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.