Provider Training Provider: Variability Guaranteed

The goal in developing efficient, high quality and user-friendly systems is to eliminate as much variability as possible. Creating such systems depends on the collection of meaningful data and on the identification of the best practices that will serve as the backbones of the processes. What is frequently overlooked in the implementation of care processes is how we train care providers effectively in their use, particularly at the physician level. We usually fail to recognize that training is itself a system and that the outcome of the training is greater than 90% dependent on how the training is set up. Contrary to our popular belief in medicine, there are best practices in virtually all care processes and what we should be doing to provide the best care is to train directly to these practices. What we usually use instead is the model of care provider training care provider, and it guarantees the following:

1. Deviation from every best practice
2. Variability of care delivery between virtually every care provider
3. Inefficiency
4. Increased cost
5. Staff dissatisfaction
6. Compromised quality and safety

Care provider training care provider is suboptimal because of the following: When a care provider relies on his or her understanding and experience to pass on a best practice, it is inevitable that the transfer of the practice will be incomplete and that it will be modified; disagreement with the parts of the best practice or a particular anecdotal patient experience are frequent causes. The recipient of this training then applies his or her own interpretation and experience to the passed-on practice, which in turn gets passed on to the next recipient. And on and on… Before you know it, everybody is doing things their own way and the best practice becomes a distant memory. It’s not a big stretch to see how efficiency, quality and safety plummet while costs skyrocket.

Our suboptimal training model becomes invisible because it fits right into our culture of autonomous care – in fact it reinforces the culture! The dysfunctional training model, however, becomes visible to the user when it is taken to extremes (catch phrases to explain processes such as, “do as I say, not as I do” or “this is the way we’ve always done it” are good markers). Occasionally a dangerous practice points to the risk of the provider training provider model, as I experienced recently.

I was working with a senior resident who was supervising a very junior resident. We induced general anesthesia and the junior resident intubated our patient without incident. While I was holding the endotracheal tube in place so that the junior could presumably secure the tube in place with tape, he instead proceeded to protect the eyes with eye guards. I suggested to him that the first order of business should be to secure the airway and that he please do so, to which he replied “I’m sorry, but I’ve been told by many others to tape the eyes first,” while continuing to take care of the eyes. The senior resident then informed me that several years prior she had missed a coffee break because her attending, while taking care of a patient in another room, had accidentally spilled benzoin (liquid adhesive) into his patient’s eye during tube taping – since then she had trained everyone to protect the eyes first.

Fortunately, there were plenty of us around so that I could continue to hold the tube until it was taped in place, but you can imagine what could happen if this becomes his standard and there is less help available or during an emergency. The junior resident will be exposed to multiple variations to airway management as he works with different staff members during his training – what will he teach his junior when the time comes?

Food for Thought:
Everything is connected. Think about the perpetual loop of dysfunction that results in a healthcare system that embraces autonomy, the provider training provider model and the underlying absence of basic care processes. Each component reinforces the next and around we go. Systems-thinking is the only way to break the cycle, and education is another area that needs a systems fix.

Bells and Whistles vs. Tape and Safety Pins

Our obsession with providing the latest clinical interventions and technologies for our patients is both a blessing and a curse. As we have seen in previous posts, our attraction to the shiny new, the technically sophisticated, the next best thing results in our losing sight of the basic care processes that provide the critical support to innovation. Aside from the fact that we have never really learned how to implement and integrate new technologies using systems-thinking, our disregard for the basics repeatedly sabotages the success of any new intervention or technology.

As I was rounding on the post-operative pain service this week, I hit upon a great example of the new being implemented upon the crumbling old. We manage a large percentage of our post-surgical patients’ pain with epidurals and with peripheral nerve catheters. Regional anesthesia is particularly useful for major thoracic, abdominal and orthopedic cases, and by the end of the week we are usually managing pain for thirty to forty patients. Patients with epidurals and peripheral nerve catheters are generally very appreciative of the pain control provided with this modality, which validates and reinforces our use of regional anesthesia.

Regional anesthesia has been around for a long time and traditionally blocks were placed without direct visualization. When I did my regional anesthesia fellowship eleven years ago, we relied on superficial anatomic landmarks, tactile and verbal feedback from patients to guide our block placement. To reduce the risk of injury and to improve the success of the peripheral nerve block, we started using electrical nerve stimulators, which served as a type of homing signal and provided visual feedback as the nerve to be blocked was approached. The sophistication of the nerve stimulator increased but this was not good enough, so along came the next technology: Ultra-sound guidance. Now the possibility exists for direct visualization of the nerves to be blocked, presumably with another jump in successful pain control and a reduction of complications.

On the post-surgical side, the technology focus was on the pumps used to deliver the local anesthetics. What started out as adaptations to pumps used for intravenous medications evolved into sophisticated, patient controlled pumps designed specifically for local anesthetics. They were safer and provided the opportunity patient-centered pain control. The technology development for these devices continues.

Enter the snafu. In the fifteen years that I have been doing regional anesthesia and acute post-operative pain management, I would be hard pressed to say that the quality of pain management with nerve blocks has improved significantly. How can this be? We have better techniques for placing nerve catheters, the pumps are better, the technology in these areas keeps advancing. There are numerous reasons, but the one that jumped out at me was in the picture above: the connector piece between the block catheter and the pump tubing. The technical challenge is to secure the small bore nerve catheter to the large bore pump tubing such that it will be resistant to disconnection; disconnection disrupts the continuous delivery of local anesthetic, resulting in pain, and disconnection contaminates the nerve catheter end, resulting in an increased risk of infection. Catheter disconnects occur on an almost daily basis and in spite of this, look at the technology applied to this problem: safety pins, three way stop-cocks, tongue depressors, tape, more tape. This method of connection has not changed in at least fifteen years, not because we can’t improve upon it but because it just isn’t sexy enough to grab our attention! The absurd juxtaposition of the high tech supported by the primitive is not lost on the patients, who frequently let out a nervous chuckle as we jerry rig their lifeline for pain control.

What struck me about this example is how analogous it is to the current condition of healthcare. Technology advances and the focus of most quality initiatives occur on top of an invisible infrastructure of basic care processes that are barely being held together by creative repair jobs. When they break, we add more tape. They get our reactive attention only when something catastrophic happens. Usually we add more tape…

Until we make these basic care processes visible and important (the critical 20%), quality improvement will remain marginal and expensive.

Wrong Site Surgery: What do we expect?

An article was published in the Boston Globe this week about a wrong site surgery that happened at the Beth Israel Deaconess Hospital (BIDMC) on Monday (see http://www.boston.com/news/health/blog/2008/07/surgeon_operate.html). Unfortunately, wrong site surgery continues in many hospitals in spite of all of the attention placed on prevention. Why does this continue? Here are two likely contributors.

1. Nobody is paying attentions to the broken care processes that support the high profile safety initiatives. Even though my blog post from last week did not depict BIDMC, the chaotic OR work environment that the nurse describes in her hospital has parallels in almost every US hospital. Nurses spend as much as 45% of their time looking for missing instruments and equipment every day – if everyone is hunting and gathering just to get a case going, is it any wonder that site verification and the safety pause gets overlooked? There’s another systems principle that states that an organization will only measure what it considers to be important – if it’s not measured, it’s not important. Reflect on the computer entries for OR efficiency in my preceding post and you will notice that the only thing that’s important is getting into the room on time; there’s no valuable measure of the underlying process for room preparation that would flag anything that the nurse describes. If it’s not measured, it’s not important.

2. We have misunderstood the use of inspection in a quality process. Here’s a fundamental rule on the use of inspectors: they are not to be used as part of the quality process; instead they are there to identify problems that have already occurred in the process so that they can be fixed! Further, the more inspectors you have the worse the quality oversight; nobody takes responsibility for overseeing the process. Think about how we do site verification. Every care provider involved is typically responsible to site verify before they do anything with the patient. Most of the time every care provider is already multi-tasking, hunting and gathering and doesn’t have the time to be thorough; “No problem,” they think, “somebody else will catch any issues I miss before we get to the OR.” The patient comes into the OR, and now we have the safety pause being performed by everyone who has already done their own verification process in preop: think they’re focused, especially now where they’re under pressure to get the case started? To them it’s a redundant formality and there are more important things to do.

Food for thought:
Care providers are set up for failure when they work within these care and quality processes. The 90/10 rule rears it's ugly head again to create catastrophic patient harm! Until we make these underlying care processes visible and fix them with frontline input, we don’t have a prayer in eliminating wrong site surgery. We also have to learn to use inspection (site verification and the safety pause) in a way that it can be effective – with undiluted accountability and to improve the care process.

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I will be on vacation next week, so no blog post until the week of 7/14/08.