When the Pain Scale Cannot Tell the Story: A Project Business Teaching Case
Neuroinclusive Pain Communication Across Healthcare Contracts, Insurance, & Organizational Boundaries
Casey LaFrance & Alexandra Robuste
Abstract
A patient can be transferred successfully between healthcare facilities according to the terms of a contract while clinically important information fails to reach the people responsible for providing care.
This teaching case examines that problem through our work developing a Neuroinclusive Pain Scale and related Pain Communication Wheel.
Research on pain, autism, communication barriers, and healthcare transitions suggests that standardized assessment practices may not adequately represent every patient’s experience.
These limitations become particularly consequential when information must pass among healthcare providers, insurers, transportation contractors, and technology vendors.
Drawing on the Project Business Foundation’s approach to customer — contractor relationships, we examine how contractual requirements, risk allocation, acceptance criteria, and organizational accountability influence the delivery of value. A hypothetical patient transfer provides the central case, followed by applications involving insurance documentation, technology procurement, and services outside healthcare. The accompanying activities and glossary support professional education and discussion. Our purpose is to examine how more inclusive communication practices might improve decisions while recognizing that the proposed tools require further clinical and organizational evaluation.
Keywords: neuroinclusive pain communication, project business management, patient transfers, insurance, accessibility, contracting, relational value, Project Business Professional
The Transfer Was Complete. Was the Work Successful?
A patient is discharged from a community hospital and transferred to a rehabilitation facility. The sending hospital completes its documentation, the transportation contractor arrives within the agreed service window, and the receiving organization accepts the patient. The transfer is recorded as complete.
The organizations involved have evidence that their respective responsibilities were fulfilled, and the transaction can be closed according to established procedures.
Several hours later, the patient becomes increasingly distressed. Staff consult the records and find a numerical pain rating of three on a ten-point scale. The patient is autistic and has difficulty translating physical sensations into numerical ratings. A family member explains that changes in movement, sensory tolerance, and behavior have historically been more useful indicators of the patient’s discomfort than the numbers the patient provides. This information had been shared during the original admission but did not accompany the transfer.
The receiving facility contacts the hospital for clarification. The family member repeats information that was already available to the sending organization. Staff spend additional time reassessing the patient, reviewing the available records, and determining whether the reported discomfort requires further intervention.
Meanwhile, the patient remains distressed, and the people responsible for providing care must reconstruct information that should have been available when responsibility changed hands.
This is a hypothetical teaching case, but the problem is recognizable. Communication failures during transitions of care are well documented, and the consequences can extend beyond inconvenience to include delays, misunderstanding, and patient safety risks (Gurses et al., 2024).
The case also raises questions that should interest people working in project business management.
Each organization may have fulfilled its own contractual obligations while the overall arrangement failed to support the intended outcome.
Who was responsible for ensuring that the information arrived? Was the sending organization required to transmit communication preferences, or only the information identified in a standardized form? Did the receiving organization have a responsibility to verify that the documentation was sufficient? Could the transportation contractor have been expected to recognize a problem with the records, or would that place an unreasonable clinical responsibility on a nonclinical service provider?
These are questions about healthcare, but they are also questions about requirements, contracts, accountability, and value. They become particularly important when the organizations involved have different financial interests, operational priorities, and definitions of successful performance.
Literature Review: Pain Is Personal, but the Systems Are Standardized
What Does a Pain Score Tell Us?
The numerical pain rating scale has become familiar in healthcare because it provides a relatively simple way to document a subjective experience. Patients are asked to assign a number to their pain, often using a range from zero to ten, and clinicians can use that information alongside other observations to assess changes over time. The method is inexpensive, easy to administer, and compatible with standardized electronic records. These are meaningful advantages, particularly in environments where staff must make decisions quickly and communicate across shifts or departments.
The limitations become apparent when the number is treated as a complete representation of the patient’s experience. Pain involves sensory and emotional dimensions that cannot always be separated from the person’s circumstances, expectations, and previous experiences. The International Association for the Study of Pain revised its definition in 2020 to recognize pain as a personal experience influenced by biological, psychological, and social factors. Its accompanying explanation also acknowledges that verbal description is only one of several ways people may express pain (Raja et al., 2020).
Experiencing pain and communicating pain are related activities that place different demands on a person. Someone may recognize discomfort without being able to describe it precisely.
Another person may identify a physical sensation but struggle to compare its intensity with previous experiences. A patient may understand the numerical scale perfectly well and still find that the number does not communicate the characteristics of pain that matter most to the clinical decision.
A rating of three, for example, tells us what the patient reported in response to a particular question. It does not independently establish the cause of the discomfort, its effect on daily functioning, or the patient’s ability to tolerate a particular intervention. Clinicians generally recognize that pain ratings must be interpreted alongside other evidence.
Nevertheless, the convenience of numerical information can encourage organizations to build documentation and performance systems around what is easiest to record.
The problem becomes more significant when information is removed from the original interaction. A clinician who has spoken with the patient may understand the circumstances surrounding the rating.
A receiving provider who sees only the number may interpret it differently.
The record appears complete because the required field contains a value, even though the meaning of that value may not have traveled with it.
Neurodivergence, Sensory Experiences, & Communication
Research involving autistic adults provides additional reasons to examine how healthcare organizations communicate with patients. Strömberg et al. (2022) studied sensory discomfort and communication barriers among autistic and nonautistic adults in healthcare settings. Autistic participants described difficulties associated with background noise, sensory environments, and providers’ expectations about communication. They also reported situations in which healthcare professionals misunderstood their needs or failed to recognize difficulties that were not immediately visible.
These findings are particularly relevant to pain assessment because the conditions under which someone is asked to communicate may affect the information that becomes available. A patient who has spent an extended period in a noisy waiting room may be managing sensory discomfort while also attempting to answer questions about a medical concern. A person who needs additional processing time may be expected to respond before they have adequately considered the question. Someone whose facial expressions or body language differ from a clinician’s expectations may find that their verbal report is interpreted through assumptions that do not accurately represent their experience.
Shaw et al. (2024) examined healthcare barriers reported by autistic adults and described problems involving communication, trust, fear, and the relationship between patients and providers. Their findings are useful because they place some responsibility for misunderstanding within the interaction itself. Communication difficulties cannot always be attributed to a patient’s inability to express information. Providers and organizations also influence whether information is recognized, understood, and used appropriately.
Interoception adds another consideration. The term refers to the perception and interpretation of internal bodily signals. People differ in how readily they recognize, distinguish, and describe those signals. These differences may be relevant to pain communication, although they should not be assumed to characterize every autistic person or every neurodivergent individual. The important point is that a standardized question may require abilities or forms of expression that vary across patients.
Masking also deserves attention. People sometimes learn to minimize or conceal outward expressions of discomfort because of social expectations, previous experiences, or concerns about how others will respond. A calm appearance may be interpreted as evidence that pain is limited, even when the person’s report or other information suggests otherwise. In these circumstances, the provider’s interpretation of behavior can become as consequential as the patient’s answer.
These concerns extend beyond autism. People with cognitive or communication disabilities, children, older adults, individuals experiencing language barriers, and patients under significant stress may encounter similar difficulties. A neuroinclusive approach offers a way to reconsider the assumptions built into communication practices without requiring every patient to use the same alternative method.
The Problem of Information That Does Not Travel
Healthcare delivery frequently requires information to move between individuals and organizations. A patient may interact with emergency department staff, specialists, nurses, rehabilitation professionals, transportation providers, insurers, and administrative personnel during a single episode of care. Each interaction creates information that may be useful to someone else, but the systems responsible for recording and transferring that information do not always preserve its meaning.
Gurses et al. (2024) explain that communication during transitions of care is essential to patient safety and that structured handoff practices can help reduce the loss of important information. Their discussion also makes clear that standardized tools alone cannot guarantee effective communication. A checklist can help ensure that required information is transmitted, but its usefulness depends on whether the requirements adequately represent what the receiving team needs to know.
Our hypothetical transfer illustrates this limitation. The sending hospital may have completed every required field, and the receiving facility may have received the entire standardized record. The difficulty arose because the patient’s communication preferences and the context needed to interpret the pain rating were not part of the information required by the process.
This suggests that some communication problems should be examined before the handoff occurs. Who determined what information belonged in the transfer record? Were patients and caregivers involved in developing those requirements?
Did the organizations consider circumstances in which a numerical assessment might need additional explanation? How would the receiving facility know that relevant information was missing?
These questions move the discussion from individual performance to organizational design. They also establish the connection between our work on pain communication and the field of project business management.
Our Work on Neuroinclusive Pain Communication
Alexandra Robuste and I have been developing a Neuroinclusive Pain Scale and related Pain Communication Wheel to explore alternatives to relying exclusively on numerical pain ratings. Our work begins with the recognition that people may communicate physical experiences through different combinations of language, sensory descriptions, changes in functioning, behavior, and other forms of expression. We are interested in how these forms of communication can be made more accessible and useful without assuming that one approach will work equally well for everyone.
The question guiding this work is relatively simple. What might we learn if we gave people additional ways to communicate pain rather than expecting every experience to fit a numerical response?
That question has implications for the design of assessment tools, but it also raises concerns about how clinicians interpret information and how organizations preserve it. A patient may find a particular description meaningful, while a provider may need to understand how that description relates to clinical assessment. The interaction requires attention to the person communicating and the person receiving the information. It also requires care when information is documented for later use by someone who was not present during the original conversation.
Our work is informed by the broader literature on pain and communication, including the recognition that an inability to communicate in conventional ways does not establish the absence of pain (Raja et al., 2020). Research on autistic adults’ healthcare experiences further suggests that individualized communication practices may address barriers that arise when providers rely too heavily on familiar expectations about verbal and nonverbal behavior (Shaw et al., 2024; Strömberg et al., 2022).
The Neuroinclusive Pain Scale and Pain Communication Wheel are being developed as approaches to communication. We are not presenting them as clinically validated diagnostic instruments or suggesting that they should replace established assessments. Research is still needed to determine their usability, reliability, validity, accessibility, and appropriate clinical applications. Any implementation in healthcare would require professional judgment, patient participation, and appropriate safeguards.
We are also interested in what happens after someone successfully communicates an experience. If the information remains with the individual clinician who collected it, its usefulness may be limited when responsibility changes. If the information becomes part of a record that another organization cannot access or interpret, the original communication problem may reappear.
This is where the project business connection becomes especially useful. The value of improved communication depends partly on whether the organizations involved have agreed to preserve, transmit, and act upon the information. A tool may help someone express pain more effectively, but the contractual and organizational arrangements surrounding care influence whether that expression affects subsequent decisions.
Project Business Management & the Problem of Shared Responsibility
The Project Business Foundation approaches project management through the relationships between organizations that purchase and perform project work. These customer — contractor relationships involve commercial interests, contractual commitments, legal responsibilities, and operational risks that extend beyond managing activities within a single organization (Lehmann, 2022). The Project Business Professional certification addresses practitioners working on both the customer and contractor sides of these arrangements (Project Business Foundation, n.d.).
This perspective is particularly relevant to healthcare because patients frequently receive services through networks of organizations that operate under different agreements. A hospital may contract with a transportation company, a technology vendor, or a rehabilitation provider. Insurers may establish coverage and documentation requirements. Some services are delivered through long-standing agreements, while others involve temporary projects intended to introduce new systems, facilities, or ways of working.
The patient experiences these relationships as part of a connected service. The organizations involved may experience them as separate transactions.
That difference matters when we evaluate success. A transportation contractor may be paid for completing a trip. A technology vendor may be paid when software meets agreed acceptance criteria. A receiving facility may be evaluated according to admission procedures and documentation requirements. Each organization has reasons to concentrate on the responsibilities it can control and the performance measures attached to its agreement.
The intended value of the overall service may depend on activities that fall between those responsibilities.
Project business management gives us a way to examine these gaps. Requirements define what must be delivered. Contracts establish obligations and allocate risks. Acceptance criteria determine whether the work meets agreed expectations. Change control provides a process for modifying requirements when circumstances or needs become clearer. Commercial management addresses the resources and financial arrangements needed to perform the work.
These are concerns for anyone attempting to introduce a new communication process across organizational boundaries. If a hospital wants communication preferences included in transfer records, it must determine whether existing systems support that requirement, whether staff need training, whether receiving facilities can interpret the information, and whether contracts must be modified.
The Project Business Professional perspective also helps us distinguish among different kinds of value. A customer may value timely performance, predictable costs, and contractual compliance. A contractor may value clear requirements, reasonable risk, and payment for completed work. A patient may value being understood and receiving appropriate care. These interests can support one another, but they are not always identical.
The challenge is to develop arrangements that recognize their differences and make informed decisions about how they can be reconciled.
The Teaching Case: A Transfer That Met the Contract
Return to the patient transferred from the community hospital to the rehabilitation facility. The sending hospital is experiencing pressure to make beds available for incoming patients. Administrators have established performance measures related to discharge efficiency, and the transportation provider operates under an agreement that emphasizes pickup times, delivery times, and safe transportation.
The receiving facility has its own admission procedures. Staff review the records supplied by the hospital, complete an initial assessment, and establish a care plan. The agreement between the organizations specifies the documents required for transfer, including current medications, discharge instructions, and relevant clinical assessments.
The hospital’s record contains the patient’s numerical pain rating. It also contains information from an earlier conversation with a family member about the patient’s difficulty using numerical ratings and the importance of changes in movement and sensory tolerance. However, the standardized transfer summary does not include that contextual information.
The receiving facility accepts the patient and begins its usual procedures. When the patient becomes distressed, staff rely initially on the available records and their own observations. They subsequently contact the sending hospital and speak with the family member to obtain a more complete understanding of the patient’s communication needs.
For the purpose of this exercise, assume that the organizations complied with the requirements of their existing agreements. Participants should not begin by deciding which party violated the contract. Instead, they should examine whether the agreements adequately addressed the information needed to support continuity of care.
The sending hospital might argue that it transmitted the required documentation and that the receiving facility was responsible for conducting its own assessment. The receiving facility might respond that the sending organization possessed clinically relevant information that should have accompanied the patient. The transportation provider might explain that its responsibilities did not include interpreting clinical records. Each position has a reasonable basis within the organization’s assigned role.
The patient and family member may see the situation differently. They already provided information intended to help clinicians understand the patient’s experience. The need to repeat that information suggests that the organizations did not preserve its usefulness as responsibility changed.
A project business review would examine how the original requirements were developed, what information the receiving organization reasonably needed, and how the parties could modify their arrangements to address similar situations. It would also consider the costs of any proposed changes. Additional documentation takes time, technology modifications require resources, and staff training may affect operations. Those costs must be weighed against the expected benefits and the risks of continuing current practices.
The Neuroinclusive Pain Scale could be considered as part of a future pilot if it proves appropriate for the intended use. The more immediate lesson concerns the relationship between assessment, documentation, and organizational responsibility. Even a useful communication tool cannot improve a handoff if the relevant information is excluded from the process.
Insurance, Medical Necessity, & the Value of Better Documentation
Insurance provides another setting in which communication differences can become project business concerns. Providers must often document the clinical circumstances supporting a requested service, and insurers review that information according to applicable coverage requirements. The process depends on records that may have been created by several professionals across different settings.
Consider a patient requesting continued rehabilitation services. The documentation contains a relatively low numerical pain rating, but other information indicates that discomfort affects movement, sleep, and participation in daily activities. The patient has difficulty explaining these effects through numerical ratings, and the clinician’s initial documentation does not adequately describe the functional limitations.
The insurer may request additional information before making a coverage decision. The provider must then gather records, clarify the clinical circumstances, and submit the material required for review. The patient may experience uncertainty or delay while the organizations complete these activities.
The Centers for Medicare & Medicaid Services explains, in its requirements for durable medical equipment claims, that documentation supporting medical necessity may include the patient’s condition, clinical course, functional limitations, and other relevant evidence. The medical record must support the requested item or service according to applicable coverage criteria (CMS, n.d.). Although these particular requirements concern durable medical equipment, they illustrate the broader importance of documentation that represents clinically relevant circumstances rather than relying on isolated entries.
A neuroinclusive communication approach might help clinicians gather information that is otherwise difficult for some patients to express. It would not establish medical necessity by itself, nor would it guarantee authorization or reimbursement. The information would still need to be interpreted within the relevant clinical and coverage requirements.
The project business question concerns how organizations establish documentation requirements and manage the work needed to meet them. If a provider introduces a new assessment process, who determines which information should be collected? How will that information enter the medical record? Will the insurer be able to interpret it? What additional training or technology will be required?
How will the organizations evaluate whether the change improves the quality of decisions?
There is also a risk of creating more administrative work without improving understanding. A new form may produce additional information while leaving the underlying problem unresolved. The objective should be to improve the usefulness of documentation, including its relevance to clinical decisions and its availability to authorized parties.
Technology Procurement & the Requirements We Forgot to Write
Imagine a healthcare organization purchasing an electronic documentation system. The procurement team develops requirements based on existing clinical workflows and reporting obligations. The system must record numerical pain ratings, support transfer summaries, and produce standardized reports for administrators and clinicians.
The vendor demonstrates these capabilities during procurement. The contract is awarded, implementation proceeds, and the system passes its acceptance tests. From the standpoint of the agreed technical requirements, the project has been successful.
After implementation, clinicians discover that documenting individual communication preferences requires additional free-text entries. These entries are not consistently included in transfer summaries, and receiving organizations may not know that the information exists. Staff develop informal workarounds, including separate notes and verbal reminders, to compensate for the limitation.
The vendor delivered what the customer requested. The customer now recognizes that the requirements did not adequately reflect the needs of some patients and clinicians.
This is a familiar project business problem because it involves the relationship between customer expectations, contractual specifications, and the work required to correct omissions. The organization must decide whether to request modifications, how those modifications will be priced, and whether the changes fall within the original agreement.
The case also raises questions about participation in requirements development. If patients with communication differences and the clinicians who support them had been involved earlier, the organization might have identified the need to preserve individualized communication information before the contract was awarded.
A more inclusive procurement process would not require every technology vendor to adopt a particular assessment instrument. It would require the customer to consider how the system accommodates different communication needs and how relevant information can be shared appropriately across authorized settings.
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The practical lesson is that accessibility belongs in the definition of the work. Addressing it only after implementation may create additional costs and contractual disputes that could have been reduced through better requirements development.
Measuring Whether the Change Delivers Value
Any proposal to introduce the Neuroinclusive Pain Scale into organizational practice should be accompanied by an evaluation plan. The first concern is whether patients find the approach accessible and useful. We would want to understand whether participants can communicate information that they previously found difficult to express and whether the process accommodates different preferences without creating additional confusion or distress.
Clinical usefulness would require separate examination. Clinicians would need to determine whether the information supports appropriate assessment and decision-making. Reliability and validity would need to be studied, and the tool’s limitations would have to be clearly understood before it could be recommended for particular clinical applications.
The organizational evaluation would consider how the information moves through existing processes. We might examine whether transfer records contain relevant communication preferences, whether receiving staff can locate and interpret those preferences, and whether clarification requests or documentation rework change during the pilot.
Project business measures would address implementation costs, contract modifications, training requirements, and the distribution of benefits among participating organizations. If one organization pays for the intervention while another receives most of the operational benefit, the parties may need to negotiate a shared funding arrangement.
We should also examine unintended consequences. Additional assessment requirements could increase workload or encourage staff to treat another structured instrument as a substitute for conversation. Sharing detailed communication information may create privacy concerns if access is not appropriately limited. A tool designed to improve inclusion should be evaluated with the people it is intended to serve, rather than judged solely through administrative performance indicators.
The evaluation should therefore consider patient experience, clinical usefulness, operational feasibility, and business performance together. Each provides information that the others may miss.
Applications Beyond Healthcare
The concerns illustrated by the pain communication case are not confined to healthcare. Many organizations depend on standardized records and contractual relationships to deliver services to people whose needs vary considerably.
In education, a school district may contract with an outside organization to provide specialized student services. The contractor may receive formal accommodation requirements without the contextual information needed to understand how a particular student communicates distress or requests assistance. The service can meet its scheduling and staffing requirements while failing to provide the support the student needs.
Emergency management offers another example. Transportation contractors may be responsible for moving residents from an evacuation area to temporary shelter. The contractual requirements may emphasize vehicle capacity, pickup locations, and timely arrival. Those requirements are important, but they may not adequately address how communication or accessibility needs will be conveyed to the receiving organization.
Workforce development programs face similar challenges. A training provider may satisfy contractual targets for enrollment, instructional hours, and completion while participants encounter communication barriers that interfere with meaningful participation. If performance measures concentrate exclusively on easily counted activities, the organization purchasing the service may have limited information about whether the intended benefits were achieved.
These cases illustrate why project business professionals should examine the relationship between standardized requirements and the experiences of the people receiving services. Contracts can create clarity and accountability, but the value of those arrangements depends partly on whether the requirements reflect the circumstances they are intended to address.
Conclusion: What Arrives With the Patient?
The patient in our teaching case arrived at the receiving facility. The transportation contractor completed the trip, the sending hospital transmitted the required records, and the receiving organization accepted responsibility for care. The organizations had evidence of completed activities, but the patient’s communication needs were not adequately represented in the information exchanged.
The Neuroinclusive Pain Scale and Pain Communication Wheel provide a way for us to examine how people communicate pain and how conventional assessment practices may overlook information that matters. Our work is still developing, and further research will be necessary to establish appropriate applications. The project business questions, however, can be considered now.
Contracts influence what information organizations collect, transmit, and verify. Performance measures shape the activities that receive attention. Commercial arrangements affect who pays for improvements and who has authority to introduce them. When these arrangements are developed without sufficient attention to the people receiving services, organizations may satisfy their individual obligations while leaving important needs unaddressed.
The opportunity for project business professionals is to examine those relationships before problems become disputes, delays, or failures of care. That requires a willingness to question whether existing requirements adequately represent the value that the work is supposed to deliver.
A completed transfer confirms that the patient arrived. Whether the receiving organization has what it needs to understand and support that patient is another matter.
Teaching Activities: Applying Project Business Professional Competencies
The following activities are intended for professionals working in healthcare, procurement, contract management, insurance, public administration, and other settings where organizations depend on contractors to deliver services. They connect the teaching case to the commercial and contractual concerns addressed in Project Business Professional education. The activities are applications of PBP subject matter rather than a reproduction of the official examination blueprint (Lehmann, 2022; Project Business Foundation, n.d.).
The Contract That Everyone Fulfilled
Competency connection: Customer — contractor relationships, contractual interfaces, requirements management, and acceptance criteria.
Participants represent the sending hospital, receiving rehabilitation facility, transportation contractor, and patient advocate. Each group reviews the transfer case from the perspective of its assigned organization and identifies the obligations it was expected to fulfill. The groups should consider the information available when the transfer was arranged, the requirements contained in the agreements, and the authority each organization had to address missing or unclear information.
The participants then negotiate revised transfer requirements. Their agreement should explain which communication information must accompany the patient, who is responsible for preparing and verifying that information, and how the receiving organization should respond when essential details are missing. The revised requirements should be specific enough that the parties can determine whether they have been fulfilled without requiring nonclinical contractors to make clinical judgments.
During the discussion, participants should consider whether the proposed requirements create additional work and how that work should be allocated. They should also examine whether a standardized form is sufficient or whether the agreement needs a process for communicating circumstances that do not fit predetermined categories.
The exercise concludes with each group explaining how its proposed changes would improve the transfer process and what evidence would be needed to determine whether the changes worked.
Who Pays for Better Communication?
Competency connection: Commercial management, negotiation, risk allocation, and benefits realization.
A regional healthcare network proposes a pilot involving the Neuroinclusive Pain Scale. The pilot would require staff training, modifications to documentation systems, and coordination among several participating facilities. The receiving organizations support the proposal but argue that the sending hospitals should bear the implementation costs. The hospitals believe insurers should contribute because more informative documentation may support better authorization decisions. The insurers are interested but want evidence of clinical and operational benefits before committing resources.
Participants negotiate a funding arrangement using a hypothetical implementation budget of sixty thousand dollars. They must determine how costs will be distributed, which organization will manage the pilot, and what information will be collected to evaluate the investment. The discussion should consider the possibility that one organization may bear substantial costs while another receives much of the operational benefit.
Participants should also consider what happens if the pilot does not produce the expected results. Would the organizations continue funding the intervention, modify the process, or return to existing practices? How should these decisions be addressed in the original agreement?
The exercise is intended to demonstrate that a proposal can have potential value for patients while still presenting difficult commercial questions for the organizations responsible for implementing it.
The Insurance Documentation Review
Competency connection: Documentation requirements, contractual compliance, quality assurance, and dispute prevention.
Participants receive a hypothetical insurance authorization request involving a patient seeking continued rehabilitation services. The submitted record includes a diagnosis, a numerical pain rating, and a brief description of the requested treatment. Additional case information indicates that the patient experiences difficulties with movement, sleep, and daily activities that were not adequately described in the initial documentation.
Working from the perspective of the provider, participants examine what information may be relevant to the request and how it could be documented accurately. They should distinguish among the patient’s reported experiences, the clinician’s observations, and the evidence required by the applicable coverage policy. They should also identify information that would require further clinical assessment rather than treating the communication tool as sufficient evidence by itself.
Participants then consider the insurer’s perspective. They should determine what information is necessary for a fair and informed review, how unclear documentation could be addressed, and whether the proposed process creates avoidable administrative work.
The discussion should distinguish improved communication from a guarantee of coverage. Participants should explain how better documentation could support decision-making while recognizing that medical necessity remains subject to clinical evidence and applicable coverage requirements.
Write the Requirement Before Buying the Technology
Competency connection: Procurement, requirements development, contract formation, acceptance testing, and change control.
A healthcare organization is preparing to purchase a new electronic documentation system. The initial procurement requirements specify that the software must record numerical pain ratings and produce standardized patient transfer summaries. During stakeholder consultation, clinicians and patients identify a need to document individual communication preferences and include clinically relevant supplemental information in authorized transfers.
Participants act as the procurement team and revise the proposed requirements. They should consider how the system will capture the information, how it will appear in the clinical workflow, and how receiving organizations will obtain it. The requirements must also address appropriate access controls and the possibility that patients may prefer different communication methods.
The group then develops an acceptance test. Rather than simply demonstrating that a field exists, the test should examine whether an authorized receiving clinician can locate and understand the relevant information during a simulated transfer. Participants should explain how they would document successful performance and what corrective action would be required if the system failed the test.
The discussion concludes by considering the commercial consequences of discovering the requirement after contract award. Participants should explain how change control, pricing, and responsibility for additional work might differ depending on whether the requirement was included in the original agreement.
The Value That Crosses the Boundary
Competency connection: Performance management, risk management, benefits realization, and organizational accountability.
Participants design an evaluation plan for a proposed pilot of the Neuroinclusive Pain Scale across several healthcare organizations. The evaluation must consider patient experience, clinical usefulness, operational performance, and project business outcomes.
Participants should begin by identifying what successful communication would look like from the patient’s perspective. They can then consider what clinicians would need to know, how the information would be recorded, and whether it would remain available when responsibility changed. Operational questions might concern clarification requests, documentation rework, or the time required to complete assessments. Business questions might address training costs, contractual changes, and the distribution of benefits among participating organizations.
The evaluation plan must also identify potential unintended consequences. A process that improves documentation but creates excessive workload may be difficult to sustain. A tool that provides additional information but is not understood by receiving clinicians may fail to improve decisions. A system that transfers sensitive information without appropriate safeguards may create new risks.
Participants conclude by recommending how the organizations should review the results and determine whether to continue, modify, or discontinue the pilot. They should explain which stakeholders need to participate in that decision and how disagreements about the meaning of success should be addressed.
Glossary of Key Terms
Acceptance Criteria
Acceptance criteria are the conditions used to determine whether work meets agreed requirements. They help customers and contractors establish a shared understanding of what successful completion means. In the patient transfer case, an acceptance criterion might require confirmation that essential communication information has been received and can be accessed by the appropriate clinical staff. The requirement should be specific enough to verify without relying on assumptions about what the receiving organization understands.
Benefits Realization
Benefits realization concerns whether completed work produces the improvements it was intended to achieve. A hospital might successfully implement a new documentation system, but the expected benefit would depend on whether the system improves the availability and usefulness of clinical information. Completing installation, training, and testing establishes that project activities occurred. Evaluating the benefits requires examining what changed because of those activities.
Change Control
Change control is the process used to review and authorize modifications to agreed project requirements. Suppose a healthcare organization discovers after purchasing a documentation system that it needs additional fields for communication preferences. The customer and contractor may need to negotiate the cost, schedule, and responsibilities associated with the modification. Change control helps prevent misunderstandings about what was originally promised and what constitutes additional work.
Contractual Interface
A contractual interface is a point where work, information, or responsibility moves between organizations operating under an agreement. Patient transfers create several interfaces because hospitals, transportation providers, and receiving facilities may each have separate responsibilities. An interface becomes particularly important when one organization’s ability to perform its work depends on information supplied by another.
Customer — Contractor Relationship
A customer — contractor relationship exists when one organization purchases work from another under an agreement. In healthcare, a hospital may be the customer purchasing transportation services from a contractor. The patient receives the service but may not be a party to the contract. This distinction matters because the contracting organizations may define performance through measures that do not fully represent the patient’s experience.
Handoff
A handoff occurs when information and responsibility move from one person or team to another. A nurse ending a shift may communicate a patient’s condition to the incoming nurse, while a hospital transferring a patient to another facility must communicate information across an organizational boundary. A successful handoff requires the receiving party to obtain and understand the information needed to continue the work.
Interoception
Interoception refers to awareness and interpretation of signals originating within the body. These signals may include sensations associated with hunger, temperature, physical discomfort, or other internal states. A person who has difficulty identifying or describing particular bodily sensations may find some conventional assessment questions challenging. Individual experiences vary, and interoceptive differences should not be assumed from a diagnosis alone.
Masking
Masking refers to concealing or modifying outward expressions or behaviors in response to social expectations. A patient may minimize visible signs of discomfort or attempt to appear calm during a clinical encounter. Providers who rely heavily on outward behavior may misunderstand the person’s experience if they do not consider the patient’s report and other relevant information.
Medical Necessity
Medical necessity concerns whether a healthcare service or item meets applicable clinical and coverage requirements. An insurer reviewing a request for rehabilitation services may examine the diagnosis, functional limitations, clinical findings, and treatment history. A communication tool may help gather relevant information, but it does not independently establish medical necessity or guarantee coverage.
Neuroinclusive Communication
Neuroinclusive communication recognizes that people differ in how they process, express, and understand information. In healthcare, this might involve allowing additional processing time, providing written or visual information, or offering alternatives to a numerical pain rating. The purpose is to make communication more accessible while respecting individual preferences.
Pain Communication Wheel
The Pain Communication Wheel is part of our developing work on neuroinclusive pain communication. It explores ways to support descriptions of pain that may be difficult to represent through a single numerical rating. Its potential applications include helping patients communicate aspects of their experiences and encouraging clinicians to seek relevant contextual information. Further research is necessary to establish its clinical properties and appropriate uses.
Project Business Management
Project business management addresses the commercial and contractual dimensions of projects performed through relationships between customers and contractors. It considers how organizations establish agreements, distribute responsibilities, manage risks, and coordinate the delivery of work. In healthcare, these concerns arise when organizations purchase technology, transportation, construction, consulting, and other services needed to support care.
Relational Value
Relational value refers to value that emerges through interactions and relationships among people and organizations. In the transfer case, the usefulness of pain information depends partly on how the patient, sending clinician, receiving clinician, and other participants communicate. Information may have limited value when it remains isolated, even if it was originally collected accurately.
Risk Allocation
Risk allocation concerns how responsibility for managing particular risks is distributed among parties. A transportation contractor may be responsible for safe and timely transportation, while a healthcare provider retains responsibility for clinical assessment. The contract should clarify these responsibilities so that organizations understand what they are expected to manage and where cooperation is required.
Stakeholder
A stakeholder is a person or organization that affects or is affected by a project or decision. Patients, families, clinicians, administrators, insurers, technology vendors, and contractors may all have interests in a new pain communication process. Their interests may differ, making stakeholder involvement important when developing requirements and evaluating outcomes.
Value Delivery
Value delivery concerns producing benefits that matter to the intended recipients of work. A transportation service delivers an immediate output when a patient arrives at the receiving facility. The broader value of the transfer includes supporting continuity of care and ensuring that the receiving team has access to information needed for appropriate decisions. Project business professionals should consider how contractual performance contributes to those broader benefits.
Annotated Bibliography
Centers for Medicare & Medicaid Services
Centers for Medicare & Medicaid Services. (n.d.). Standard documentation requirements for all claims submitted to DME MACs (A55426). Medicare Coverage Database. https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleid=55426
This Medicare coverage article explains documentation requirements for durable medical equipment claims, including the importance of medical records that support medical necessity. It provides a useful example of how reimbursement decisions depend on information collected and maintained by healthcare organizations. The article is particularly relevant to the insurance case because it demonstrates why a single assessment result may be insufficient to establish the clinical circumstances supporting a requested item or service. Its requirements concern a particular category of Medicare claims and should not be treated as universal rules for all insurance decisions.
Gurses, Mossburg, and Sousane
Gurses, A. P., Mossburg, S., & Sousane, Z. (2024, March 27). Communication during transitions of care. PSNet, Agency for Healthcare Research and Quality. https://psnet.ahrq.gov/perspective/communication-during-transitions-care
This article examines communication during healthcare transitions and discusses the importance of structured handoffs, teamwork, and continuity of information. It is particularly useful for the patient transfer case because it connects communication practices to patient safety and organizational processes. The authors’ discussion helps explain why transmitting standardized information does not automatically establish that a receiving team has everything needed for informed care. The article also provides a basis for evaluating handoff requirements and the limitations of relying on checklists alone.
Lehmann
Lehmann, O. F. (2022). Project business study book [Free edition]. Project Business Foundation. https://project-business.org/tools/project-business-study-book/
Lehmann’s study book introduces project business management and the commercial relationships between project customers and contractors. It provides the conceptual foundation for examining contractual obligations, organizational interfaces, risk allocation, and the management of work performed across organizational boundaries. The source is particularly useful for connecting healthcare service delivery to Project Business Professional education. It also helps explain why the interests of the organization purchasing a service, the contractor delivering it, and the person receiving the benefit may require separate consideration.
Project Business Foundation
Project Business Foundation. (n.d.). PBP certification. https://project-business.org/certification/pbp-certification/
The Project Business Foundation describes the Project Business Professional certification as a qualification for practitioners working on the customer and contractor sides of project business. This source establishes the professional education context for the teaching case and its activities. The applications developed in the essay connect healthcare communication problems to relevant project business concerns, including contracting, requirements, risk, and organizational relationships. They should be understood as instructional applications rather than a reproduction of the certification examination blueprint.
Raja and Colleagues
Raja, S. N., Carr, D. B., Cohen, M., Finnerup, N. B., Flor, H., Gibson, S., Keefe, F. J., Mogil, J. S., Ringkamp, M., Sluka, K. A., Song, X.-J., Stevens, B., Sullivan, M. D., Tutelman, P. R., Ushida, T., & Vader, K. (2020). The revised International Association for the Study of Pain definition of pain: Concepts, challenges, and compromises. Pain, 161(9), 1976 — 1982. https://doi.org/10.1097/j.pain.0000000000001939
This article explains the revised definition of pain adopted by the International Association for the Study of Pain and discusses the conceptual issues involved in defining a subjective experience. It supports the essay’s recognition that pain is influenced by biological, psychological, and social factors and that verbal communication is not the only means through which pain may be expressed. The article provides an important foundation for questioning whether numerical ratings alone adequately communicate every patient’s experience.
Shaw and Colleagues
Shaw, S. C. K., Carravallah, L., Johnson, M., O’Sullivan, J., Chown, N., Neilson, S., & Doherty, M. (2024). Barriers to healthcare and a ‘triple empathy problem’ may lead to adverse outcomes for autistic adults: A qualitative study. Autism, 28(7), 1746 — 1757. https://doi.org/10.1177/13623613231205629
This qualitative study examines barriers to healthcare reported by autistic adults, including communication difficulties, fear, and problems arising from interactions between patients and providers. It is relevant to the Neuroinclusive Pain Scale because it supports examining communication as a shared responsibility rather than treating differences exclusively as patient limitations. The study also provides a useful foundation for considering how organizational practices and professional expectations influence whether patients can communicate effectively.
Strömberg and Colleagues
Strömberg, M., Liman, L., Bang, P., & Igelström, K. (2022). Experiences of sensory overload and communication barriers by autistic adults in health care settings. Autism in Adulthood, 4(1), 66 — 75. https://doi.org/10.1089/aut.2020.0074
This study examines sensory discomfort and communication barriers experienced by autistic adults in healthcare environments. Participants described difficulties involving noise, sensory demands, provider expectations, and misunderstandings during clinical encounters. The findings are useful for understanding how healthcare environments may affect the communication of pain and other physical experiences. They also support the need to involve patients in developing communication practices that accommodate individual differences.
Final Reflection
The central concern in this case is how organizations define and preserve value when work crosses boundaries. The patient transfer provides a concrete example because it involves clinical judgment, contractual obligations, documentation requirements, and the experiences of a person who depends on several organizations working together.
Our work on neuroinclusive pain communication encourages us to reconsider the information we ask people to provide and the assumptions we make when interpreting their responses. Project business management adds another responsibility by asking whether the agreements and processes connecting organizations allow that information to be used.
For those working in healthcare, procurement, insurance, or other contracted services, the reflection is worth carrying into the next project. Consider a service that your organization currently purchases or provides. Examine what the agreement requires, how successful performance is measured, and whose experience is represented in those measures. Then consider what information might be missing because it does not fit the established reporting process.
The next useful improvement may begin with a different question, a revised requirement, or a conversation among people who have been working from different definitions of success.
The patient arrived. The paperwork was complete. Understanding still had to catch up
