Assess carefully before starting training programs
Focus education on root causes, not symptoms
By Patrice Spath, RHIT
Brown-Spath Associates
Forest Grove, OR
Monitoring of incident reports suggests that caregivers are not performing up to your patient safety expectations. People seem to make many of the same types of mistakes over and over again. Cautionary memos and discussions in staff meetings haven’t really changed the situation. What should your organization do to reduce patient incidents? Train your employees better?
Not necessarily: Be careful to assess the cause of the problem before spending time and money on training programs. When education solutions are directed toward treating the symptoms and not the underlying root causes, nothing will be resolved.
Consider the following scenario: Worried about a rise in the number of medications that were not being given to patients at the prescribed time, the nurse administrator surveyed the supervisors to find out what type of training was needed to resolve this problem. The supervisors indicated that they needed more skills in communication and employee motivation. A similar survey of staff revealed their need for time management and conflict-resolution training. The survey results yielded a shopping list of topics for inservices and workshops. Educational initiatives were undertaken, and everyone participated in the mandatory training. Upon completion of the programs, the organization anxiously waited for the rate of on-time medication delivery to improve. However, six months later, the number of late medication doses had returned to pre-training levels.
This attempt at improving patient safety was doomed from the outset. Asking people for their training needs presupposed that a lack of skills was the cause of medication being administered at the wrong time. There is an old training adage that asks the question: "If the employee’s life depended on doing the task, could he or she do it? If it could be done with this ultimate’ motivation, then training is not the solution, because a skill deficiency is not the cause of the problem." Were the supervisors really incapable of communicating with their staff or encouraging people to perform according to expectations? Were the staff nurses truly incapable of managing their time efficiently or taking charge in disruptive situations?
If supervisors and staff honestly believed that they needed training to improve on-time administration of medications, then the question that must be asked is "Why?" Why do they think they need training to perform what should be considered a routine job responsibility? What is the real problem they want to solve? Teaching supervisors better strategies for motivating employees usually will not solve a performance problem when the real cause may be unrealistic performance standards or allowing insufficient time for staff to properly complete their jobs.
Learning about conflict resolution will do nothing for employees who feel de-motivated by pressures to do more work with less-qualified staff. It would have been more useful if supervisors and staff were asked "what do you want to be able to do to improve on-time medication administration and why?"
Too often, health care organizations prescribe training solutions for problems that, when properly diagnosed, turn out not to be training-related problems. As a result, people are inundated with training and monies are expended, and yet significant problems remain unresolved. It’s no wonder that employees begin to question the credibility of performance improvement initiatives that often rely primarily on training solutions. Many times, a quality or patient-safety concern is a symptom of an organizational design or management problem and not the result of skill deficiencies in the work force. What may be missing is a systematic process for managing the performance of all employees. Focusing on a few individuals’ apparent skill deficiency will not solve the performance problem if the problem is the failure of fundamental management and supervision systems.
There are a number of reasons why people don’t properly follow procedures or fail to meet performance expectations. When designing solutions to noncompliance problems, start by investigating the cause. Through interviews and surveys, discover the causal factors that affect people’s decision not to follow generally accepted patient management practices. The knowledge gained through this analysis will lead to the right solutions.
Safeguard training dollars
With budgetary allowances for staff training and education shrinking, the need to spend training dollars wisely is more important than ever before. Accreditation standards and other external requirements consume lots of training resources, leaving very little for specially focused education. When determining the best way to solve noncompliance issues, don’t assume training is always the solution. Digging deeper into the causes of noncompliance may unearth systematic problems with the organization’s management systems that require more than a quick-fix training session. Your training resources should be preserved for those situations in which knowledge or skills deficits are at the core the problem.
[Editor’s Note: In a new book, Guide to Effective Staff Development in Health Care Organizations: A Systems Approach to Successful Training (Jossey-Bass/AHA Press, 2002), Patrice Spath and a panel of health care experts describe how to link performance improvement goals with education and training priorities. Included in the book is a model for integrating all facets of staff education and performance evaluation as well as tips on how to select the best training methods. For ordering information visit the Jossey-Bass web site (www.josseybass.com) or call (800) 956-7739. ISBN: 0-787-95874-3.]
Causal Factors and Root Causes of Noncompliance
Was noncompliance due to people not knowing what to do? If yes, which of the following causal factors were present?
- People never knew what to do. This is often an indication of inadequate training or a system failure involving lack of dissemination of guidance to the work force. Improper training methods or communication failures may be root causes.
- People forgot what to do. This problem may be resolved by increasing the frequency of training or through periodic refresher courses. In addition, a systemic problem may exist if the process lacked sufficient safeguards to correct the error before an untoward event occurred.
- People didn’t realize that specific tasks were part of the job. This is often the result of lack of experience or lack of detail in guidance. Faulty mechanics for staff orientation and/or oversight may be the root causes that need fixing.
Was noncompliance due to people not being able to do the job? If yes, which of the following causal factors were present?
- People are unable to do the job because of scarce resources. Lack of resources or funding is a common rebuttal to questions about noncompliance. However, resource allocation issues may be a symptom of flawed decision making and priority setting at some level of management.
- People don’t know how to do the job. Even when people know what to do, they might not be able to comply with job requirements due to lack of knowledge, training, or critical-thinking skills.
- People find it impossible to do the job. Are there certain tasks that cannot be completed as required? Root causes may be inadequate resources, insufficient knowledge or skills, or unrealistic job expectations. The reasons for these problems must be identified before solutions can be found.
Was noncompliance due to people’s refusal to do the job? If yes, which of the following causal factors were present?
- People are not rewarded for meeting job expectations. There may be no incentive for individuals to complete the tasks expected of them. This problem suggests that the organization’s performance management system for employees needs to be evaluated and strengthened.
- People are not penalized for failure to meet job expectations. Simple human errors should not result in disciplinary or punitive action. When individuals repeatedly and intentionally fail to carry out critical tasks, some type of enforcement action should occur. Failure to take these actions is a symptom of problems in the management and supervision system.
- People disagree that the task should be done. Some individuals refuse to comply with job requirements that they disagree with or think unreasonable. This attitude can be a symptom of a variety of problems. Collect additional facts to determine the root cause. Please save your monthly issues with the CE questions in order to take the two semester tests in the June and December issues. A Scantron sheet will be inserted in those issues, but the questions will not be repeated.
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