When Best Practices Aren't: How The Opioid Epidemic Relates to Framework Policies.

(The idea for this article was inspired during a conversation with Rob McNealy, the CEO of TUSC Network)

Zombies. That’s what I call them. You see them standing in front of stores; wobbling back-and-forth in the middle of a parking lot; leaning on and talking to telephone poles; and sometimes crawling under parked cars like a confused earthworm after a heavy rain. They are disheveled, dirty, unkempt, and completely unable to realize the reality they are in is not reality for the rest of the world. They are completely strung out and high as a kite. Unless you live in a corn field in the middle of Iowa – you’ve seen them too. They are the visible symptom of what the government and the media has labeled as “The Opioid Epidemic.”

How did they get that way; and what does this have to do with corporate frameworks?

If you’ve ever been to the doctor or ER in the past 30 years you’ve seen it and been asked. “Can you tell me your level of pain, from one to ten; with 1 being no pain, to 10 being severe pain.” Even in pediatric hospitals, this is used – and it’s standardized to the Wong-Baker FACES Pain Rating Scale which was assisted in design by children. It was, (and still is to a point) useful in the initial triage and diagnosis of a patient’s level of pain and discomfort. Thirty years ago, this didn’t exist. Thirty years ago, zombies weren’t an issue either. 

As the varied policies and practices of ERs, nurses, doctors and care-givers slowly adopted their versions of a pain scale, ten years passed and we entered the 2000s – a turning point in the culture of pain in the United States. Congress declared the first 10 years of the 2000s to be “the decade for pain, the decade for improving pain” – and then under President Bill Clinton, H.R. 3244 was signed into law making pain control and research a priority.

A culmination of historical events, private practice evolution, and government intervention gave rise to zombies. Throughout the late 1980s and into the 1990s, a growing recognition was occurring that pain, in and of itself, was being vastly under-treated and not taken seriously. Doctors were overly cautious regarding the prescribing of opioids for the treatment of pain. However, at this same time, the population of the United States was, demographically, aging and “dealing” with chronic pain. The Department of Veterans Affairs was inundated with an influx of Vietnam and Gulf War Veterans who had been suffering from chronic pain and were fed up with the lack of treatment options. The civilian population was suffering too. Vocal complaints regarding the lack of treatment began to have an affect on policy, funding, and practice. Professional societies began to take up the issue – as did drug manufacturers; and the main hospital accreditation agency stepped in and decided that they should make a quality measure about the assessment of pain and created a system to assess pain more often so that it would be treated better. They began to require that hospitals regularly assess pain as a measure of quality – like measuring a vital sign. 

The zero to ten scale was, at this time around 10 years old; and fitting that it would begin to become institutionalized in its implementation. Numbers and facial expressions are a universal language; the description of pain isn’t. So, this became an American medical-industry standard for pain measurement and description.

The historic undertreatment of pain as it relates to the quality of life for a patient lead to the Joint Commission Act. The JCAHO (Joint Commission on Accreditation of Healthcare Organizations), with congressional approval, released new pain-management standards for hospitals which included the zero to ten charts we are all now overly familiar with. This became effective in 2001 and mandated that hospitals:

• Recognize the right of individuals to receive appropriate assessment and management of pain
• Assess the existence of, and (evaluate) the nature and intensity of, pain in all patients, residents, or clients.
• Establish policies and procedures that would support the appropriate prescribing or ordering of effective pain medications
• Educate patients, residents, clients, and their families about effective pain management.
• Address the patient’s needs for managing symptoms in the discharge-planning process.
• Incorporate pain management into the organization’s performance measurement and improvement program.

And the public became aware of this through mandated educational campaigns that told the public what their “rights” were. This fully affected the legal community and began a series of high-profile lawsuits wherein patients would begin to sue, and win, hospitals and doctors for not treating their pain. If medical practitioners did not treat a patient’s pain, they could be subjected to malpractice suits; and because pain is not measurable, except for the description by the patient, practitioners were mandated to treat the pain based on the description of the patients. This, inevitably resulted in the rise and prevalence of opioid prescribing in the United States – every single year since the early 2000s. Increases in Oxycodone, hydromorphone, hydrocodone, methodone, morphine, and fentanyl prescriptions nearly doubled by 2005 – and have risen each year since; and now we have zombies. They look the same, walk the same, are covered in the same dirt; smell the same; and are addicted the same – because a policy of best practices was implemented in order to “help” – but it harmed the country more than it benefited the individual. Sure, doctors are over prescribing opioids – but it’s because we now treat pain as a vital sign. If they don’t prescribe, they get sued. 

Best Practices is a term which should be individualized to each separate organization and how they operate. It’s quite obvious that best practices are a fantastic tool. They can inspire thought; provide windows into other processes for success; safeguard operations; and even educate. There is tremendous value in learning from the experience and success of others – and it’s natural for a company to recognize the solution process of another and adopt it. But there are ALWAYS unintended consequences when best practices are copied, verbatim and implemented without consideration of the differences between your organization and the organization who created the original document.

The Children’s hospital who helped create the pediatric pain scale doesn’t operate or interact with patients in the same way that a Chicago ER facility would. Having the government step in and mandate the approach of one, to the other, helped facilitate the problem we are in now where zombies wobble in our streets. And your organization doesn’t operate in the same way as the other hundreds that have adopted any specific framework process. By implementing a rigid policy, you run the risk of becoming a carbon copy of your competitors, or at worse, failing to innovate and capturing a market share – in effect, becoming a zombie of your own making. 

Now, I’m not saying frameworks should not be implemented – quite the opposite actually. I’m saying that organizations should take from those frameworks and implement them according to their own internal processes which allow for the proper continued innovation and change inside (and outside of) that framework.

Many, (ok, most) organizations misinterpret best practices or implement them badly when they attempt to take on the implementation process internally. Even with Agile and DevOps layers, they goof it up and pigeonhole themselves, limiting internal innovation, restricting creativity and affecting growth. It’s tantamount to an errant copy-and-paste error. Without understanding the framework, an organization doesn’t understand where it can be expanded or constrained and they implement the most rigid, most restrictive, and most cookie cutter version of the guidelines – and then they suffer. 

Don’t suffer. Don’t pigeonhole yourself. When you are looking for anything from a service desk built on ISTM principles to ISO manufacturing processes – understand that companies exist who are experienced in identifying processes and implementing designs based on framework guidelines that don’t stifle your creativity and don’t restrict your growth. 

Don’t be a zombie.  

The staff here at Link Technologies (www.linktechconsulting.com) holds top industry certifications and degrees including: PCI DSS QSA - PCIP - CISSP - CEH - GPEN - GCIH -GISP - CCNP - -CISA - CISM - CGEIT - CRISC. We are a certified 8(a) Graduate, SDB, WOSB, and DBE established in 2000. We offer professional services specializing in information technology, project management, cyber security and audit and compliance support. Our solutions and services not only enable organizations to meet their needs and strategic goals, but also provide organizational efficiency and/or competitive advantages. Our full breadth of solutions and services integrate approaches that incorporate best practices and applicable federal regulations such as FISMA, NIST, ITIL, ISO and others, without stifling your innovation.