Noncompliance

When I was an angry, angry captain responsible for quality assurance, working in a basement dungeon and rarely being allowed out in public, I found out that there were three main reasons for not complying with a directive.

Dunno, can’t, and won’t.

Dunno encompasses all of the times that an employee “don’t know” something.  When an employee doesn’t know that something is required.  When an employee doesn’t know how to do something.  When an employee doesn’t know how to use a piece of equipment.  When an employee doesn’t know how to document that s/he did what was required.  Some people are just a wee tad hypocognitive and need to be reminded more than once. 

Most of the dunnos are corrected in paramedic school – a medic learns to run an arrest, intubate, start an IV, and that kind of crap.  Then they are hired into a job and an HR person goes over the other requirements, so they know how to wear the uniform, how to clock in, and how to call in sick.  Finally, a field training program of some sort covers a whole bunch of the other dunnos (and correct some of the stuff learned in school).

After all of that, though, there are still requirements that change, new procedures, and new equipment that have to be learned.  Anytime something changes, drops, or is adopted there is someone who is slow to get the proverbial memo.  Hell, I still occasionally think of Bretylium, bicarb in arrest, and MCL1 from time to time.  It took me a year or so to remember to use aspirin when we first got it.

I am optimistic that there is a bright and happy future where I
am embarrassed at being so old as to even think of this.  Credit

The “can’t comply” form of noncompliance occurs when an employee knows about a directive, but systemic factors are standing in the way.  For example, you can have a standing order that says an employee must complete the PCR before leaving the ED, but if there is another call for them that dispatch is nagging about, the run sheet is probably not going to be left. 

Another good example of this was back when we adopted waveform capnography.  End-tidal CO2 must be documented for all intubated patients.  All employees were told about the new requirement.  But even after allowing time for adoption, re-explaining the requirement, and pulling my hair out, there was still embarrassingly low compliance.  Then one day a medic explained it to me, like I should have known about it all along.  See, the EtCO2 equipment was hidden away.  Thus, it was a pain in the ass to get out and use when you had a patient sick enough to require a tube.  I don’t know why the capnography adapters were so hard to find, but all it took was moving the equipment to the airway cabinet for compliance to shoot up.  The medics wanted to comply, but there were problems standing in their way. 

If an employee knows that something is required, knows how to do it, and there is nothing standing in their way, then all you are left with is that they “won’t comply.”  Employees that truly won’t do what is asked of them shouldn’t be employees for long.  But most employees aren't actually willfully disobedient, so this is rare, and a topic for another time.

One of my biggest flaws as a manager (and, I freely admit, there were many) was that I was habitually too quick to assume “won’t” when “dunno” or “can’t” actually explained what was going on.  If you find yourself in a management position, please make sure to always look for the can’t and the dunno first.  One of the major roles of managers and supervisors is to get rid of the can’ts and dunnos in your organization and allow good employees to be good employees.