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View All ProductsIn all areas of resuscitation, from neonatal to elderly care, clinical deterioration is a risk that can be avoided with the help of HealthStream's training programs.
View All ProductsNurture the skills of your nurses and medical staff to help mold them into effective leaders with development training from HealthStream.
View All ProductsMake sure your clinicians have the support they need to provide competent care with clinical competency training and development from HealthStream.
View All ProductsHealthStream’s learning management system and comprehensive suite of competency management tools empower your healthcare workforce to deliver the best patient care.
View All ProductsThe suite of healthcare onboarding solutions available from HealthStream aids in nurse retention and improved patient outcomes.
View All ProductsGive your healthcare staff the decision support and skills training they need with the online products available from HealthStream.
View All ProductsHealthStream leverages medical professional development in healthcare by providing staff training programs
View All ProductsCreate engaging and impactful learning experiences that meet the unique needs of your acute care staff.
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View All ProductsMitigate risk and elevate your quality of care. Improving both clinical and business outcomes starts with a smarter, more integrated approach to regulatory training, continuing education and quality management.
Learn MoreBy Donna Wright, MS, RN, Consultant, Creative Health Care Management
When mistakes and errors occur in our organizations, it is our obligation to analyze these problems and assess the reason(s) why they occurred. These problems have many different names: sentinel events, incident reports, near misses, etc. When these situations (mistakes/errors) occur, we often form a group to analyze them. We put together a taskforce or committee to examine the situation, discuss it, fishbone diagram the reasons why it occurred, and so on. The most common end-product of these taskforces and committees is to come out with two options of actions to implement. These two options are usually an in-service class or a house-wide competency. Both are options that focus on educating people.
It's Easy to Jump to the Conclusion that Education is Needed
These options of education or competency assessment are frequently and easily chosen. We often believe that these are safe choices and frequently say, “Education can’t hurt.” To this statement I say, “I beg to differ.” I believe that in-service programs or house-wide mandatory competencies are not just benign interventions that can do no harm. I have seen many groups actually create greater problems by overusing educational interventions for sentinel events or incidents involving mistakes and errors that result in poor outcomes.
When you choose the option of education as the solution for preventing mistakes and errors, you are sending one of two messages to staff:
1) You do not have enough knowledge or information to do your job.
2) You do not have enough skill or talent to do your job.
Organization-Wide Education Might Convey the Wrong Message Internally
This can be very dangerous. If one person makes a mistake and you reeducate everyone to prevent this mistake from occurring again, you send a message that all the staff are “not smart enough.” If you are one of the people trying to do your best every day, follow the policies, and have good outcomes, but time and time again you are forced to be re-trained, eventually these actions can stop you from trying.
Using “education for all” to address one person’s error may erode self-esteem among your team and create a culture of compliance rather than one of commitment. The result may be a mediocre team.
It’s a simple formula: If an individual succeeds and is not recognized for that effort, and is treated like those who do not succeed, the individual will either stop striving to succeed or leave the organization.
Analyze Carefully to Know Education is the Right Choice
It’s true, of course, that education for all is occasionally the answer. If it is determined that the problem is systemic, then the solution should be systemic as well. But education as an intervention to sentinel events can cause harm and should be used rarely, carefully, and only when there is a clear assessment that a lack of knowledge or skill was the reason for the error.
When you analyze an event, make sure the analysis includes all areas of possible deficit:
1) System problems
2) Tools availability
3) Departmental barriers
4) Communication barriers
5) Attitudinal issues
6) Individual performance patterns
7) Any other barriers that hinder people from taking the right actions
My strong suggestion to every educator and leader in healthcare is to do a full, systematic reflection on the situation before using any education response or intervention in an effort to improve outcomes. It is well worth your time and resources.
Learn more about the leading learning management system in healthcare, the HealthStream Learning Center.
A staff development specialist known for her irreverent wit, Donna brings a global perspective to her work. In this country and in the over two dozen others, Donna’s best known for the work she does based on two of her books, The Ultimate Guide to Competency Assessment and Relationship-Based Care (co-authored with several Creative Health Care Management colleagues). The Ultimate Guide has become the industry standard for HR departments in establishing and assessing competency, and Donna specializes in setting up systems for organizations to ensure accountability and measure competency. Contact Donna at dwright@chcm.com.
HealthStream’s learning management system and comprehensive suite of competency management tools empower your healthcare workforce to deliver the best patient care.
View All Learning & PerformanceHealthStream offers performance learning management solutions to help develop your healthcare staff into leaders and reduce turnover.
View All ProductsHealthStream works with healthcare organizations to create engaging and high-quality training videos for your staff and management.
View All ProductsImprove care quality and save money by making informed decisions about your healthcare facility and staff with HealthStream's reporting analytics solution.
View All ProductsHealthStream's proven methods for the improvement and overall engagement of your healthcare staff foster a positive workplace and increase retention rates.
View All ProductsThe leadership development program from HealthStream helps mold your high-potential healthcare employees into proven leaders.
View All ProductsWhen you enact HealthStream's quality compliance solutions, you can do so with the confidence your healthcare organization will meet all standards of care.
View All Quality & ComplianceFulfill compliance requirements with a variety of programs and courseware designed to address critical regulatory requirements as well as educate staff to recognize and mitigate risks.
View All ProductsBy increasing your healthcare staff's focus on quality and safety with HealthStream, they can help to reduce medical errors and readmission rates.
View All ProductsLearn about what HealthStream's healthcare policy management software and how it can help aid your organization efforts.
View All ProductsHealthStream's education helps address diversity, equity, and inclusion within your organization, as well as promoting health equity in the communities you serve.
View All ProductsHealthStream offers professional training and education on how to best optimize your reimbursement process within your healthcare organization.
View All ReimbursementTeach your healthcare staff about the revenue cycle and claim management through targeted training and video tools from HealthStream.
View All ProductsLearn about our advanced resuscitation training solutions. Our solutions are designed to help improve patient outcomes.
View All ResuscitationIn all areas of resuscitation, from neonatal to elderly care, clinical deterioration is a risk that can be avoided with the help of HealthStream's training programs.
View All ProductsNurture the skills of your nurses and medical staff to help mold them into effective leaders with development training from HealthStream.
View All ProductsExpand the decision-making skills and effectiveness of your healthcare workforce with HealthStream's clinical development programs and services.
View All Clinical DevelopmentMake sure your clinicians have the support they need to provide competent care with clinical competency training and development from HealthStream.
View All ProductsHealthStream’s learning management system and comprehensive suite of competency management tools empower your healthcare workforce to deliver the best patient care.
View All ProductsThe suite of healthcare onboarding solutions available from HealthStream aids in nurse retention and improved patient outcomes.
View All ProductsGive your healthcare staff the decision support and skills training they need with the online products available from HealthStream.
View All ProductsHealthStream leverages medical professional development in healthcare by providing staff training programs
View All ProductsLearn more about HealthStream's provider credentialing, privileging, & enrollment solutions for healthcare organizations.
View All CredentialingExperience standardized and centralized healthcare provider credentialing, privileging, and enrollment that is smarter and faster than ever before.
View All ProductsAutomated, web-based provider credentialing and enrollment software for growing medical groups.
View All ProductsNCQA-certified CVO verification services for initial and re-credentialing files in an overflow or full-service capacity for healthcare organizations.
View All ProductsSearch, review, and add providers into the Epic provider master file with our Epic app integration, Provider Validate.
View All ProductsMake sure your healthcare staff can schedule out appointments and work schedules with ease using HealthStream's line of software solutions.
View All SchedulingHealthcare scheduling software designed to optimize staffing requirements & elevate patient care
View All ProductsPrecisely align staffing and needed resources to enable efficient patient flow and high-quality, cost-effective patient care.
View All ProductsHealthStream’s free nurse schedule app, NurseGrid™, is built to help you care for your staff and engage with their specific needs.
View All Products