). Following discussions within the pain care team, the EMR system of a hospital for pain management and assessment processes was streamlined. The team also conducted regular discussions and monitoring of the indicators to achieve the improvement in KPI in this study. By integrating the medication administration platform, pain assessment platform, and nursing records platform within the EMR, pain assessment could be seamlessly conducted before, during, and after medication administration. Additionally, a reminder mechanism for pain assessment within 30 minutes after medication administration was implemented in the EMR system.

Figure 1. The Root Cause Analysis Chart
Factors contributing to the low rate of pain assessment record after medication administration. The main factors are highlighted in red circles.

Table 1. Plan-Do-Check-Act Strategy for Improving Pain Assessment Record Rates

We believe that integrating medication and assessment records within a single platform and reminder mechanisms can expedite the documentation process and improve compliance of execution. Although the modification of the EMR system was hospital-wide, we initially chose a demonstration ward to execute the plan. After a month of implementation in June 2021, the KPI achievement rate increased from 5.4% to 66.4%. Following team discussions, the plan was implemented hospital-wide in July 2021.

Since the initiation of the QI plan by the pain care team in 2021, monthly monitoring and tracking of the KPI have been conducted. The results of KPI execution are communicated to various units, and ongoing education and training were also provided. Statistical data has been tracked from July 2020 to June 2023 for outcome analysis, divided into three phases: Pre-PDCA Implementation (July 2020– June 2021), Post-PDCA Implementation (July 2021–June 2022), and Continuous Tracking (July 2022–June 2023).

Additionally, we categorized the wards into four major types: internal medical wards, surgical wards, internal medical, and surgical intensive care units (ICUs). We then compared whether there were differences in the effectiveness of the pain assessment QI plans among these four types of wards.

Three analysis methods were employed for statistical analysis. Independent t-test: using June 2021 (when the QI plan was initiated) as a cutoff point, the data was divided into two groups: the first half of the year and the second half of the year. This test was conducted to examine whether there was a significant improvement in pain assessment before and after implementation across the entire hospital; Cochran-Armitage test for trend: this test was used to evaluate whether there was a significant trend in pain assessment record rates in both the entire hospital and the four types of wards, across the three identified phases;Linear regression: it was employed to investigate the impact of different wards (with internal medicine ward as the reference group) and different phases (with the period before implementation from July 2020 to June 2021 as the reference group) on the pain assessment rate.

The results of the implementation of the QI plan across the entire hospital, with June 2021 as the cutoff point revealed a significant improvement in the proportion of inpatients assessed for pain within 30 minutes after medication administration (P for change < 0.001) (Figure 2). This outcome indicated that the improvement strategy was both feasible and effective. In terms of the impact of implementing the QI plan during different periods on the pain assessment rates, when using July 2020–June 2021 as the reference group, it was observed that both the post-implementation and continuous tracking phases showed improved pain assessment rates across the entire hospital as the improvement plan was implemented (P < 0.001) (Table 2).

Over the three phases from July 2020–June 2021 to July 2022–June 2023, the achievement rate of the indicator increased from 7.87% to 48.74% and further continued to rise to 70.49%, with a significant upward trend (P for trend < 0.001) (Figure 3). Additionally, whether it was in internal medicine, surgery wards, or their respective ICUs, there was a significant improving trend over time (P for trend < 0.001) (Figure 4). Regarding the impact of implementing the QI plan in different types of wards on the pain assessment rate, when using the internal medicine ward as the reference, the improvement in the surgery ward is more significant (P < 0.001). The improvement in the internal medicine ICU is lower than that in the internal medicine ward, while the improvement in the surgery ICU is slightly higher than the internal medicine ward, but without significant differences. Therefore, during the implementation of the QI plan, the surgery wards had the highest rate of conducting pain assessments within 30 minutes after medication administration among all the hospital wards (Table 3).

Figure 2. Hospital-Wide Quality Improvement Plan Effectiveness Chart in 2021
The improvement effects before and after the implementation of the hospital-wide quality improvement plan were evaluated, with June 2021 as
the reference point.

Table 2. Period Associated With Rate of Pain Assessment From 2020/07 to 2023/06

Figure 4. The Quality Improvement Plan Effectiveness Chart of Four Different Types of Wards
During the period from July 2020 to June 2023, there was an improvement trend in the pain assessment indicators across four types of wards as a
result of the implementation of the quality improvement plan. ICU, intensive care unit.

Table 3. Ward Type Associated With Rate of Pain Assessment From 2020/07 to 2023/06

By monitoring the pain assessment indicator— namely, the percentage of hospitalized patients who are assessed for pain within 30 minutes following the administration of injectable analgesics as per STAT and PRN orders—we implemented the PDCA improvement strategy to enhance the quality management of inpatient pain assessments. The results demonstrate a two-phase increase in the indicator’s achievement rate.

With QI in healthcare systems and processes, adjustments were made to the medication administration mechanism, post-medication reminder reporting mechanism, and overall process. In the first phase, the achievement rate increased from 7.87% before implementation to 48.74% after implementation. In the second phase, managerial improvements were introduced. Each month, the pain care team received performance reports for all wards, and regular meetings were held to review and amend strategies. Consequently, the rate continued to ascend, reaching 70.49% during the continuous QI period.

During the periods of pre-implementation (July 2020–June 2021), post-implementation (July 2021– June 2022), and continuous improvement (July 2022– June 2023) of the QI plan, the integration of the medication administration system, pain assessment system, and nursing documentation systems into a unified platform significantly streamlined the workflow. By enabling an automated input of pain assessment records into nursing documentation through a pointand-click interface, as well as incorporating a reminder and feedback mechanism, the platform simplified the user interface. Alongside continuous education and training by the pain care team, this comprehensive approach led to a significant upward trend in the achievement rate of the pain assessment indicator across all hospital wards. The PDCA plan not only enhanced the platforms and processes but also refined the pain assessment record reporting process, interconnected medication and pain assessment record systems, provided regular performance reporting and monitoring, and facilitated ongoing QIs. Clinically, this approach also elevated the willingness of nursing staff to execute these protocols.

The 2008 study by Gordon et al. [7] presents an early, yet pivotal examination of the PDCA cycle in improving documentation for pain reassessment, resonating with the themes of our current research. Their research emphasizes the vital importance of systematic documentation and reassessment in pain management, a key element also integral to our study. Our research aims to provide historical context, illustrating the ongoing significance and evolution of the PDCA model in enhancing healthcare quality, particularly in the realm of pain assessment. By integrating the foundational research of Gordon et al. [7], our study aims to enrich and broaden the perspective on the use of the PDCA cycle in enhancing pain assessment practices. This inclusion not only acknowledges the significant contributions of Gordon et al. [7] but also facilitates a deeper understanding of the PDCA cycle’s role in the continuous improvement of pain management methodologies.

While there was a significant improvement in the hospital-wide KPI for pain assessment, a closer look at the different types of wards revealed that the surgical wards outperformed others in terms of improvement. We believed that this discrepancy could be attributed to the differing nature of the wards, leading to variations in the healthcare priorities emphasized by the medical staff. Surgical wards focus on postoperative wound care; thus, there is a stronger emphasis on pain assessment and management compared to other wards. In contrast, internal medicine wards prioritize disease management and patient care, while ICUs focus on monitoring vital signs and providing critical care for patients.

The study on the application of the PDCA cycle in pain management, while providing significant insights, has certain limitations. Firstly, the complexity and resource-intensive nature of the PDCA model may hinder its practical implementation in varied healthcare settings, especially in resource-limited environments [8]. Secondly, the subjective nature of pain assessment poses a challenge to standardization efforts inherent in the PDCA cycle [9]. Resistance to change among healthcare professionals could also affect the model’s effectiveness, as it requires significant shifts in clinical practice and documentation processes [10]. Additionally, the iterative nature of PDCA could potentially delay responses in urgent pain management scenarios, an aspect critical in clinical settings [11]. The risk of overemphasizing documentation at the expense of holistic patient care is another concern [12]. Lastly, while the study addresses general pain management, the specific challenges in managing complex or chronic pain conditions may require more tailored approaches beyond the standardized PDCA framework [13].

Regarding the study limitations, the improvement in the pain assessment indicator was most significant in the surgical ward from July 2020 to June 2023, while there was no difference observed in the medical ward and both the medical and surgical ICUs. Exploring strategies to enhance the pain assessment performance indicators in non-surgical wards is a topic worthy of further investigation in the future.

In terms of quality management for pain assessment in hospitalized patients, the PDCA model has not only improved the reporting process for pain assessment records but has also enhanced the KPI for pain assessment in our study. Through continuous tracking by the pain care team, regular review and ongoing improvement of the quality management of pain assessment for hospitalized patients have been conducted, establishing an effective cycle of improvement. In the future, this improvement strategy could be applied to other healthcare performance indicators, further elevating the overall quality of healthcare provided by the hospital.

We appreciate the technical support provided by the staff of the Information Technology Office,Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan.

There are no conflicts of interest.

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors