Background: Pain is experienced by a majority of cancer patients, often having a significant negative impact on their quality of life. Effective documentation of pain scores and plan of care provide care teams with data for decision-making to improve pain management. In Q2 of 2021 documentation deficiencies were identified. Process improvement interventions were initiated through the remainder of 2021 to support clinical teams. Methods: Over the course of twelve months our practice sought to improve documentation of pain management through a multi-pronged approach. Execution began with initiation of the Quality and Safety Committee early in 2021 to engage key stakeholders. Our Chain of Command Project identified strategic members of the administrative and clinical leadership teams at the individual clinic level who initiated monthly meetings to promote quality awareness and engagement. Quality measures associated with pain management, MIPS 143 and 144, were examined with assistance from our Value Based Care Transformation Team. Monthly provider scorecard distribution commenced Q2 to identify documentation inconsistencies related to pain management. Providers, medical assistants, and scribes were provided education and training related to appropriate pain management documentation workflows. Follow up audits were performed by the Quality team. In Q3 and Q4 the Quality team collaborated with Human Resources to identify new employees and facilitate education on quality metric capture within a month of hire. Results: The data above is a representation of all clinics and patients treated. The interventions resulted in improved metrics from 2020 to 2022 YTD: MIPS 143 +5.5%, MIPS 144 +27.3%, and PIMSH4 +6.3%. Conclusions: Effective change management occurred from the top down with additional engagement of administrative and clinical members. Analysis of the internal structure and deficiencies was needed with implementation of metric training. Data transparency helped with engagement and managing documentation of MIPS 143 and 144. Next steps include leveraging the current documentation processes to improve PIMSH4, ultimately improving the quality of life for patients.

*Data represents January-May 2022