Date of Completion
Summer 2026
Document Type
DNP Scholarly Project
Academic Department
School of Nursing
Degree Type
Doctoral
Degree Name
Doctor of Nursing Practice
First Advisor
Corinne Cochran
Second Advisor
Lois Marshall
Abstract
Problem: In a hospice care organization, a practice gap was observed in prompt pain reassessment with an onset or increase of pain, as mandated within a 48-hour timeframe by the Centers for Medicare and Medicaid Services (CMS). Baseline data showed that only 40% of eligible patients with a pain score of ≥ 6 received a documented pain reassessment within 48 hours. Overall patient satisfaction with hospice services was 45%.
Aim of the Project: The quality improvement project aimed to enhance pain management by increasing the percentage of eligible hospice patients with a documented pain score of ≥ 6 from a baseline of 40% to 100% over a 12-week implementation timeframe through the initiation of an evidence-based pain reassessment protocol.
Review of the Evidence: The reviewed evidence persistently reflects that structured, timely pain reassessment is linked to enhanced pain management, patient-centered care and comfort, symptom monitoring, and documentation consistency. The literature strengthened structured pain reassessment processes to support prompt identification of uncontrolled pain and navigate suitable interventions.
Project Design: The project utilized the Plan-Do-Study-Act (PDSA) quality improvement process model and the OhioHealth Change Management Model during the 12-week project implementation period.
Intervention: The STARS 2 (2025) pain reassessment protocol was implemented over a 12-week timeframe. Hospice nurses were educated on timely reassessment, provider notification, patient/family education, documentation, and use of a tracking spreadsheet for compliance monitoring.
Significant Findings/Outcomes: Upon completing the 12-week implementation, 48-hour pain reassessment adherence increased the baseline from 40% to 90% amongst the qualified hospice patients with a documented pain score of ≥ 6. In addition, a pain score < 6 was attained by 76% of patients, and 90% of qualified patients had a notification to the provider completed. Clinical process efficiency was sustained without expanding visit times. Although the 100% compliance target wasn’t achieved, the project aim illustrated meaningful progress through the 50-percentage-point increase.
Implications for Nursing: The findings reinforce the utilization of a standardized pain reassessment protocol to demonstrate consistency in timely pain reassessment and documentation in hospice nursing practice. The protocol’s feasibility and sustainability were supported by maintaining existing hospice workflows.
Recommended Citation
Strong-Mosley, Brianna, "Improving Timely Hospice Pain Reassessments Through a Quality Improvement Initiative" (2026). Doctor of Nursing Practice (DNP) Scholarly Project. 73.
https://fuse.franklin.edu/dnp-project/73
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