- Email: [email protected]
Houston, We’ve Had a Problem: When Do We Override Rules?
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There is an old adage that “Rules are made to be broken.” But how are we to decide how and when rules are to be broken? FORUM
Houston, We’ve Had a Problem: When Do We Override Rules? DANIEL E. HAUN ARGIE LEACH, MHS RITA VIVERO, MBA SARAH W. FRASER
I
magine this scenario:
It is 2108h on April 13, 1970, and Apollo 13 is speeding toward the moon. Lovell: “Houston, we’ve had a problem.” Mission Control: “This is Houston. Say again please.” Lovell: “Houston, we’ve had a problem. We’ve had a main B bus undervolt.” Mission Control: “The book says to turn up the voltage control.” Lovell: “Well, I tried that but there’s been an explosion.” Mission Control: “Well, it always works to turn up the voltage.” Lovell: “We are in a tough jam. Can you think of something else?” Mission Control: “Listen, we have to follow procedure.”
Daniel E. Haun, is Director of Client Services; Argie Leach, MHS, is Competency Coordinator; and Rita Vivero, MBA,
is a Performance Improvement Analyst, Department of Pathology, Medical Center of Louisiana at New Orleans, New Orleans. Sarah W. Fraser is an Independent Consultant and Visiting Professor, Middlesex University, London. Copyright © 2002 by the Joint Commission on Accreditation of Healthcare Organizations
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Now compare the scenario to the following incident: A cerebrospinal fluid (CSF) specimen is collected in four tubes and delivered to the laboratory with the proper requisitions, but the tubes are not labeled correctly in that the patient’s name is not printed on the tubes as required. The group of orders consists of a CSF cell count; glucose, bacterial, and fungal cultures; and cytological evaluation. The receiving area forwards the tubes and paperwork to the appropriate laboratories, and by the end of the day almost all specimens have been successfully analyzed—all except for the fungal culture and the cytological evaluation. Both of these samples have been rejected and returned to the nursing station. Although three lab supervisors modified the specimen acceptance rules and took other steps to determine specimen integrity, two other supervisors followed the rules—to reject all incorrectly labeled specimens. The authors thank Dan Kiff, RN, Geraldine Marquez, RN, and Tommy Lotz, RRT, for their input on rule breaking in other disciplines. Please address requests for reprints to Daniel E. Haun, Department of Pathology, 1532 Tulane Ave, New Orleans, LA, 70112; phone 504/903-7528; fax 504/903-5634; e-mail [email protected].
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THE JOINT COMMISSION The quality improvement (QI) team in our pathology department discussed the incident and asked, “Should we try to teach people how to make exceptions, bend rules, and even break rules when necessary?” As a team we modify and rewrite rules all the time because we are empowered and unified behind the shared goal to improvement. Yet we see the need to extrapolate the responsibility to make exceptions and break rules to the individual practice level so that problems can be solved.
Where Do the Rules Come From? Rules, which are intended to maintain a standard that will ensure quality and efficiency in normal circumstances, are used in every workplace. In the health care setting, specimen acceptance criteria is one set of rules required by accrediting agencies, but there are many other examples. The rules are very important, and skipping rules or misapplying rules is a major source of medical error1 and error in general.2 For instance, skipping a rule to check for a specimen artifact may easily result in a missed diagnosis. For a physician to skip a foot examination on a patient with diabetes can result in a less-than-optimum patient outcome. There is little justification for skipping steps or modifying rules to save time or improve productivity. But what if the rule modification will serve a patient outcome by preserving a sample that was obtained at high risk to the patient or was otherwise very difficult to collect? What if fast (but unauthorized) action by a critical care nurse can save a life? When the circumstances permit, can we make exceptions to the rules and still maintain the order and safety that rules provide? The key here is “normal” circumstances. Although the hospital is made up of buildings, equipment, and materials, the main components are human operation and interaction. The nature of complex human interdependencies means that the context and operation of the hospital will constantly be adapting to small changes, some of which mean the rules are no longer applicable3; namely, the circumstance has moved outside the norm. In the CSF example, the error of poor labeling created the opportunity for even more error and poor patient outcomes. When the rules no longer apply, the responsible action is the one that breaks the chain of adverse events.
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People Make Mistakes–Get Over It! In 1994 Leape described the need to abandon the “perfectibility model” of error prevention.4 Instead, the call is for systems that detect, correct, or at least mitigate the effects of the error—to move from the person approach to a system approach to human error.5 This is more than quality assurance or inspection of tasks and processes. The behavior of human systems is not linear; each interaction and result affects the next person in a cumulative and uncertain way.3 Most of the time, the system behavior is well within the norms that the rules define. However, when the unpredictable occurs and the operation falls outside the norm, then the idea is to somehow achieve the best patient outcome in spite of the error. So how are we to proceed in the context of our rules-driven work? A bit of theory might help. Reason’s and Mycielska’s cognitive theory leads to the understanding of rules as schemata, much like the mental schemata that we use in everyday life.6 But to be successful, we must oversee our schemata by paying attention. Nurses are trained to follow physicians’ orders and can generally follow the order to the letter. But nurses by training and experience come to be quite skilled at recognizing physicians’ errors and must oversee the normal scheme of following orders. All automobile drivers have schemata that make the driving experience seem effortless, but skilled drivers apply attentional oversight and observe for rule violations. One simply cannot expect that all drivers will drive within parameters all the time. People speed, run stop signs, and make mistakes. Rules do not always lead us to the desired outcome because either they are no longer fit for the purpose–namely, the circumstances have changed–or there has been a drift in performance. Think about the small bad habits that have crept up on your driving skills since you passed your driver’s test. Yes, you are still operating within the rules, yet you have made adaptations that over time may increase your liability to error. When the outcomes are endangered, we need to recognize we are no longer operating within the norm and devise alternative solutions. Effective performance improvement teams are charged with measuring outcomes and devising solutions at the system level, but individuals also do this at the practice level. Suppose that a respiratory therapist finds that a patient is in respiratory distress or has
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become hemodynamically Takin’ Care of Mama: The Performance Improvement Report unstable. Yet the therapist cannot reach the attendNew Year’s Day 2001 ing physician because the Inside: beeper system is temJust-in-time training. porarily broken. The therElectronic knowledge support at MCL apist has to make a New staffing and development plan. New MCL career path established in partnership with LSU judgment and perhaps Continued laboratory reorganization. break a rule by obtaining Full integration of receiving allows for oversight and error blood gases and altering reduction. gas ratios before receiving Mama presents at CDC. the orders. The rules are Team invited to present ideas and findings Trini’s Mom, Antoinette made on the assumption that a physician can All this and more in this issue of TCM always be reached in time, but in real life we Figure 1. Performance improvement efforts are reported in a newsletter that always features someone’s mother (an “honored” staff member or a staff member’s mother) to reinforce the goal of “mama quality.” see otherwise. Suppose you are dri- MCL, Medical Center of Louisiana; LSU, Louisiana State University; CDC, Centers for Disease Control and Prevention; TCM, Takin’ Care of Mama. ving during a power outage and come to a traffic light, where suddenly you have a problem. Do you reach the level of “mama quality”—quality suitable for speed through the light, slow down, or stop? To find my mama, not just any mama. your solution you will consider the circumstances— When we initially designed our competency weather conditions, time of day, and traffic patterns— assessment methods for our laboratory, our goal was and you will devise an alternative course of action to meet an accreditation standard in the easiest possitaking into account all the variables known to you. ble way. At the time, we thought that competency assessment was unnecessary, and we did not want to affect productivity negatively. Our competency assessWhat About Goals? The intention of the rules-based world is to efficiently ment program showed us to test at near 100% perforreach our goals, just as the traffic signal rules help us mance, and yet we had failures in practice. However, efficiently and safely reach our driving destinations—a when we changed the goal of our assessment program goal shared by all drivers. Each health care worker also to that of detecting (and predicting) poor perforhas a set of goals—some personal and some shared mance, we discovered significant incompetence at across the organization. As an organization, we hope many levels in the organization.8,9 We also found that our workers share the general goal of improving meaningful improvement opportunities. the health status of our patients, and the goal is marAlthough the goal of mama quality is easy to sell keted to workers in the form of mission statements and to a handpicked team, the issue of conflicting goals value statements. When mission drives individuals and looms large in any discussion of empowering larger teams they enter into a world where rules can be mod- numbers of people to break rules. We try to sell this ified to meet the goal, be it saving a single laboratory idea in many ways. For instance, we report all of our outcome or changing an outmoded process.7 Shared efforts in a newsletter, and we always put a picture of goals in complex situations allow individuals and someone’s mother on the cover (Figure 1, above). We teams to self-organize and respond to problems tell the story of the improvement effort rather than simply present numerical data, and when improve(opportunities) with creative rule-breaking ideas. Our laboratory-based teams ask a simple ques- ments are made we give the human side using a scetion when starting any improvement project: What nario (for example, improved turnaround time means would we do if the patient were our mother?8 In this less stress for a worried parent). We often present realway our teams devise and test interventions until we istic background drama in the form of vignettes when
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THE JOINT COMMISSION Table 1. Bloom’s Taxonomy Levels of the Cognitive Domain* Taxonomy level
Which is
Level 1: Knowledge
The factual foundation for higher levels of thought
Level 2: Comprehension
The ability to grasp the meaning
Level 3: Application
The use of the learned material in actual situations
Level 4: Analysis
The examining of the conditions, circumstances, options, and reasons for a problem
Level 5: Synthesis
The design and assembly of ideas to form new thoughts or solutions
Level 6: Evaluation
Judging the value or worth of an idea or thought
* Source: Bloom B: Taxonomy of Educational Objectives: Cognitive, Psychomotor, and Affective Domains. New York: Davis McKay Co, 1967.
Table 2. Verbs Used to Test the Various Levels of Bloom’s Taxonomy*
For example, a phlebotomist refused to collect an additional Taxonomy tube of blood because the order Level Key Verbs for Educational Objectives was not on his computerized I Knowledge Name List Define drawlist (the order was entered Record Cite Repeat after the list had been printed). II Comprehension Explain Express Describe We publish the complaint data Restate Translate Review in our newsletter. During the III Application Apply Employ Use last 3 years, the number of comPractice Sketch Illustrate plaints received has decreased by IV Analysis Analyze Examine Compare Appraise Debate Question more than 50%. These results are encouraging, but they are V Synthesis Create Design Construct Plan Formulate Assemble hardly proof that we have sucVI Evaluation Choose Rank Judge cessfully developed a shared Select Rate Estimate goal. The issue of goals remains * Source (taxonomy): Bloom B: Taxonomy of Educational Objectives: Cognitive, Psychomotor, and problematic. In the end we are Affective Domains. New York: Davis McKay Co, 1967. left with two realities: we would like our employees to perform to creating a written competency exam. To do this, we a set of higher-order values, which requires an alert add information about the state of mind of the patient affect, but at the same time we train people to follow rules. To do both seems impossible. or loved one. Our hospital always prints letters of praise from patients, but we never see the complaints that represent We Were Taught to Follow Rules Not our failed outcomes. In the laboratory we redesigned How to Problem Solve our complaint investigation and response procedure to Beginning in 1956, Benjamin Bloom led a team of ensure that anyone who makes an error is informed and education psychologists in developing a comprehenresponds in writing as does the supervisor. In this way sive taxonomy of educational domains-cognitive, psywe create an environment for coaching employees.10 chomotor, and affective, with levels of difficulty Through this process we have uncovered instances in within each domain.11 We are particularly interested in which personnel have skipped procedural steps such as taxonomy levels of the cognitive domain (Table 1, failing to perform a low-power scan of a blood smear, above), which offer a vocabulary suitable for teaching which resulted in reporting of a falsely low platelet how to work outside of rules. Verbs used to test proficount. We have also uncovered instances where ciency within each taxonomy level are displayed in personnel have been excessively rigid in applying rules. Table 2 (above).
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Application of Bloom’s Taxonomy to Illustrate Problem Solving
Comprehension
Rule-based thought
Knowledge
Improperly labeled samples are to be rejected Rejecting improperly labeled samples is the most efficient method of securing compliance and promoting patient safety. Unlabeled samples are routinely rejected.
Analysis
What is the intent of the rule and what are the considerations if we break the rule?
Synthesis
What else can we do to ensure patient safety and still save the sample?
Evaluate
Choose rejection or choose plan B?
Knowledge-based/synthetic thought
Application
Oversight-by-evaluation detects a problem if the rule is followed in this case. Proper labeling ensures patient safety. The sample is rare and important. Breaking the rule might compromise patient safety but it might save the outcome. Proposed plan B: Visit the nursing station. Review the chart with the nurse. Determine that the sample was collected on the proper patient at the documented date and time. Plan B breaks the rule but solves the problem.
Figure 2. Bloom’s taxonomy model is useful for teaching employees and for developing patient safety strategies.
Bloom’s taxonomy offers a framework (Figure 2, above) for teaching employees and for developing patient safety strategies as we constantly assess and test systems of rules to enhance outcomes. Yet the framework is limited insofar as it will only apply under the assumption that we share the same or congruent goals, which is an ambitious assumption. Educators have a fairly easy time with the three lower levels—knowledge, comprehension, and application—because they are the levels of predictable performance. The outcome of this training is rulebased performance, which works effortlessly as long as the situation remains predictable. But the higher three levels are useful for problem solving and are more difficult to teach because problems are, by nature, unpredictable and novel. If you could predict a situation you could make a rule and teach it, but then it would not be a problem. The problem-solving levels challenge a person to analyze the situation, synthesize a new set of options, and finally evaluate which option will produce the best outcome. This entails discovering a useful level of certainty and agreement about the action to be taken and the possible outcome. It seems that we were trained to use rules, but we were not trained for the uncertainties of problem solving. And yet with sufficient clinical training and expe-
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rience, we seem to be very good at problem recognition, which we accomplish by predicting the outcome of an action or intervention, in light of the clinical setting. We believe that professionals practice at the evaluation level, even though the routine actions might be rule based, and that this oversight-by-evaluation is essential to good outcomes. Nurses recognize physician errors and dangerous situations and do not blindly follow erroneous orders. They also must synthesize new solutions in chaotic circumstances. For example, in an incident (which occurred elsewhere), as recounted by one of our critical care nurses, the patient’s condition had rapidly deteriorated, and yet the attending physician failed to respond to the beeper. After more than an hour had elapsed, the nurse determined that the situation was so critical that she went to the emergency department and begged a physician to come see the patient and write appropriate orders. She was commended for her resourcefulness, as there was no protocol for this situation. Bloom’s taxonomy demonstrates that the higher levels of learning where emergent problem solving takes place requires operational and educational interventions that go beyond generating and applying rules. Competency assessments that are checklist based or use low-level examinations are unlikely to
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THE JOINT COMMISSION patient, the nurse was able to achieve a successful intubation. The nurse was com• If rejection compromises patient care, mended by the unit’s medical do something to save the sample director but was fired for vio• “One time specimens” like CSF, some lating policy. In this unusual cultures, and some STATs are so imporexample, the nurse had full tant that the rules must be modified knowledge that he could be • Managers and supervisors are empowfired but chose the course of ered to make exceptions If in doubt, you can think of action anyway in accordance a way to save an outcome with the higher-order responsibility. So even an action that would improve a patient outcome can be criticized. It may be illegal or too costly. We would never accept breaking sample identification protocol for a blood bank speciFigure 3. A Web page is used to empower employees to resolve specimen identity problems. men, and, certainly, rule breaking to meet personal detect poor performance and need to be replaced with goals deserves criticism and cannot be tolerated. The approach we advocate is that exceptions to measurements that predict performance.8,12 Similarly, low-level training interventions need to be replaced rules can be made but that they should also be docuwith nonlinear learning methods such as case-based mented and reviewed. To implement this approach for discussions, simulations, and role play.13 Attending an sample identity problems, we developed a written polinservice or watching a film about hazardous chemi- icy that states that it is acceptable and desirable that cals does not prepare an employee for the problem of charge personnel use judgment to override rules. We suddenly finding a long-forgotten cache of outdated also developed a form to document labeling errors and chemicals (including explosive picric acid) in a storage the corrective action which allows for trending and reporting so that we can improve our labeling systems. area. In a high-stakes industry no one likes to make The hospital is currently piloting bar-coded labeling mistakes, which further complicates our ability to in the emergency department. To train our staff we developed an intranet-based solve problems. Ultimately, the problem solver must make a decision as to what solution would be best, tutorial that discusses the theoretical models of rules and that decision is then subject to the judgment of discussed in this article. A guide is posted in our labobosses and coworkers, which represents a risk. This is ratory’s specimen-receiving area which presents three especially problematic in a “blame and punish” culture typical scenarios in a case-based role-play exercise to because it creates an environment of fear, and fearful illustrate the thought processes behind exceptions. people hate to make decisions.14 The fear of “sticking Our laboratory’s Internet site includes a page that tells your neck out” and making a tough decision deters clients and employees that we authorize exceptions in people from problem solving. A critical care nursing unusual circumstances (Figure 3, above). We have also supervisor has described an incident that occurred at a presented these ideas in continuing education activiteaching hospital. A critical care nurse who had for- ties. Finally, we continue to market the idea of shared merly been a licensed emergency medical technician goals with our “Takin’ Care of Mama” approach to (and therefore was trained and skilled at inserting air- performance improvement. Yet we must be rigorous in enforcing rules that ways) was now licensed as a nurse and prohibited by state law from inserting airways. In a critical situation, are broken for the wrong reason. For example, we after the resident repeatedly failed to intubate the recently uncovered instances in which nurses skipped
Rejections and Exceptions for “One-Time Specimens”
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confirmation steps in performing point-of-care glucose measurements. In one instance we determined that an insulin intervention was initiated based on a falsely elevated reading. Proper confirmation would have prevented this inappropriate intervention. We now are looking at 100% of these instances so that we can ensure that this rule is being followed. Our connected point-of-care data management allows for the rapid oversight and identification of exceptions, which are promptly reported for corrective action.
Zone of Complexity Chaos
Low
Agreement
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Zone of Complexity
What Can We Do? The majority of the processes in the health care environment can be planned and controlled according to known rules. Sometimes, when there is less agreement or certainty about what needs to take place, then we need to move away from our rule-based operation and recognize we are in the “zone of complexity”3 (Figure 4, right.) The laboratory is an excellent place to study the dilemma of rule breaking, but other medical disciplines encounter the same issue. Experienced critical care nurses frequently initiate interventions while simultaneously seeking doctor’s orders. For example, nurses have been known to draft nonattending physicians to sign orders when the attending physician cannot be reached. Critical care nurses report that experience with interventions and outcomes enables the nurse to more easily recognize the situations in which rule breaking may be required to achieve optimal patient outcomes (seeing the goal is easier because they are so close to the patient). They report that they have also been able to persuade other services to make exceptions to meet patient needs, although a service’s flexibility seems to vary by the individual not the discipline. A pharmacy department might or might not extend a deadline for orders submission depending on who is in charge on a given day. In an emergency, the material service might or might not issue supplies without the prerequisite paperwork. Just as in our laboratory, some people will break rules to solve problems and some will not. Whenever a rule does not clinically or morally fit a circumstance, we need to “problem solve in action,” which means fixing the problem now and not waiting for a monthly meeting. If an event falls outside the regular pattern of what can be planned and controlled, we need to take action based on our shared goal of
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High
Plan and Control
High
Certainty
Low
Figure 4. Source: Plsek P, Greenhalgh T: Complexity science: The
challenge of complexity in health care. BMJ 323:625–628, 2001. Copyright © 2001 by the BMJ Publishing Group. Adapted with the permission of the publisher.
improved health status. Breaking rules is risky, and making exceptions can be costly. It takes effort and time to break rules and still maintain safety and accountability. Not every outcome will develop as predicted. That is why we are so annoyed when someone makes a mistake or asks us to make an exception. We are bothered because we have to leave our normal scheme and weigh the need to maintain order and economy versus the need of an individual patient. And thinking at the problem-solving level requires the best of our clinical and moral judgment–often in uncertain circumstances. By creating a documented system of solving sample identity problems we add some certainty and support to our technologists. It is our hope that frank dialogue about the role of rules will help alleviate fear and help our workers become better problem solvers and more creative improvers. Our three laboratory problem solvers (p 453) predicted that rejecting the CSF samples outright would result in a bad patient outcome. This decision moved them from the realms of plan and control to a more complex and foggy world where their actions could be subject to criticism. Their analysis revealed that these specimens, which were important, relatively rare, and collected at some risk,
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THE JOINT COMMISSION would be worth the effort to save. They synthesized an alternative method of determining specimen integrity and chose that as the better course of action. Their process was one of problem solving in action because timely correction of this error saved the lab outcome. Contrary to the scenario at the beginning of this article, mission control didn’t tell Commander
Lovell to follow the book. In fact, it threw away the book, looked at all available resources and options, put together a number of new options, and considered each one. Finally, the mission control leaders used their best judgment to choose a risky but spectacularly successful solution. We owe it to our patients to be equally thoughtful and creative in solving both individual and systematic problems. J
References 1. Vincent C, et al: How to investigate and analyze clinical incidents: Clinical risk unit and association of litigation and risk management protocol. BMJ 320: 777–781, 2000. 2. Dorner D: The Logic of Failure: Recognizing and Avoiding Error in Complex Situations. Reading, MA: Addison-Wesley, 1997. 3. Plsek PE, Greenhalgh P: Complexity science: The challenge of complexity in healthcare. BMJ 323:625–628, 2001.
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4. Leape L: Error in medicine. JAMA 272:1851–1857, 1994. 5. Reason J: Human error: Models and management. BMJ 320: 768–770, 2000. 6. Reason J, Mycielska K: Absent Minded? The Psychology of Mental Lapses and Everyday Errors. Englewood Cliffs, NJ: Prentice-Hall Inc, 1982. 7. Juran JM: Juran on Leadership for Quality: An Executive Handbook. New York: The Free Press, 1989. 8. Haun DE, Leach AP, Vivero R: Takin’ Care of Mama: From
competency assessment to competency improvement. Laboratory Medicine 31:106–110, 2000. 9. Haun DE, et al: Assessing the competence of specimen-processing personnel. Laboratory Medicine 31:633–636, 2000. 10. Haun DE, et al: The complaint department: How does a lab properly investigate a problem? MLO Med Lab Obs 33(12):26–29, 2001. 11. Bloom B: Taxonomy of Educational Objectives: Cognitive, Psy-
chomotor, and Affective Domains. New York: Davis McKay Co, 1967. 12. Haun DE, et al: A better way to assess WBC differential counting skills. Laboratory Medicine 31:329– 333, 2000. 13. Fraser SW, Greenhalgh P: Coping with complexity, educating for capability. BMJ 323:799–803, 2001. 14. Kriegel R, Brandt D: Sacred Cows Make the Best Burgers. New York: Warner Books, 1996.
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There is an old adage that “Rules are made to be broken.” But how are we to decide how and when rules are to be broken? FORUM
Houston, We’ve Had a Problem: When Do We Override Rules? DANIEL E. HAUN ARGIE LEACH, MHS RITA VIVERO, MBA SARAH W. FRASER
I
magine this scenario:
It is 2108h on April 13, 1970, and Apollo 13 is speeding toward the moon. Lovell: “Houston, we’ve had a problem.” Mission Control: “This is Houston. Say again please.” Lovell: “Houston, we’ve had a problem. We’ve had a main B bus undervolt.” Mission Control: “The book says to turn up the voltage control.” Lovell: “Well, I tried that but there’s been an explosion.” Mission Control: “Well, it always works to turn up the voltage.” Lovell: “We are in a tough jam. Can you think of something else?” Mission Control: “Listen, we have to follow procedure.”
Daniel E. Haun, is Director of Client Services; Argie Leach, MHS, is Competency Coordinator; and Rita Vivero, MBA,
is a Performance Improvement Analyst, Department of Pathology, Medical Center of Louisiana at New Orleans, New Orleans. Sarah W. Fraser is an Independent Consultant and Visiting Professor, Middlesex University, London. Copyright © 2002 by the Joint Commission on Accreditation of Healthcare Organizations
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Now compare the scenario to the following incident: A cerebrospinal fluid (CSF) specimen is collected in four tubes and delivered to the laboratory with the proper requisitions, but the tubes are not labeled correctly in that the patient’s name is not printed on the tubes as required. The group of orders consists of a CSF cell count; glucose, bacterial, and fungal cultures; and cytological evaluation. The receiving area forwards the tubes and paperwork to the appropriate laboratories, and by the end of the day almost all specimens have been successfully analyzed—all except for the fungal culture and the cytological evaluation. Both of these samples have been rejected and returned to the nursing station. Although three lab supervisors modified the specimen acceptance rules and took other steps to determine specimen integrity, two other supervisors followed the rules—to reject all incorrectly labeled specimens. The authors thank Dan Kiff, RN, Geraldine Marquez, RN, and Tommy Lotz, RRT, for their input on rule breaking in other disciplines. Please address requests for reprints to Daniel E. Haun, Department of Pathology, 1532 Tulane Ave, New Orleans, LA, 70112; phone 504/903-7528; fax 504/903-5634; e-mail [email protected].
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THE JOINT COMMISSION The quality improvement (QI) team in our pathology department discussed the incident and asked, “Should we try to teach people how to make exceptions, bend rules, and even break rules when necessary?” As a team we modify and rewrite rules all the time because we are empowered and unified behind the shared goal to improvement. Yet we see the need to extrapolate the responsibility to make exceptions and break rules to the individual practice level so that problems can be solved.
Where Do the Rules Come From? Rules, which are intended to maintain a standard that will ensure quality and efficiency in normal circumstances, are used in every workplace. In the health care setting, specimen acceptance criteria is one set of rules required by accrediting agencies, but there are many other examples. The rules are very important, and skipping rules or misapplying rules is a major source of medical error1 and error in general.2 For instance, skipping a rule to check for a specimen artifact may easily result in a missed diagnosis. For a physician to skip a foot examination on a patient with diabetes can result in a less-than-optimum patient outcome. There is little justification for skipping steps or modifying rules to save time or improve productivity. But what if the rule modification will serve a patient outcome by preserving a sample that was obtained at high risk to the patient or was otherwise very difficult to collect? What if fast (but unauthorized) action by a critical care nurse can save a life? When the circumstances permit, can we make exceptions to the rules and still maintain the order and safety that rules provide? The key here is “normal” circumstances. Although the hospital is made up of buildings, equipment, and materials, the main components are human operation and interaction. The nature of complex human interdependencies means that the context and operation of the hospital will constantly be adapting to small changes, some of which mean the rules are no longer applicable3; namely, the circumstance has moved outside the norm. In the CSF example, the error of poor labeling created the opportunity for even more error and poor patient outcomes. When the rules no longer apply, the responsible action is the one that breaks the chain of adverse events.
454
People Make Mistakes–Get Over It! In 1994 Leape described the need to abandon the “perfectibility model” of error prevention.4 Instead, the call is for systems that detect, correct, or at least mitigate the effects of the error—to move from the person approach to a system approach to human error.5 This is more than quality assurance or inspection of tasks and processes. The behavior of human systems is not linear; each interaction and result affects the next person in a cumulative and uncertain way.3 Most of the time, the system behavior is well within the norms that the rules define. However, when the unpredictable occurs and the operation falls outside the norm, then the idea is to somehow achieve the best patient outcome in spite of the error. So how are we to proceed in the context of our rules-driven work? A bit of theory might help. Reason’s and Mycielska’s cognitive theory leads to the understanding of rules as schemata, much like the mental schemata that we use in everyday life.6 But to be successful, we must oversee our schemata by paying attention. Nurses are trained to follow physicians’ orders and can generally follow the order to the letter. But nurses by training and experience come to be quite skilled at recognizing physicians’ errors and must oversee the normal scheme of following orders. All automobile drivers have schemata that make the driving experience seem effortless, but skilled drivers apply attentional oversight and observe for rule violations. One simply cannot expect that all drivers will drive within parameters all the time. People speed, run stop signs, and make mistakes. Rules do not always lead us to the desired outcome because either they are no longer fit for the purpose–namely, the circumstances have changed–or there has been a drift in performance. Think about the small bad habits that have crept up on your driving skills since you passed your driver’s test. Yes, you are still operating within the rules, yet you have made adaptations that over time may increase your liability to error. When the outcomes are endangered, we need to recognize we are no longer operating within the norm and devise alternative solutions. Effective performance improvement teams are charged with measuring outcomes and devising solutions at the system level, but individuals also do this at the practice level. Suppose that a respiratory therapist finds that a patient is in respiratory distress or has
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become hemodynamically Takin’ Care of Mama: The Performance Improvement Report unstable. Yet the therapist cannot reach the attendNew Year’s Day 2001 ing physician because the Inside: beeper system is temJust-in-time training. porarily broken. The therElectronic knowledge support at MCL apist has to make a New staffing and development plan. New MCL career path established in partnership with LSU judgment and perhaps Continued laboratory reorganization. break a rule by obtaining Full integration of receiving allows for oversight and error blood gases and altering reduction. gas ratios before receiving Mama presents at CDC. the orders. The rules are Team invited to present ideas and findings Trini’s Mom, Antoinette made on the assumption that a physician can All this and more in this issue of TCM always be reached in time, but in real life we Figure 1. Performance improvement efforts are reported in a newsletter that always features someone’s mother (an “honored” staff member or a staff member’s mother) to reinforce the goal of “mama quality.” see otherwise. Suppose you are dri- MCL, Medical Center of Louisiana; LSU, Louisiana State University; CDC, Centers for Disease Control and Prevention; TCM, Takin’ Care of Mama. ving during a power outage and come to a traffic light, where suddenly you have a problem. Do you reach the level of “mama quality”—quality suitable for speed through the light, slow down, or stop? To find my mama, not just any mama. your solution you will consider the circumstances— When we initially designed our competency weather conditions, time of day, and traffic patterns— assessment methods for our laboratory, our goal was and you will devise an alternative course of action to meet an accreditation standard in the easiest possitaking into account all the variables known to you. ble way. At the time, we thought that competency assessment was unnecessary, and we did not want to affect productivity negatively. Our competency assessWhat About Goals? The intention of the rules-based world is to efficiently ment program showed us to test at near 100% perforreach our goals, just as the traffic signal rules help us mance, and yet we had failures in practice. However, efficiently and safely reach our driving destinations—a when we changed the goal of our assessment program goal shared by all drivers. Each health care worker also to that of detecting (and predicting) poor perforhas a set of goals—some personal and some shared mance, we discovered significant incompetence at across the organization. As an organization, we hope many levels in the organization.8,9 We also found that our workers share the general goal of improving meaningful improvement opportunities. the health status of our patients, and the goal is marAlthough the goal of mama quality is easy to sell keted to workers in the form of mission statements and to a handpicked team, the issue of conflicting goals value statements. When mission drives individuals and looms large in any discussion of empowering larger teams they enter into a world where rules can be mod- numbers of people to break rules. We try to sell this ified to meet the goal, be it saving a single laboratory idea in many ways. For instance, we report all of our outcome or changing an outmoded process.7 Shared efforts in a newsletter, and we always put a picture of goals in complex situations allow individuals and someone’s mother on the cover (Figure 1, above). We teams to self-organize and respond to problems tell the story of the improvement effort rather than simply present numerical data, and when improve(opportunities) with creative rule-breaking ideas. Our laboratory-based teams ask a simple ques- ments are made we give the human side using a scetion when starting any improvement project: What nario (for example, improved turnaround time means would we do if the patient were our mother?8 In this less stress for a worried parent). We often present realway our teams devise and test interventions until we istic background drama in the form of vignettes when
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THE JOINT COMMISSION Table 1. Bloom’s Taxonomy Levels of the Cognitive Domain* Taxonomy level
Which is
Level 1: Knowledge
The factual foundation for higher levels of thought
Level 2: Comprehension
The ability to grasp the meaning
Level 3: Application
The use of the learned material in actual situations
Level 4: Analysis
The examining of the conditions, circumstances, options, and reasons for a problem
Level 5: Synthesis
The design and assembly of ideas to form new thoughts or solutions
Level 6: Evaluation
Judging the value or worth of an idea or thought
* Source: Bloom B: Taxonomy of Educational Objectives: Cognitive, Psychomotor, and Affective Domains. New York: Davis McKay Co, 1967.
Table 2. Verbs Used to Test the Various Levels of Bloom’s Taxonomy*
For example, a phlebotomist refused to collect an additional Taxonomy tube of blood because the order Level Key Verbs for Educational Objectives was not on his computerized I Knowledge Name List Define drawlist (the order was entered Record Cite Repeat after the list had been printed). II Comprehension Explain Express Describe We publish the complaint data Restate Translate Review in our newsletter. During the III Application Apply Employ Use last 3 years, the number of comPractice Sketch Illustrate plaints received has decreased by IV Analysis Analyze Examine Compare Appraise Debate Question more than 50%. These results are encouraging, but they are V Synthesis Create Design Construct Plan Formulate Assemble hardly proof that we have sucVI Evaluation Choose Rank Judge cessfully developed a shared Select Rate Estimate goal. The issue of goals remains * Source (taxonomy): Bloom B: Taxonomy of Educational Objectives: Cognitive, Psychomotor, and problematic. In the end we are Affective Domains. New York: Davis McKay Co, 1967. left with two realities: we would like our employees to perform to creating a written competency exam. To do this, we a set of higher-order values, which requires an alert add information about the state of mind of the patient affect, but at the same time we train people to follow rules. To do both seems impossible. or loved one. Our hospital always prints letters of praise from patients, but we never see the complaints that represent We Were Taught to Follow Rules Not our failed outcomes. In the laboratory we redesigned How to Problem Solve our complaint investigation and response procedure to Beginning in 1956, Benjamin Bloom led a team of ensure that anyone who makes an error is informed and education psychologists in developing a comprehenresponds in writing as does the supervisor. In this way sive taxonomy of educational domains-cognitive, psywe create an environment for coaching employees.10 chomotor, and affective, with levels of difficulty Through this process we have uncovered instances in within each domain.11 We are particularly interested in which personnel have skipped procedural steps such as taxonomy levels of the cognitive domain (Table 1, failing to perform a low-power scan of a blood smear, above), which offer a vocabulary suitable for teaching which resulted in reporting of a falsely low platelet how to work outside of rules. Verbs used to test proficount. We have also uncovered instances where ciency within each taxonomy level are displayed in personnel have been excessively rigid in applying rules. Table 2 (above).
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Application of Bloom’s Taxonomy to Illustrate Problem Solving
Comprehension
Rule-based thought
Knowledge
Improperly labeled samples are to be rejected Rejecting improperly labeled samples is the most efficient method of securing compliance and promoting patient safety. Unlabeled samples are routinely rejected.
Analysis
What is the intent of the rule and what are the considerations if we break the rule?
Synthesis
What else can we do to ensure patient safety and still save the sample?
Evaluate
Choose rejection or choose plan B?
Knowledge-based/synthetic thought
Application
Oversight-by-evaluation detects a problem if the rule is followed in this case. Proper labeling ensures patient safety. The sample is rare and important. Breaking the rule might compromise patient safety but it might save the outcome. Proposed plan B: Visit the nursing station. Review the chart with the nurse. Determine that the sample was collected on the proper patient at the documented date and time. Plan B breaks the rule but solves the problem.
Figure 2. Bloom’s taxonomy model is useful for teaching employees and for developing patient safety strategies.
Bloom’s taxonomy offers a framework (Figure 2, above) for teaching employees and for developing patient safety strategies as we constantly assess and test systems of rules to enhance outcomes. Yet the framework is limited insofar as it will only apply under the assumption that we share the same or congruent goals, which is an ambitious assumption. Educators have a fairly easy time with the three lower levels—knowledge, comprehension, and application—because they are the levels of predictable performance. The outcome of this training is rulebased performance, which works effortlessly as long as the situation remains predictable. But the higher three levels are useful for problem solving and are more difficult to teach because problems are, by nature, unpredictable and novel. If you could predict a situation you could make a rule and teach it, but then it would not be a problem. The problem-solving levels challenge a person to analyze the situation, synthesize a new set of options, and finally evaluate which option will produce the best outcome. This entails discovering a useful level of certainty and agreement about the action to be taken and the possible outcome. It seems that we were trained to use rules, but we were not trained for the uncertainties of problem solving. And yet with sufficient clinical training and expe-
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rience, we seem to be very good at problem recognition, which we accomplish by predicting the outcome of an action or intervention, in light of the clinical setting. We believe that professionals practice at the evaluation level, even though the routine actions might be rule based, and that this oversight-by-evaluation is essential to good outcomes. Nurses recognize physician errors and dangerous situations and do not blindly follow erroneous orders. They also must synthesize new solutions in chaotic circumstances. For example, in an incident (which occurred elsewhere), as recounted by one of our critical care nurses, the patient’s condition had rapidly deteriorated, and yet the attending physician failed to respond to the beeper. After more than an hour had elapsed, the nurse determined that the situation was so critical that she went to the emergency department and begged a physician to come see the patient and write appropriate orders. She was commended for her resourcefulness, as there was no protocol for this situation. Bloom’s taxonomy demonstrates that the higher levels of learning where emergent problem solving takes place requires operational and educational interventions that go beyond generating and applying rules. Competency assessments that are checklist based or use low-level examinations are unlikely to
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THE JOINT COMMISSION patient, the nurse was able to achieve a successful intubation. The nurse was com• If rejection compromises patient care, mended by the unit’s medical do something to save the sample director but was fired for vio• “One time specimens” like CSF, some lating policy. In this unusual cultures, and some STATs are so imporexample, the nurse had full tant that the rules must be modified knowledge that he could be • Managers and supervisors are empowfired but chose the course of ered to make exceptions If in doubt, you can think of action anyway in accordance a way to save an outcome with the higher-order responsibility. So even an action that would improve a patient outcome can be criticized. It may be illegal or too costly. We would never accept breaking sample identification protocol for a blood bank speciFigure 3. A Web page is used to empower employees to resolve specimen identity problems. men, and, certainly, rule breaking to meet personal detect poor performance and need to be replaced with goals deserves criticism and cannot be tolerated. The approach we advocate is that exceptions to measurements that predict performance.8,12 Similarly, low-level training interventions need to be replaced rules can be made but that they should also be docuwith nonlinear learning methods such as case-based mented and reviewed. To implement this approach for discussions, simulations, and role play.13 Attending an sample identity problems, we developed a written polinservice or watching a film about hazardous chemi- icy that states that it is acceptable and desirable that cals does not prepare an employee for the problem of charge personnel use judgment to override rules. We suddenly finding a long-forgotten cache of outdated also developed a form to document labeling errors and chemicals (including explosive picric acid) in a storage the corrective action which allows for trending and reporting so that we can improve our labeling systems. area. In a high-stakes industry no one likes to make The hospital is currently piloting bar-coded labeling mistakes, which further complicates our ability to in the emergency department. To train our staff we developed an intranet-based solve problems. Ultimately, the problem solver must make a decision as to what solution would be best, tutorial that discusses the theoretical models of rules and that decision is then subject to the judgment of discussed in this article. A guide is posted in our labobosses and coworkers, which represents a risk. This is ratory’s specimen-receiving area which presents three especially problematic in a “blame and punish” culture typical scenarios in a case-based role-play exercise to because it creates an environment of fear, and fearful illustrate the thought processes behind exceptions. people hate to make decisions.14 The fear of “sticking Our laboratory’s Internet site includes a page that tells your neck out” and making a tough decision deters clients and employees that we authorize exceptions in people from problem solving. A critical care nursing unusual circumstances (Figure 3, above). We have also supervisor has described an incident that occurred at a presented these ideas in continuing education activiteaching hospital. A critical care nurse who had for- ties. Finally, we continue to market the idea of shared merly been a licensed emergency medical technician goals with our “Takin’ Care of Mama” approach to (and therefore was trained and skilled at inserting air- performance improvement. Yet we must be rigorous in enforcing rules that ways) was now licensed as a nurse and prohibited by state law from inserting airways. In a critical situation, are broken for the wrong reason. For example, we after the resident repeatedly failed to intubate the recently uncovered instances in which nurses skipped
Rejections and Exceptions for “One-Time Specimens”
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confirmation steps in performing point-of-care glucose measurements. In one instance we determined that an insulin intervention was initiated based on a falsely elevated reading. Proper confirmation would have prevented this inappropriate intervention. We now are looking at 100% of these instances so that we can ensure that this rule is being followed. Our connected point-of-care data management allows for the rapid oversight and identification of exceptions, which are promptly reported for corrective action.
Zone of Complexity Chaos
Low
Agreement
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What Can We Do? The majority of the processes in the health care environment can be planned and controlled according to known rules. Sometimes, when there is less agreement or certainty about what needs to take place, then we need to move away from our rule-based operation and recognize we are in the “zone of complexity”3 (Figure 4, right.) The laboratory is an excellent place to study the dilemma of rule breaking, but other medical disciplines encounter the same issue. Experienced critical care nurses frequently initiate interventions while simultaneously seeking doctor’s orders. For example, nurses have been known to draft nonattending physicians to sign orders when the attending physician cannot be reached. Critical care nurses report that experience with interventions and outcomes enables the nurse to more easily recognize the situations in which rule breaking may be required to achieve optimal patient outcomes (seeing the goal is easier because they are so close to the patient). They report that they have also been able to persuade other services to make exceptions to meet patient needs, although a service’s flexibility seems to vary by the individual not the discipline. A pharmacy department might or might not extend a deadline for orders submission depending on who is in charge on a given day. In an emergency, the material service might or might not issue supplies without the prerequisite paperwork. Just as in our laboratory, some people will break rules to solve problems and some will not. Whenever a rule does not clinically or morally fit a circumstance, we need to “problem solve in action,” which means fixing the problem now and not waiting for a monthly meeting. If an event falls outside the regular pattern of what can be planned and controlled, we need to take action based on our shared goal of
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High
Plan and Control
High
Certainty
Low
Figure 4. Source: Plsek P, Greenhalgh T: Complexity science: The
challenge of complexity in health care. BMJ 323:625–628, 2001. Copyright © 2001 by the BMJ Publishing Group. Adapted with the permission of the publisher.
improved health status. Breaking rules is risky, and making exceptions can be costly. It takes effort and time to break rules and still maintain safety and accountability. Not every outcome will develop as predicted. That is why we are so annoyed when someone makes a mistake or asks us to make an exception. We are bothered because we have to leave our normal scheme and weigh the need to maintain order and economy versus the need of an individual patient. And thinking at the problem-solving level requires the best of our clinical and moral judgment–often in uncertain circumstances. By creating a documented system of solving sample identity problems we add some certainty and support to our technologists. It is our hope that frank dialogue about the role of rules will help alleviate fear and help our workers become better problem solvers and more creative improvers. Our three laboratory problem solvers (p 453) predicted that rejecting the CSF samples outright would result in a bad patient outcome. This decision moved them from the realms of plan and control to a more complex and foggy world where their actions could be subject to criticism. Their analysis revealed that these specimens, which were important, relatively rare, and collected at some risk,
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THE JOINT COMMISSION would be worth the effort to save. They synthesized an alternative method of determining specimen integrity and chose that as the better course of action. Their process was one of problem solving in action because timely correction of this error saved the lab outcome. Contrary to the scenario at the beginning of this article, mission control didn’t tell Commander
Lovell to follow the book. In fact, it threw away the book, looked at all available resources and options, put together a number of new options, and considered each one. Finally, the mission control leaders used their best judgment to choose a risky but spectacularly successful solution. We owe it to our patients to be equally thoughtful and creative in solving both individual and systematic problems. J
References 1. Vincent C, et al: How to investigate and analyze clinical incidents: Clinical risk unit and association of litigation and risk management protocol. BMJ 320: 777–781, 2000. 2. Dorner D: The Logic of Failure: Recognizing and Avoiding Error in Complex Situations. Reading, MA: Addison-Wesley, 1997. 3. Plsek PE, Greenhalgh P: Complexity science: The challenge of complexity in healthcare. BMJ 323:625–628, 2001.
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4. Leape L: Error in medicine. JAMA 272:1851–1857, 1994. 5. Reason J: Human error: Models and management. BMJ 320: 768–770, 2000. 6. Reason J, Mycielska K: Absent Minded? The Psychology of Mental Lapses and Everyday Errors. Englewood Cliffs, NJ: Prentice-Hall Inc, 1982. 7. Juran JM: Juran on Leadership for Quality: An Executive Handbook. New York: The Free Press, 1989. 8. Haun DE, Leach AP, Vivero R: Takin’ Care of Mama: From
competency assessment to competency improvement. Laboratory Medicine 31:106–110, 2000. 9. Haun DE, et al: Assessing the competence of specimen-processing personnel. Laboratory Medicine 31:633–636, 2000. 10. Haun DE, et al: The complaint department: How does a lab properly investigate a problem? MLO Med Lab Obs 33(12):26–29, 2001. 11. Bloom B: Taxonomy of Educational Objectives: Cognitive, Psy-
chomotor, and Affective Domains. New York: Davis McKay Co, 1967. 12. Haun DE, et al: A better way to assess WBC differential counting skills. Laboratory Medicine 31:329– 333, 2000. 13. Fraser SW, Greenhalgh P: Coping with complexity, educating for capability. BMJ 323:799–803, 2001. 14. Kriegel R, Brandt D: Sacred Cows Make the Best Burgers. New York: Warner Books, 1996.
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