Learning vs. Management Problems

Healthcare has often turned to education to ‘fix’ management problems, which contradicts one of the core principles of learning in healthcare (Learning Card 10). Giving more education ‘checks a box’, but may not improve the outcome. To focus on improving outcomes, we need to do an assessment to determine if this is truly a learning problem or if it is a management problem.

A somewhat classic example goes as follows:

The education department at a hospital received a phone call stating that they needed to retrain all caregivers on HIPAA privacy regulations. The educator dives deeper and finds out that what happened was that the hospital had a HIPAA violation. The violation occurred when a caregiver looked up information on their neighbor (who they were not caring for) and shared the information with their spouse. The regulatory department is now demanding that everyone has to complete the 2-hour HIPAA online learning module.

In the above example, the regulatory and legal departments are trying to demonstrate that they have addressed the issue, preventing further HIPAA violations (checking the box). Unfortunately, there is very little or no data that backs up the effort that completing an online module will prevent future HIPAA violations. Additionally, the caregiver who violated HIPAA had completed that module and was aware that what they were doing was a violation. In this case, the problem may need to be addressed by a management pathway (progressive discipline) with the particular caregiver rather than by learning or education.

Healthcare has placed itself in a ‘weird’ position when it comes to issues such as the one in the example above. Efforts to embrace a ‘blameless culture’ mean that the system may be broken rather than one individual violating a rule. The problem for educators is that once someone knows what is expected of them, demonstrates competency in that skill (in this case maintaining HIPAA privacy practices), and consciously chooses to go against their education, it is now a willful act that needs to be punished, not an education problem.

The problem with thinking that learning or education can fix all problems is that it only reflects one part (either the learner or their experience) of the Learning Outcomes Model (Learning Card 1), and may neglect the other components, including the environment. It may be easier for management to check the box that they did something by doing an educational initiative rather than fixing the environment or addressing individual behaviors.

As educators, we need to feel comfortable pushing back when something is not a learning problem.

Another example:

The Med-Surg unit has had high turnover and is running short staffed. Nurses each have 7-8 patients (normal is 5 for this unit) as they are ‘flexed up’. There has been an increase in the number of falls in the unit, and the educator has been asked to do an in-service on fall prevention.

In this case, the higher patient loads have caused the staff to have to cut corners, and not only are falls increasing, but patient satisfaction is also suffering. Holding an in-service class would just stretch the staff further as they are familiar with the fall protocols, procedures, and precautions. The problem is that fixing staffing takes time, and the natural inclination is to ‘do something’ even if it is not going to fix the problem.

The results of years of fixing things through learning can be seen in any orientation program or online learning/learning management system (LMS). When you analyze existing orientation programs, you will find repeated content in the classroom and online learning. This repetition is because the first learning initiative didn’t ‘fix’ the issue, so more learning must be needed. My favorite is hand washing, where some systems have grown to over 8 hours of classroom, videos and online modules to fix the problem (for more on this see Learning Card 11).

So how can someone in education or learning stop the insanity?

  1. Educate leaders on the Learning Outcomes Model and the interactions between the learner, experience, and environment. In hospital systems that have embraced ‘lean’ you may find that solutions are either seen as learning (learner and experience) or Lean/Six Sigma (the environment). Fixing most problems takes a sustained change in all three areas.
  2. Quantify the cost of the learning initiative. Part of the reason learning is the “solution to everything” is that learning appears to be inexpensive. If your organization has 10,000 caregivers, and they average $30 per hour (normal in healthcare) then assigning a two-hour online HIPAA module costs $600,000 in staff time, in addition to any educational design cost.
  3. Push back (appropriately). Find an issue that is truly not a learning problem and use it to educate management (such as the HIPAA example). Be aware that this may cause ‘rogue’ education, where management decides to do the education without you.
  4. Create partnerships and relationships with management. Education and learning need to be seen as a resource and needs to be at the table when decisions are being made. Volunteer to sit on committees and go to the root cause analysis (RCA) events. It is much easier to shift management early in the process than when they have already decided it is a learning problem.

When learning departments start pushing back, it may be difficult, as the worry is about budgets and usefulness. I ask every person who makes a request: “Are you doing this to check the box (just to say you did it) or to achieve an outcome?” The answers are rather surprising. I have had people admit they are just checking the box (and then we work on making it the least painful as possible), and others have wanted the outcome. Those who are looking for an outcome will value your expertise on how to fix their problem as long as you build partnerships and relationships.

The result is that learning initiatives all become focused on improving outcomes, and both the patients and staff benefit. Staff have become numb to education, as it has been used inappropriately. Once they start seeing the results and value, their interest (and motivation levels) will rise. The budget is easy to get if you are truly solving problems and improving outcomes. Just be careful as if you become the one who can truly solve problems you will have more business than you know what to do with.

Application experience:


Participants: 8-12 (in pairs)

Time to complete: 30 minutes

With a partner, make a list of the last 5-10 ‘education problems’ that were brought to you. Discuss if they indeed are learning problems or management problems. Use Learning Card 11 to help you in problem identification. After you have categorized learning vs management problems, identify ways to engage management in solving the problem together. Share your findings with the group.

This part of a series called “Learning That Works” by Jason Zigmont, Ph.D., (jay.zigmont@gmail.com ). For a video on this topic and more information, visit http://L17.LearningInHealthcare.com . The principles above are part of the core content (Learning Card 17) of the Foundations of Experiential Learning Manual (available on Amazon).

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