There is a saying that your process is perfectly configured to give you the output you are receiving. This is usually used to lead into a discussion of the necessity to improve a process if the outcomes it produces are not what are desired. However, that is not the whole story. What if the process is perfectly configured but not faithfully followed as designed?

Protocols and Compliance

Processes consist of both protocols and compliance. If hospital-acquired infections are higher than desired, the root cause could be a poorly designed protocol or a well-designed protocol that is not being followed. To take action without knowing which of these is the root cause is foolhardy and unlikely to result in meaningful improvement.

Let’s say we have a good protocol but compliance is poor. If we improve the protocol further, but compliance remains low, the results will be disappointing. If we have a poorly designed protocol but we treat the problem as if it was due to lack of compliance, the results will be equally disappointing.

Determining the root cause

It is important to determine the root cause(s) of a problem with a process in order to design an effective action to improve the outputs from that process. Are high bacteria counts on high touch surfaces in a recently disinfected room due to a protocol that does not emphasize the importance of paying close attention to those surfaces or human failure to follow the established protocols? If the latter, is the non-compliance due to inadequate training or overwork? If so, administrative action is required to provide better training on the existing protocol and an appropriate workload. Well trained but overworked employees tend to find work-arounds just to cope with overloads. A common work-around is to skip compliance with a less observable protocol step in order to accomplish a more observable outcome measure. So, an overworked RN might skip hand sanitizing in order to take care of a patient in order to get to the next call light without an unacceptable delay and possible patient complaint.

If the non-compliance is due to carelessness, inattention, or outright lack of concern, then it is probably a problem with an employee. In our experience, this is a rare occurrence. But treating an administrative problem as if it were an employee problem will not result in the desired improvement and may even make the problem worse.