Spirit vs. Letter of the Law

Jeff Clawson, M.D.

Jeff Clawson, M.D.

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Jeff Clawson, M.D.

Question: Awhile back, I was asked to address a group of ED-Qs meeting here in Salt Lake about my take regarding what constitutes “MINOR” or “INSIGNIFICANT” deviations from scripted interrogation. This issue had become an increasingly more common topic for internal discussion at IAED, specifically about scoring emergency dispatcher compliance deviation, which can often become a fuzzy line during verbal interaction with callers. Essentially, where can we draw the line between what word changes are significant and which are not? And how should we apply this in our ED-Q activities? There is a good example (that is part of the protocol used on every single call) we can use to aid in our understanding and application of this concept. This is certainly an area begging for the application of common sense.

Note: Since that time the ED-Q Council of Standards has recently issued an interim clarification document shown here, which certainly constitutes movement in this direction

Answer: We all, in QA, need some better-defined rules for the application of the MINOR deviation label to better guide our direction when these “issues” are encountered in case review processes.

I personally believe there is a best, right way to do things in asking most questions and providing most instructions. However, this does not mean the best way is the only correct way.

There is a little-discussed concept I have referred to before as “learned phrasing.” This has been seminal in the process of having precise scripts applied for virtually everything involving caller/calltaker interaction throughout the MPDS®. The concept is this: If there were a correct way to say something, it would be best to create a mental and muscle memory of its use, so that when application decision-making is encountered, this version of the “script” comes out first. This, I believe, helps to ensure that the best thing is used most of the time, especially when the “chips are down” and/or chaos or something unexpected occurs.

There should be a rational reason for doing a thing a certain way. For example, Case Entry Question 3 (CEQ3) starts with the word “Okay …” Is this an essential word in the clinical structure of the protocol—no. Will choking babies die if it is not said or substituted with something else—no. Does it have a reason for being there—yes. In case review, it appeared to be a very commonly used, natural segue from CEQ2 wherein we end the verification of the phone number, and therefore, by saying “Okay,” we acknowledge what was just said, and then flow more smoothly into, “Tell me exactly what happened.” It could just have easily been, “Okay now …” or “All right …” or “Good, tell me…” In the case of this sentence query, we chose “Okay” as the written, first-applied wording, not because it was absolutely necessary, but because it was commonly used, seemed very natural, and was easily remembered. Are there occasional times when this CE question segue is better without it? I suppose so, but I have not heard anything better specifically occur, and if so, for any apparently better reason.

It is hard to teach how the correct way of a MINOR or INSIGNIFICANT deviation can be allowed. The only exact way is to be the mindless enforcer of case review—wherein we commit ourselves to being not only “right,” but often “dead right,” and incur the unnecessary wrath of our emergency dispatchers by adhering blindly to exact wording, always. This is not the best course to take.

I feel the ED-Q Council of Standards can start to address these issues a few at a time, and has as of the May release of INTERIM CHANGE TO UNIVERSAL PROTOCOL STANDARD 1 (UPS 1 AS WRITTEN), so that we can more consistently follow the spirit, not just the letter, of the law. Whether we can easily identify every case of where things like “Okay” at this end of the spectrum of case review, remains to be seen, as there will always be some subjectivity involved, no matter how much we would like to define things in black and white. However, deviation, simply for deviation’s sake (without any evident or persuasive rationale), is just that—blind deviation from what we initially thought was the best way to do it, as far as we can understand at this time. Case review, QA, and the quality improvement that should result from it are essential elements of doing what we are initially trained and expected to do—at the highest possible level. Without robust QA, we are like helicopter pilots flying in a snowstorm without instruments (the protocols) or air traffic control (ED-Q feedback) trying blindly not to crash or hit anything. To that I say, “Good luck!”

J. Clawson