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Restrictive EMS protocols increase likelihood of deviation

Highly detailed and specific protocols might create better employees but they don't create better providers


"Cowboy", "paragod" and, my personal favorite, "They’ll yank your certification."

Those comments and more came at me during a Facebook discussions in which I was advocating for paramedics to use critical thinking to guide their clinical decision-making. I mentioned the Dreyfus Model of Skill Acquisition, and how mastery of your craft often meant that you outgrew your protocols.

One commenter summed up the most common objection perfectly, stating, "Deviate from protocol? No thanks, I’d like to keep my job."

Experienced novice

It’s not surprising the number of providers in EMS – EMTs or medics – who function at the novice level. EMS is a high-turnover career field, after all, and it takes years to develop significant skills and knowledge, and the wisdom to know when and where to apply them. But what is truly distressing is the number of experienced EMTs or paramedics who are quite content to stay novices.

Or perhaps, they don’t realize they’re novices.

If they truly believe that experience is the best teacher, regardless of the quality of that experience, then it’s hard to grasp that rigid adherence to your protocols doesn’t necessarily make you a good provider. It only makes you a good employee.

And believe me, there’s a difference.

A supervisor colleague once summed it up thusly, "Show up to work with your boots shined, turn in your paperwork on time and billable, run a mop and a brush through your rig every shift, and don’t get any patient complaints… and you can retire here, without ever becoming a decent medic."

And that got me to pondering a little profundity I like to call the "protocol paradox". It goes like this:

"The more restrictive your agency’s protocols are, the more likely it is necessary to deviate from them, and the more likely that agency is to punish harshly for such deviations."

The bottom line is, you simply can’t mandate good care. The harder you try to mandate good care, the more detailed and zealously enforced your protocols, the more likely those protocols are to form a ceiling rather than a floor. And you wind up with great employees but mediocre medics who make patients fit the protocol, and not the other way around.

Except, patients haven’t read our protocols.

Patients are funny like that. They have a nasty tendency to present in shades of gray, which can be quite inconvenient when protocols require medics to think in black and white.

Hire for attitude, train for ability

You can’t make medics into the providers you want by bludgeoning them with a heavy protocol book. What you can do is hire good medics in the first place, and by good I don’t mean experienced or mature. Hire for attitude, train for ability. A good paycheck and the freedom to practice go a long way toward investing your medics in your agency’s success.

If the latter doesn’t describe your agency, then chances are you’ve fallen victim to the protocol paradox. If you haven’t fallen victim to that paradox, then you need to seriously consider the fact that you are still functioning as a novice provider, and whether you are content to stay there.

When a protocol deviation is flagged, does your CQI program focus on your decision-making, the clinical appropriateness of the treatment rendered, and whether your documentation reflects that?

Or does it stress following the letter of the law (protocol), considering you guilty until proven innocent?

Having been on both sides of the CQI process at agencies both good and bad, I have found that the approaches to protocol deviations are polar opposites. At both, protocol compliance is something that is closely monitored. All reputable EMS agencies do this.

Protocol deviation

What distinguishes the good agencies from the bad is how they approach the deviation.

At my current agency – one that, while possessing a positive national reputation, is not one that is widely considered clinically progressive – the approach to my deviations from protocol has simply been 1) was it clinically appropriate and medically sound, and 2) did my documentation reflect that?

Most of my interactions with my quality improvement coordinator and my medical director have been nonpunitive, fact-finding sessions mainly focused on thorough documentation of my treatment rationale. When my documentation already provided all the facts they needed, it usually didn’t even go that far.

When an agency’s approach to deviation is like that, they don’t need robust, everything and the kitchen sink treatment protocols to deliver quality patient care. All the agency needs is good medics who can document.

But I’ve been on the other side of the fence as well, at an agency where every interaction with the CQI process began with, "Kelly, this is not about you being a good medic, this is about you being a good employee."

It didn’t take me long to ask myself why, at that agency, it was impossible to be both. And I soon moved on to places that allowed me to grow as a provider.

You have a choice

If you’re stuck at an agency where you’ve fallen victim to the protocol paradox, your choices are to move on to a better place, or stick around and try to change the agency from within.

Just because you’re stuck at such an agency isn’t the end of the world. EMS agencies can mature just like individual providers.

Protocols are, for the most part, written for the least skilled 10 percent of your agency’s employees. They are intended to be a floor for care delivery. If you can show your bosses and medical director that the floor they put in place has now become a ceiling, you can effect change. At my first EMS employer, very little was expected of us because our medical director simply assumed that was all he could expect.

When we proved otherwise, his respect and trust for us grew, and our protocols loosened accordingly. We experienced some reluctance from the novices among us, but soon those novices matured, as well.

It’s a management truism; people meet the expectations you set of them. When those expectations grow, so do the people, if you’ve hired the right ones.

If your expectations of yourself have begun to outstrip those of your agency, it might be time to seek new employment somewhere that will give you the room to grow.

And the funny thing is, the paychecks cash just the same, and often better.

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