One patient has died. Two healthcare providers have been infected with the ebola virus in Texas. It’s too early to know for sure what happened, but somewhere there is a “learning” issue that needs attention. Last night, Texas Health Presbyterian Hospital announced that it had given its staff mandatory training and that it had a heavy commitment to safety. No doubt that safety and proper procedure are urgent concerns at the hospital; they are in any healthcare facility. In fact, the CDC announcedthat it would be stepping up safety training resources: offering seminars, webinars, and other educational tools to assist in communicating proper and safe standards regarding ebola. Last evening, a nurses union in California issued a release indicating that it had spoken to several healthcare practitioners at Texas Health Presbyterian who indicated that protocols were not followed and that they were afraid of retaliation for speaking up.
Time will tell what happened, but just what’s in the public record raises learning concerns and several questions. First, take a look at the CDC’s protocols for what should be worn in handling infectious materials including ebola. There are multiple steps and, presumably, the failure to follow any one of them could lead to exposure and infection. This appears to involve a complex process with small steps of great significance.
Somewhere, something happened that shouldn’t have. Among many questions to consider are:
What was the nature of the mandatory training?
Was it a check-the-box online protocol that people could take while multitasking?
When was the mandatory training given? Was it months ago or was it recent?
Did the Hospital take any steps to test what care givers knew and did it require them to actively demonstrate their application of what they learned?
Did the Hospital include opportunities to practice the use of protective clothing?
Did the Hospital refresh lessons that had previously been taught?
It’s clear that the Hospital is concerned about patient and staff safety – but how clear were the statements of leaders and team members about the importance of rigorously following procedures? There’s a big difference between asking individuals to complete a protocol and then requiring that they demonstrate competence, apply what they have learned and that someone is monitoring their practices to make sure that they are as close to 100% as possible.
The perils of check-the-box learning are seen in many situations – it’s one thing to be able to say, as we’ve written elsewhere, that learning has been delivered so that a technical requirement has been fulfilled. But patients, staff, and, ultimately, the public face great dangers that require much more be done than delivering training and assuring its completion. Accurate, clear information must be delivered carefully and repeatedly and competence be demonstrated not once but on an ongoing basis. If learning cannot be distributed and its application be repeatedly verified to hospital staff then, perhaps, significant efforts need to be made to limit those responsible for dealing with individuals infected, or possibly infected, by the virus to stem its fatal spread.