Author’s note: In my last column, I wrote about how one minor clinical mistake or misdiagnosis can lead to a bias cascade or compounding errors that result in a bad outcome for the patient. In this one, I’ll talk about how a series of rationalizations of “that’s the way we do things here” can lead to disastrous results for the EMS system.
“That’s not how we do things here.”
That objection was spoken by one of my paramedic students in a recent class. It wasn’t a challenge, merely a statement that he was unfamiliar with the concepts I was discussing. His entire concept of an EMS system was based upon his personal experience in a system that was dysfunctional on its best days, and hopelessly broken on every other day that ended in Y. Whether it was response time standards, unit hour utilization, QA/QI, continuing education, protocol development, standard of care or whatever, I got similar responses.
- “That’s not how we do things here.”
- “That’s not in our protocols.”
- “We’d never get orders to do something like that.”
- “We don’t have that drug in our formulary.”
- “That will never work at our agency.”
It happened so often that I had to remind myself to stop saying, “It doesn’t matter how screwed up things are here, this is a state exam you’ll be taking, and for those of you who aspire to NREMT certification, you’ll be tested on national standards, which are considerably higher than your state’s.”
I struggled at advocating treatment and performance standards to a class who grew up in a system when the performance standard was, “Have a pulse and a patch, show up however you’re dressed and take the patient to the hospital.”
Agents of change
One day in class, as I was explaining the actions and indications of inotropic drugs, a student raised his hand and said, “Yeah, but we don’t carry dopamine or dobutamine. All we carry is norepinephrine. Why do we have to learn drugs we’ll never carry?”
My answer was, “Just because they’re not in your protocol, doesn’t mean you shouldn’t know them. They’re on the state exam, and they’re useful drugs that you should know how to use.”
“Even if they’re not in our protocol?”
“Yes.”
“If they’re so good, why are they not in the protocol?”
I had heard enough. I asked the entire class, “Do any of you ever wonder why your protocols are so restrictive and your drug formulary is so limited?” I was met with shrugs and blank stares.
“Because the medical directors who wrote those protocols think you’re too stupid to learn any more. And you have given them no reason to think otherwise.”
I went on to point out that the average career span of an EMT is 5 years. In recent years, a majority of new EMTs leave the profession within 1 year, and if they can last longer than that, they could reshape the culture of their agencies.
“If all of you graduate, do you realize you will have more than doubled the number of paramedics in this region?” I exhorted. “Who else is better suited to be agents of change? Don’t be like the paramedics you’ve seen, be better than that. Be the paramedics the next few cohorts can aspire to.”
That got through to them. I abandoned the lesson plan at that point and we spent the next 2 hours discussing how their EMS system was broken and why, and what could be done to fix it. The only rule was, nobody could say, “That’s not how we do things.”
Tolerance stacking
In the class, we had a student who held a PhD in an engineering discipline. I had him explain to the class the concept of “tolerance stacking.”
He went on to explain that a single part of a machine could be technically within the maximum tolerances allowed for that part, but if other parts of the machine were similarly machined – within parameters but only just so – that eventually the combination of shoddy tolerances would make the entire machine fail.
I went on to explain the concept of “normalization of deviance,” in that if you accept deviations from the standard often enough, that deviation becomes the new standard. I explained it a little more scatologically: “If things are crappy long enough, people began to think that crappy is the way it’s supposed to be.”
EMS has a critical staff shortage, so anyone that has a pulse and a patch can get a job.
Because the primary job qualification is now a pulse and a patch, poor performance is accepted as a cost of putting meat in the seat.
Since we’re hurting for people, minor deficiencies in performance and minor instances in misconduct get ignored as a cost of doing business. Employers become afraid to fire anyone for anything but the most egregious of offenses.
If you do fire someone, employers are reluctant to give bad references to other prospective employers because they misunderstand how much information they can share, and the bad employee gets a job at a new agency. The cycle continues in what respected EMS leader and advocate Job Politis calls “cross-pollination of a**holes.”
The minor deficiencies and mistakes become the new standard, and what was once considered a major mistake is now a relatively minor one.
The good employees at an agency, the ones who held themselves to a higher standard, see what is accepted now and ask themselves, “Why do I bother if this is what earns a paycheck here? They gave this idiot a signing bonus, and I haven’t gotten a rise in 3 years.”
So rather than bring the new employees up to their standards, they either leave or lower their standards to that of their less-dedicated peers.
Eventually, you wind up with an agency or entire system who has no idea what quality EMS looks like, and the members of it say things like, “That’s not how we do things here.”
Tolerance stacking caused the system to fail.
Become the destination for new grads with talent
The process can be reversed. Instead of that signing bonus to fill an empty seat with the guy who has been fired from multiple other agencies, devote that money to pay raises to your best employees. Show them their efforts are not unappreciated.
They’ll be happier and more loyal to your agency. They’ll stick around longer. You may spend more money on overtime in the short term, but eventually you’ll be able to fill those empty seats with the right people, not just the available ones.
Quicker than you’d think, your agency becomes the destination for new grads with talent; a place filled with happy and well-paid employees, fierce and passionate ambassadors of your way of doing things, where job openings are a coveted rarity.
Your agency becomes the place where everyone wants to go and siphons off all the best people from the agencies who didn’t have your foresight. Those agencies either improve their standards to remain competitive, or they fail. Eventually, the entire system grows around you to become the place where the best paramedics come instead of the system they flee.
Tighten your tolerances, and your machine will start working again.
