Culture and Patient Safety (or, "The No-A**hole Rule")

[EpiEMS]

Saw a fun (if a tad dated) little experiment in a write up in the news today, and I thought I'd mention it:

Briefly (taken from a WSJ blog post linked to above)...

Researchers in Israel analyzed 24 neonatal intensive-care teams (physicians and nurses) doing a training exercise to diagnose and treat a premature newborn whose health was rapidly deteriorating because of necrosis of the intestines. (It was a mannequin, not a real baby.) One group of teams received an introduction from an observing ICU chief from the U.S. who stated that he was “not impressed with the quality of medicine in Israel” and that Israeli medical staff “wouldn’t last a week” in his department. The other teams received neutral comments about improvement.


The teams randomly exposed to incivility made significantly more diagnostic errors (e.g., not recognizing bowel perforation) and treatment errors (e.g., improperly ventilating the baby). Analysis of videotapes showed that reduced collaboration and communication (like information sharing and help-seeking) accounted for the inferior performance.

This made me think about the culture of EMS - and how a no-a**hole rule would go a long way. I can't tell you how many times I've been yelled at or seen somebody yelled at - particularly a younger provider by an older "experienced" provider.

Do you think the culture of EMS in your service, area, or nation is consistent with quality care? How can we make it better? Anything we can do as individuals to advance the "no-a**hole" concept?

 

[hometownmedic5]

Ive often thought one of the biggest problems we have in this industry is the institutional history of eating our own young. When we were new, our seniors berated us, forced us to tech every call, our work was never good enough, we did all the chores(or at least the bulk of the less popular chores) and on and on. We all hated it, felt abused, and many didn't make it out the other side. Fast forward a few years to when we're training the next group and what do we do? The same thing. "Well, that's how its always been done" and so forth.

I think this affects patient care in many ways. One, people who under different circumstances would have grown to be excellent providers, are run out of the service(ad perhaps the profession). Those who remain may be the toughest but potentially not the best providers that could have been. Two, we force people to handle work beyond their capacity. Naturally, we all have to be challenged to grow, but there is a line and I feel the typical method of training crosses it time and time again. This puts incompetent providers in charge of patients outside of their capabilities. Three, there exists a distinct "my way or the highway' approach that is frequently outdated or blatantly wrong due to ignorance or laziness in regards to the lastest methods. While not every new idea is better than the old, or even as good, the idea that "this is how I've always done it" forces new thinking out of the truck; so we breed another generation of people doing the same old tired crap we KNOW doesn't work, but we do it anyway because its comfortable and familiar.

I don't know how to fix the system, but the problems are right there to see. Yes, i think a DBAA policy would immensely help us grow as a business; but who decides the standards, how do we implement them, ensure compliance, strive for continuous improvement, and train the next generations of not AH's?

 

[DrParasite]

Three, there exists a distinct "my way or the highway' approach that is frequently outdated or blatantly wrong due to ignorance or laziness in regards to the lastest methods. While not every new idea is better than the old, or even as good, the idea that "this is how I've always done it" forces new thinking out of the truck; so we breed another generation of people doing the same old tired crap we KNOW doesn't work, but we do it anyway because its comfortable and familiar.

Honestly, this is one of the reasons I don't miss EMS. I had a FTO who was always "my way or the highway," and even when he was wrong, if a better idea was suggested, he didn't want to hear it. He was the FTO, and he knew everything.

I had another one who wanted me to make my own decisions..... which was great, except if I didn't do what she would have done, it was considered a negative mark on my review. She also didn't want me to ask her what she wanted to do (which was contrary to the other FTO), so if I asked her I was wrong, and if I didn't do exactly what she would have done, I was also wrong.

I'm also not saying the book is always right, but if the training in the classroom/academy and the training in the field aren't lining up, than you really can't blame the students for not knowing what they are supposed to do when they get into the "real world."

 

[EpiEMS]

I've yet to see the "my-way-or-the-highway" approach be as prevalent in settings outside EMS. I have to wonder if it is an artifact of an ingrained protocol-driven mindset.

 

[VentMonkey]

I'm seeing a lot of the "my preceptor/ trainer/ FTO is the coolest" and the results yielded are no better.

I don't think a "my way or the highway" approach is by any means rational anymore, but clearly the opposite is hardly any better. Structure is important, but not overkill. Not everyone appreciates gunny (I personally loved that mentality and occasionally miss it), but where's the fine line when handed the unrealistic "whacker", or "squirrel" fresh out of EMT or paramedic school?

Mentorship is by no means for most people, I think it's a gift given to a select few that (as was pointed out in another thread) is oftentimes indirectly taken in when the mentor may be completely unaware.

 

[EpiEMS]

@VentMonkey, no disagreement that "my FTO is so cool, bro" could easily be just as bad as "my FTO is so mean, bro". That said, at least there isn't the element of paramilitary...lines of authority, say, but something closer to a pedagogical relationship befitting a professional environment.

Structure is certainly important, and it would be very useful around a whacker-type, but I think you'd agree that, eventually, it'd be awfully nice to ensure that it isn't drill sergeant-like?

 

[VentMonkey]

Thing is- it's not solely up to the FTO, or training program. Just ask any former, or current trainer with enough time on if they've had their fair share of knuckleheads, or trainees that just plain didn't take their role as the trainee all that seriously.

I mean if we're going to keep talking about what we can do to improve EMS, or training, or pay, or any of these endlessly redundant subjects why not start with one phrase? That phrase is "individual accountability".

Here's a question to ponder for another thread or study: how many trainers are driven away from training (which I'm sure they started out doing with good intentions) because of its lack of, yep, structure?

It works both ways, and it's like most things in EMS a bigger problem than we seem willing to own up to. Harsh? Sure, but truthful nonetheless. My service is currently short of qualified paramedic trainers, I doubt we're the only service with this issue as well.

 

[DrParasite]

I've yet to see the "my-way-or-the-highway" approach be as prevalent in settings outside EMS. I have to wonder if it is an artifact of an ingrained protocol-driven mindset.

Have you looked at the military? How about med school? or even better, ever spoken to a PhD candidate, who is writing his or her thesis and disagrees with the suggestions their adviser suggests?

Truth be told, I'm a "rules and by the book" kinda of guy. Well, I like knowing what the rules are, so I know where I have wiggle room. But I also think (I know this is going to blow your mind) that the rules should apply to everyone, and not just a select few.

If the "organization's" rules say every call WILL be answers with a lights and sirens response, that's cool..... but if my FTO says "we won't be using our L&S on these calls" then conflict occurs. if my FTO says "every patient will be carried out in a stairchair, regardless of complaint," because that's how the agency wants it, no biggie; but if I go with another FTO, they should be telling me the same thing.

When you are in basic EMT class, an EMS agency academy, or a company's orientation, you are taught "the rules." these rules should be in use in the field as well. and a good FTO needs to be proactive, and guide the newbie employee, as well as quiz them to make sure they know the rules. and if the FTO doesn't know the rules, or predated said rules, or have issues following the agency's rules, than they shouldn't be an FTO, regardless of how long they have been with the agency.

I don't care if my FTO is mean to me. Provided that person makes sure that I know my job, tests me on what I need to know to be cleared, and educates me on what I need to know to be cleared, including on stuff that wasn't covered in the academy. Yes, there are some snowflakes out there that get their feelings hurt if you tell them they were wrong, but if you are clear in your expectations, give them the tools to do the job, and correct them objectively when they screw up, then they should be fine and become a productive member of the organization. Oh, and just we are are clear, I'm completely against being mean just for the sake of being mean; that's called bullying, and I have zero tolerance for bullies in the work place.

I also don't want an FTO who is too nice to do his or her job, where they won't correct screw ups, until final testing occurs and the person thinks they know it all when they don't.

While I will admit there is often a large gray area in EMS, newbies should be given a black and white setting so they can learn the rules; once they know the agency's rules, than they can learn where they have the gray areas.

 

[EpiEMS]

@DrParasite, your points are well taken - I'm a bit more concerned about the pervasive bullying that I've seen with several services in my response area, and, as you say, there should be zero tolerance for that.
When you reference the military, I don't disagree -- but that is an unfair comparison. Medical school, PhD programs, etc. - that's more like it. As rigorous as graduate school can be, I would be thoroughly surprised if people are unwilling to listen or discuss issues/alternative approaches - I never saw that in my undergraduate studies (nor in my work outside of EMS, whether in healthcare or not). Heck, it's the rare professor or boss that wouldn't consider an alternative way of doing something if they were presented with it cogently.

 

[StCEMT]

It wasn't that long ago that I was in the student position. The best people to ride with were the ones that set out clear expectations from the very beginning (not my way or the highway type), asked me questions before and during the call to see what I was thinking, let me get out there and do things on my own, and gave helpful feedback at the end.

Recently had an EMT student ride with me. Enjoyed having someone ride, but it is easy to forget to slow down and and keep them up to speed.

 

[NomadicMedic]

This is a great discussion. One of my favorites of the week.

 

[VentMonkey]

Alright, well then to further contribute:

The title and Ep's questions ask about a "no a-shole rule", or culture. Life is full of them, this industry is no better. FWIW, most public service agencies very much have a "my way or the highway" mentality about their particular department, or service.

Does it make it right? Probably not, as change can bring about positives more often than negatives if embraced correctly, and within reason.

We teach EMT's a few hundred hours of book work at best, and often put them with trainers who for a number of reasons may not "fit" their need. Again, our supply of efficient and willing (key words) trainers is lacking, though demand is high.

When I started training I had quizzes, goals, and routines depending on the particular student. After a while I saw more often than not people who expected to "just pass"; honestly, it was disheartening.

I'm not justifying hazing, or bullying. I'm not saying that the trainer found screaming at their intern or trainee is right. All I am saying is what lead them to that? Should they have been a trainer in the first place? Are they burnt out? Are they at that final hour, or "breaking point" with said trainee?

It can be extremely frustrating when you've attempted to "adapt" to one's style of learning only to find out they're still not retaining anything.

So again, who's to blame? The school for not "teaching" the student? The service for not strictly enforcing all rules across the board? The student for not taking their studies seriously, and expecting to be spoon fed their training? The preceptor who perhaps should not have been a trainer in the first place, or at least long removed from the environment, and/ or given a break some time ago?

This problem is everywhere, and anywhere. Sure, it's more prevalent in the public services, but the bigger question to me is why does it seem more tolerated with fire, and police services?

Again, no excuses here, we're all accountable for our own decisions in life. Whether we choose to accept the "rough around the edges" preceptor, or whine our way through life holding everyone else accountable EMS won't have any of the "accepted culture" seen elsewhere for all the same reasons we don't deserve pay raises; none of which need to be constantly beaten into every thread, though the relevance always seems to blend together.