D156 Patient Fall Reduction Improvement Project Analysis and Implementation

Grace J.
January 3, 2026January 3, 2026
D156, MSN, Western Governors University

Student Name

Western Governors University

D156 Business Case Analysis for Healthcare Improvement

Prof. Name

Date

D156 Improving Inpatient Pain Management Protocols and Training

Healthcare Improvement Project: Introduction and Project Initiation

Organizational Problem

The focus of this Healthcare Improvement Project is to revise and update the inpatient unit’s policies and educational practices regarding pain medication administration. This initiative was prompted by findings from a recent Joint Commission survey, which revealed discrepancies between patients’ reported pain levels and the pain medication administered. For example, a patient reporting a pain intensity of 9 was given Tramadol, a medication intended only for moderate pain levels between 4 and 6. This discrepancy highlighted a gap: no existing policy required prescriptions to cover all potential pain intensities comprehensively.

Although a pain medication algorithm existed specifying which medications corresponded to different pain levels, there was no protocol mandating prescriptions for every level of pain. The inpatient unit is small, with a census typically ranging from 2 to 14 patients and staffed by 2-3 nurses per shift. Patient care is managed by a hospitalist group with a nurse practitioner (NP) available five days a week and a physician twice weekly. The NP predominantly handles medication prescriptions. This relatively streamlined care environment ideally supports coordinated efforts among providers, pharmacists, and nursing staff to ensure thorough and appropriate pain medication ordering.

Stakeholders

Key stakeholders in this project include the Medical/Surgical (Med/Surg) unit director, pharmacist, prescribing providers, and charge nurse. The Med/Surg director is responsible for drafting new policies and leading staff education efforts. The pharmacist collaborates with providers by reviewing and approving medication orders to ensure appropriateness. Prescribers hold the authority to write prescriptions, and the charge nurse is vital in applying updated policies and educating nursing staff. Each stakeholder plays a crucial role in preventing lapses in pain management, which could negatively affect Centers for Medicare & Medicaid Services (CMS) reimbursements, patient satisfaction, and overall quality of care.

The collaborative relationship between providers and pharmacists is essential for managing pain medications correctly, while nursing leadership ensures policy compliance through ongoing education and enforcement.

Project Team

The project manager oversees assembling the team, securing necessary resources, and maintaining alignment with project goals. Their duties include selecting qualified team members, coordinating educational content, and communicating with both staff and patients affected by the project. The project manager also monitors quality and outcome measures throughout the project lifecycle (VanDenBerg, 2023).

Critical skills contributing to the project’s success are strong interpersonal communication and multitasking. For instance, the Med/Surg unit director works closely with the project manager to implement policies and conduct audits ensuring accurate pain assessments and medication administration.

Needs Assessment

Using the “Five Whys” root cause analysis, the team identified that the main problem was insufficient education and awareness among providers and nursing staff. Providers often failed to prescribe medications that covered the full spectrum of pain intensity, and nursing staff lacked adequate training on pain assessment and matching medication to patient-reported pain levels. The analysis revealed that the issue was primarily a knowledge gap rather than a procedural failure.

SWOT Analysis

Category	Strengths	Weaknesses	Opportunities	Threats
Details	Strong collaboration between providers and pharmacists; administrative support for policy updates	Potential resistance from providers to comprehensive prescribing; nursing staff requiring education	Staff education on new policies; enhanced patient communication	Staff noncompliance; patient dissatisfaction due to medication changes

Mitigation Strategies:

Foster open communication and weekly meetings between providers and pharmacists to maintain transparency.
Provide thorough education to nursing staff to enhance pain assessment and medication administration skills.
Engage patients with clear explanations regarding the rationale behind pain medication protocols to reduce dissatisfaction.
Perform regular audits to ensure adherence to policies and effective pain management.

Impact Analysis

The project received a benefit score of 11 and a risk score of 8, producing an impact ratio of 1.4, indicating that benefits outweigh risks. Benefits to the organization include improved medication management, enhanced patient satisfaction, and elevated care quality. Patients benefit through better pain control, leading to quicker recovery and fewer complications related to inappropriate dosing.

Risks involve possible provider resistance to changing prescribing habits and patient dissatisfaction if they perceive limitations on medication availability. However, the overall positive effect on patient outcomes and satisfaction justifies moving forward with the project.

Justification and Project Purpose

The purpose of this project is to optimize pain control by aligning pain medication prescriptions with patients’ reported pain levels precisely. Weekly collaboration between providers and pharmacists will help overcome prescribing barriers, while nursing staff will receive education to verify and administer appropriate medications. By addressing educational gaps and improving interdisciplinary collaboration, the project aims to enhance pain management quality.

Strengths such as strong interdepartmental cooperation and administrative support, alongside policy development and targeted education, provide a solid foundation for success. While challenges like provider resistance exist, these can be mitigated through continuous education and monitoring.

Review of Relevant Scholarly Sources

Multiple studies emphasize the critical need for education and systematic pain management protocols:

Malones et al. (2021) found that improper nurse pain assessment compromises treatment quality, revealing an educational deficiency.
Rababa and Hayajneh (2021) identified barriers including inconsistent pain assessment tool use and lack of standard prescribing practices, advocating for enhanced training and teamwork.
Stearns et al. (2021) recommended that providers prescribe PRN (as-needed) medications for all pain levels to enable flexible dosing.
Germossa et al. (2019) demonstrated improved pain control following a nurse-led educational initiative and increased patient rounding.
Kankkunen et al. (2023) showed that education enhances nurse documentation and patient-reported pain relief, reinforcing ongoing training as best practice.

The consensus from these studies highlights two best practices: educating staff on pain assessment and management and encouraging providers to prescribe comprehensive PRN pain medication orders (Malones et al., 2021; Stearns et al., 2021).

Project Environment

The Centers for Disease Control and Prevention (CDC) 2022 clinical practice guideline on opioid prescribing stresses balancing benefits and risks in pain management, enhancing clinician-patient communication, and minimizing opioid-related harm (Dowell et al., 2022). This project supports these goals by promoting safe, patient-centered pain management strategies aligned with national recommendations.

SMART Goal

The project team and stakeholders have established a SMART goal: to improve patient pain control and overall experience by educating bedside nurses in accurate pain assessment and proper medication administration. The timeline runs from June 13, 2024, to September 30, 2024, focusing on policy updates and comprehensive education to enhance pain management outcomes.

Project Management Lifecycle

The project adheres to the traditional four-phase lifecycle: initiation, planning, implementation, and evaluation. Initially, the problem was identified and the team assembled with clear objectives. Planning involved developing new policies and educational resources. Implementation introduced these interventions and monitored compliance. Evaluation will include patient rounding and chart audits to measure improvements in pain control and patient satisfaction.

SMART Goal Worksheet

SMART Criterion	Question	Answer
Specific	What is the project? How will it be achieved?	Improve patient pain control by aligning medication and dosage with reported pain. Develop educational tools and collaborative policies.
Measurable	What metrics indicate success? How will change be detected?	Use patient rounding and chart audits to assess proper prescribing and pain assessment. Target 90% patient comfort improvement by 9/30/24; 100% staff education by 7/31/24.
Achievable	What support and resources justify the project?	Administrative support, provider-pharmacist collaboration, and educational resources. Benefits extend to patients and organization.
Relevant	Why is this project important?	Pain management impacts patient health, satisfaction, and institutional reputation. Nurse skills improvements enhance care.
Time-Bound	What are the project and milestone dates?	Approval by 6/3/24; project start 6/13/24; end 9/30/24; graduation 4/30/25.

SMART Project Goal:
By September 30, 2024, patients will experience a 30% increase in effective pain control through proper administration of pain medications based on their reported pain levels. This will be evaluated by auditing 100% of patient charts before and after project implementation, supported by interdisciplinary collaboration.

Process Key Performance Indicators (KPIs)

KPI Number	Description
KPI #1	Achieve 100% staff education on pain assessment and medication management prior to project launch.
KPI #2	Develop 100% of the audit tools for collecting pain management data before project implementation.

References

Dowell, D., Ragan, K. R., Jones, C. M., Baldwin, G. T., & Chou, R. (2022). CDC Clinical Practice Guideline for Prescribing Opioids for Pain — United States, 2022. MMWR Recommendations and Reports, 71(No. RR3), 1–95. https://doi.org/10.15585/mmwr.rr7103a1

Germossa, G. N., Hellesø, R., & Sjetne, I. S. (2019). Hospitalized patients’ pain experience before and after the introduction of a nurse-based pain management program: A separate sample pre and post study. BMC Nursing, 18, 40. https://doi.org/10.1186/s12912-019-0362-y

Kankkunen, P. K., Voutilainen, A. V., Vaajoki, A. V., & Grommi, S. G. (2023). Effect of Pain Education Interventions on Registered Nurses’ Pain Management: A Systematic Review and Meta-Analysis. Pain Management Nursing. https://www.painmanagementnursing.org/article/S1524-9042(23)00061-9/fulltext

D156 Improving Inpatient Pain Management Protocols and Training

Malones, B. D., Kallmyr, S. S., Hage, V., & Eines, T. F. (2021). How hospitalized patients evaluate and report their pain together with nurses: A scoping review. Nordic Journal of Nursing Research, 41(4), 197–206. https://doi.org/10.1177/20571585211013480

Rababa, M., Al-Sabbah, S., & Hayajneh, A. A. (2021). Nurses’ Perceived Barriers to and Facilitators of Pain Assessment and Management in Critical Care Patients: A Systematic Review. Journal of Pain Research, 14, 3475–3491. https://doi.org/10.2147/JPR.S332423