Health care institutions must use the principles of quality improvement to demonstrate appropriate assessment and effective management of pain. Here, we describe the quality improvement initiative implemented at our pediatric institution to improve the quality of pain management. We conducted chart audits for the previous 24 hours during which patients received inpatient care. Over six years, 2,478 charts were audited for 87 24-hour periods (average 1.2 days/month) to answer the following: (1) Was pain intensity assessed as per the institutional pain standard of care, (2) What proportion of audited inpatients had significant pain (>or=5/10), and (3) When significant pain (>or=5/10) occurred, was treatment effective (pain score <or=4/10) within one hour of an intervention? Data were analyzed for quarterly time periods (n=24). Compliance with pain assessment guidelines improved from 77% initially to consistently greater than 90%. The mean proportion of patients with significant pain each quarter was 21%. Sixty-six percent of patients with significant pain had pain treated effectively within one hour of intervention. Lack of documentation of pain reassessment within one hour of the intervention was consistent throughout the study period (overall frequency 22%). Comprehensive pain management guidelines have been established. Leaders of health care organizations need to provide the support and resources needed to incorporate these guidelines and standards into institutional culture. We present a simple quality improvement approach to patient care that can be modified to fit the unique aspects of other institutions.