Narrative vs entire PCR

[Eli]

If you are so good at your job, why are you unable to document that very fact?

Beauty is in the eye of the beholder. Who says that I am not able to document that fact? Is it the doc at the receiving facility? The attorney representing the agency in the face of a law suit? Some QI guy who was never anything other than average when they were in the field? As long as the professionals and the billing folks get what they need out of the chart, I don't care what some mean spirited paper pusher has to say.

Wielding subjective criteria around like a weapon is something I see happen too often in EMS. It's like a bad version of the high school popularity contest. The premise of my post was that silly comment about how if one has issues with duplication in documentation in EMS that perhaps they should find another job. The concept is asinine in my opinion and if you disagree, then your opinion is asinine as far as I am concerned. A grown person who has issues with jumping through pointless hoops is being reasonable. The person insisting that that grown person is being unreasonable is the one who is actually being unreasonable IMO. You aren't one of those people, are you?

 

[Eli]

you know, I've never thought of it like that. and I've never actually documented the dust level of a house....

If it drives your decision making or would help the receiving facility focus on pertinent aspects of the patient's life, why would you not have charted it? Think of a pattern of elements like that that you've seen. Perhaps it was house tidiness. More likely it was something like ambient temperature or something like that. Did you think about including it in the narrative? My problem is that often I make a mental note of these things, tell myself to be sure to write it down and then forget. That is a product of my broadstroke outlook on life. To counteract it, I actually am more persnickety than the typical medic about keeping my clipboard with me. If I remember to write it down at the time, then I don't forget later. Otherwise.....

Clearly you can see the value in the observation. There is some reason why it is something you've overlooked over the years. Identify it and find your workaround. Your probably not as spacey as I am, so the solution will likely be less cumbersome than mine.

 

[mgr22]

If you feel you have to use any tools to figure out if the medics know what they are doing, you might be hiring the wrong people all the way around. I've been in the position where my hiring criteria had to be a pulse and a certification. It is not desirable. If that situation is anything other than short term, that is the issue that needs to be addressed. Wouldn't you agree?

So how do you figure out if your medics know what they're doing?

 

[FiremanMike]

The mean QI man in our minds is an idiot who wouldn't recognize a sick patient if it were in front of his face, yet tells everyone how he saved the day given the slightest chance. Unless you are one of them, you know the type. They used to say that those who can't, teach. In modern EMS, what I see is those who can't, learn to suck *** well enough to get themselves promoted into positions to get out of doing the real work of EMS.

If you feel you have to use any tools to figure out if the medics know what they are doing, you might be hiring the wrong people all the way around. I've been in the position where my hiring criteria had to be a pulse and a certification. It is not desirable. If that situation is anything other than short term, that is the issue that needs to be addressed. Wouldn't you agree?

Are you implying that you work for some mythical agency where everyone is at the top of their game at all times and never need to grow?

Give me a break..

 

[Eli]

So how do you figure out if your medics know what they're doing?

Well the standard is a review of specific criteria and a random review of X % of all calls. But I wouldn't characterize the review as looking to see if your crews know what the they're doing. The thought of that approach is pompas and exemplifies the very mentality that I am taking issue with. Any idiot manager who has even the slightest belief that this is their job function would benefit greatly from some "Just Culture" training. If that training doesn't get the idea across, perhaps it is them that should find another line of work. Excellence in human behavior has never come at the end of a rod or as a result of a person who relishes in carrying one.

You folks might be trying to be careful and crafty with your words, but to me, the meaning is coming through loud and clear. All I see is some people rationalizing their primary desire to bust balls, not improve quality. Don't you think that impacts your performance?

 

[Eli]

Are you implying that you work for some mythical agency where everyone is at the top of their game at all times and never need to grow?

Give me a break..

I am getting the idea that if you were on my team, I would love to give you a break. Maybe a very long, long break.

 

[mgr22]

Well the standard is a review of specific criteria and a random review of X % of all calls. But I wouldn't characterize the review as looking to see if your crews know what the they're doing. The thought of that approach is pompas and exemplifies the very mentality that I am taking issue with. Any idiot manager who has even the slightest belief that this is their job function would benefit greatly from some "Just Culture" training. If that training doesn't get the idea across, perhaps it is them that should find another line of work. Excellence in human behavior has never come at the end of a rod or as a result of a person who relishes in carrying one.

You folks might be trying to be careful and crafty with your words, but to me, the meaning is coming through loud and clear. All I see is some people rationalizing their primary desire to bust balls, not improve quality. Don't you think that impacts your performance?

I think you're raising two separate but related issues. One is collection and interpretation of information that tells you something about your employees' performance. The other is how you use and present that information.

I think it's perfectly acceptable -- even imperative -- to find a relatively objective approach for the former. In my opinion, those of us who supervise others have a responsibility to evaluate them and give them feedback based on those evaluations. The tools I use to do that might not be the same as the tools you use, due to differences in data availability, expectations, and local customs.

As for the latter issue, I don't see anyone here advocating a Theory X management style -- i.e., busting balls, as you've characterized it. I think most of us would agree that a negative bias or confrontational affect is usually counterproductive.

 

[FiremanMike]

I am getting the idea that if you were on my team, I would love to give you a break. Maybe a very long, long break.

<shrug> ok.

 

[FiremanMike]

Well the standard is a review of specific criteria and a random review of X % of all calls. But I wouldn't characterize the review as looking to see if your crews know what the they're doing. The thought of that approach is pompas and exemplifies the very mentality that I am taking issue with. Any idiot manager who has even the slightest belief that this is their job function would benefit greatly from some "Just Culture" training. If that training doesn't get the idea across, perhaps it is them that should find another line of work. Excellence in human behavior has never come at the end of a rod or as a result of a person who relishes in carrying one.

You folks might be trying to be careful and crafty with your words, but to me, the meaning is coming through loud and clear. All I see is some people rationalizing their primary desire to bust balls, not improve quality. Don't you think that impacts your performance?

I'm going to go out on a limb and say you're at the 3-10 year mark in your career, where ego and anti-management attitude tends to overwhelm your ethos.. I'm also going to assume that you've never spent a second doing system-wide chart review.

Chart review is absolutely not the ONLY metric I use for determining competency, but it is a daily interface that I have to see where deficiencies lie. Sometime it's a lack of mastery of the English language alone, sometimes it guides conversations that reveal significant deficiencies in clinical ability.. Actively seizing patients not getting meds.. patient's in v-tach not getting shocked, crashing trauma patients being bypassed from a level 2 to a level 1 trauma center because "well it's a level 1 trauma patient". These are just small examples of things I learn from chart review which leads to individual and or crew level debrief sessions where learning happens.

It works. I will allow that it's possible that quality improvement at your agency is lacking, but that doesn't mean it doesn't work elsewhere. Furthermore, I think it's fair based on your abrasive attitude here that it's possible your agency does have a functional quality improvement program, but your level of arrogance blinds you to attempts to help you and/or those around you.

 

[Eli]

I'm going to go out on a limb and say you're at the 3-10 year mark in your career, where ego and anti-management attitude tends to overwhelm your ethos.. I'm also going to assume that you've never spent a second doing system-wide chart review.

Chart review is absolutely not the ONLY metric I use for determining competency, but it is a daily interface that I have to see where deficiencies lie. Sometime it's a lack of mastery of the English language alone, sometimes it guides conversations that reveal significant deficiencies in clinical ability.. Actively seizing patients not getting meds.. patient's in v-tach not getting shocked, crashing trauma patients being bypassed from a level 2 to a level 1 trauma center because "well it's a level 1 trauma patient". These are just small examples of things I learn from chart review which leads to individual and or crew level debrief sessions where learning happens.

It works. I will allow that it's possible that quality improvement at your agency is lacking, but that doesn't mean it doesn't work elsewhere. Furthermore, I think it's fair based on your abrasive attitude here that it's possible your agency does have a functional quality improvement program, but your level of arrogance blinds you to attempts to help you and/or those around you.

Try counting decades.

 

[Eli]

I think you're raising two separate but related issues. One is collection and interpretation of information that tells you something about your employees' performance. The other is how you use and present that information.

I think it's perfectly acceptable -- even imperative -- to find a relatively objective approach for the former. In my opinion, those of us who supervise others have a responsibility to evaluate them and give them feedback based on those evaluations. The tools I use to do that might not be the same as the tools you use, due to differences in data availability, expectations, and local customs.

As for the latter issue, I don't see anyone here advocating a Theory X management style -- i.e., busting balls, as you've characterized it. I think most of us would agree that a negative bias or confrontational affect is usually counterproductive.

I would agree that most talk that talk. Based on my experience, I do not agree that in reality, many actually walk that walk.

 

[Eli]

Actively seizing patients not getting meds.. patient's in v-tach not getting shocked, crashing trauma patients being bypassed from a level 2 to a level 1 trauma center because "well it's a level 1 trauma patient". These are just small examples of things I learn from chart review which leads to individual and or crew level debrief sessions where learning happens.

Holy ****e dude! What kind of people are you hiring? I worked the hood in a system that ran 100,000 calls a year for 10+ years. We didn't have issues like those. Trauma wise our issues were with scene times. Often they were related to trying to resolve airway issues that were not going to get resolved. We didn't distinguish between Level 1 & 2 trauma centers. When to discontinue care vs not was a common source of discussion. I don't recall any reviews related to not giving meds to seizure patients. We did have one related to allowing a post ictal patient to walk to the ambulance and didn't adequately protect him before he had another seizure and was injured in a fall. That was one incident in 1990. We all learned from that one. All 88 medics. Not shocking a lethal rhythm.

All sounds to me like an employee selection issue. Perhaps the QI should start there. All in all, a management issue. Not an employee issue. You can train an unintelligent person until the cows come home. They will still be unintelligent people. I have always had good results from the Mike Taigman S.W.A.N. method. We want people on our team that are smart, willing to work hard, have good attitudes and are genuinely nice. The closer to get to having all of those, the less QI you need on a routine basis.

 

[FiremanMike]

Holy ****e dude! What kind of people are you hiring? I worked the hood in a system that ran 100,000 calls a year for 10+ years. We didn't have issues like those.

Lol, ok bro.. go on and believe that.