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Creating an EMS Culture of Safety


The following article is an EMS Insider exclusive from the June 2013 issue. EMS Insider, the premier publication for EMS managers, supervisors, chiefs and medical directors, is a must-have resource for the critical, accurate information EMS leaders need. The monthly publication offers quality investigative reporting, exclusive articles, management tips and the very latest news on legislative issues, grants, current trends and controversies. For more about how to become an Insider, click here.

Editor’s Note: This is part two of a two-part article on strategies for creating an EMS culture of safety, based on the EMS Culture of Safety Project. Read part one here.

For the past three years, 18 EMS leaders have been meeting to tease apart and examine the bits and pieces that form an overall strategy for safety in the workplace. After obtaining input and feedback from a variety of stakeholders both inside and outside the EMS community, the group presented their recommendations to the National Highway Traffic Safety Administration (NHTSA).

The resulting 97-page EMS Culture of Safety document is the most comprehensive, collaborative effort on the subject to date. It represents a scientific, organized approach, designed to allow EMS agencies of every size, type and delivery model, to build (or rebuild) the foundations of a system of safety that permeates every aspect of emergency medical care by employing specific strategies to mitigate risk and prevent harm to providers, patients and the community.

On May 15, the EMS Culture of Safety members submitted the document, based on input from the National EMS Advisory Council (NEMSAC), to NHTSA, who will pass it through its internal clearance process. The final document is expected to be published in  September.

According to the EMS Culture of Safety chair Sabina Braithwaite, MD, MPH, FACEP, the purpose of the document is not to provide a specific “how to” guide. There are no detailed procedures regarding operations, medical protocols or vehicles. Instead, the goal is to help EMS agencies understand how to fundamentally shift the culture within their organization to one where safety is an integral component of everything they do.

There is precedent. Forty years ago this month, the Report of the National Commission on Fire Prevention and Control was delivered to the president of the U.S. Commonly referred to by its subtitle, “America Burning,” it defined the scope and extent of longstanding fire losses, analyzed the issues and offered detailed recommendations for fire prevention and protection. Today, due in large part to the recommendations in that document, the number of fire deaths among firefighters and the public has dropped dramatically. Braithwaite says the EMS Culture of Safety could have the same positive effect on the EMS world. As a profession, EMS must be willing to commit to safe practices, collect data and apply science, with the goal of reducing deaths and injuries among providers, patients and the public.

She notes that there will still be risks because EMS is an inherently complicated business, rife with perils that include aggressive patients, hazardous environments and speeding vehicles. Providers, who often juggle two jobs to make ends meet, work long hours under stressful situations. Fatigue, or perhaps just inattention, can lead to critical medical mistakes or driving errors. Moving an obese patient can turn a routine response into a lifelong disability.

By establishing a framework that anticipates risk and promotes safety, an EMS agency can develop strategies that don’t simply react to an adverse event, but proactively inform the entire practice of EMS within the agency. The high-level document identifies six key elements that can help move an EMS agency toward a culture of safety. Part one of this series discussed three elements that occur prior to a 9-1-1 response. The last three examine recommendations for changes during and after a response. These include creating a “Just Culture,” coordinating support and resources, and requirements for reporting and investigation.

‘Just Culture’
Widely adopted by various industries, including healthcare and aviation, “Just Culture” is described by the Culture of Safety strategy as “an open-source, non-proprietary approach that embodies fairness and accountability.” Organizations that embrace the practice will promote transparency and encourage employees to report errors and near misses in order to better understand areas of risk. Opportunities to modify processes can be assessed so future adverse events can be prevented.

The approach is counter to a punitive system where errors are often hidden in order to avoid retribution. As a result, the ability to learn from mistakes is lost.

By bringing errors out into the open, the culture of silence is replaced with trust. A Just Culture requires an atmosphere of trust that permeates the entire organization from top to bottom. Everyone has three duties:
1. To act;
2. To follow a procedural rule; and
3. To avoid causing unjustifiable risk.

Every effort is made to identify the factors that led to an error in order to identify ways to avoid recreating the same circumstances and resultant error in the future. The perspective expands from a focus on the error itself to a broader approach that considers risk, incorporating the human and process components for a more integrated approach.

The key word is “accountability.” However, this is not a “no harm, no foul” or “blame-free” approach. When it comes to unsafe acts, Just Culture requires a response, but what differentiates this approach from others is that the behavior is viewed separately from the outcome. Coaching may be appropriate for at-risk behavior, while punishment is still warranted for reckless behavior—regardless of the outcome. In other words, just because a no one died due to a consciously reckless action this time, the behavior can’t be overlooked since it creates significant risk of error when repeated. Conversely, if someone dies due to an inadvertent error, punishment is not the appropriate response and does not prevent recurrence of the adverse event. A more appropriate approach is coaching or even consoling. The idea is that no one should be punished for an inadvertent error.

Coordinated support & resources
Working together within the EMS community to present a unified, credible message regarding responder safety and the safety of patients and the public will require coordination. The Culture of Safety document recommends creating a centralized resource and coordination center called the EMS Safety Resource Center (EMSSRC).

The role of the EMSSRC would be to support, coordinate and monitor progress while sharing centralized information regarding a variety of safety issues. It wouldn’t have a direct role in conducting research or implementing specific intervention programs nor would it replace existing programs or initiatives. The idea is to avoid “reinventing the wheel.”

By housing existing resources, among other things, it could:

  • Communicate with a broad group of stakeholder organizations of all types to coordinate efforts for a unified message;
  • Provide visibility for an EMS Culture of Safety;
  • Function as a communication channel to the EMS community;
  • Serve as a repository for tools, best practices, education, research, standards and other related resources;
  • Work closely with state EMS officials and federal stakeholders;
  • Provide outreach resources within EMS and for the public;
  • Collaborate with appropriate entities in advancing the other five elements in the Culture of Safety strategy; and
  • Share research activities with related boards and groups.

The Culture of Safety strategy envisions that the EMSSRC consist of a consortium from the spectrum of stakeholder groups, but makes no specific recommendation regarding the structure.

Requirements for reporting & investigation
The final element in the strategy is a recommendation to establish a national EMS safety data system that would include data gathered from all EMS provider agencies using a standardized reporting method.

This function would also fall under the purview of the EMSSRC, which would partner with others in an effort to develop a mechanism for investigating safety concerns, particularly regarding EMS vehicle crashes.

Only limited data currently exists about these high-risk, high-profile incidents. Even less is known about non-crash incidents involving injuries that occur during EMS vehicular operations, such as personnel who are injured when the ambulance makes a sudden stop or turn.

The Culture of Safety strategy lays out recommendations for developing a reporting mechanism, from determining what data types are necessary to assigning authorization for an investigative body. Further, they strongly believe that some aspects of the reporting should be government-mandated in order to obtain more complete and accurate data.
Implementing change

Braithwaite doesn’t just talk the talk. As medical director of the Wichita-Sedgwick County (Kan.) EMS System, the primary agency responsible for BLS and ALS prehospital care and transportation in south-central Kansas, she has invested time and energy in implementing many of the recommendations included in the Culture of Safety strategy. This includes the Just Culture approach, revamping leadership training, reducing medical errors and creating a more collegial workplace that replaces the typical hierarchical structure seen in many EMS agencies.

Overall, she reports, the results have been good, but she admits the process takes time. Most of the staff understood why the change is necessary and agreed with the goal of providing better and safer patient care. However, understanding the words and seeing the actions are two different beasts. “People need to know that management will listen and cooperate with field personnel. This is very much a team approach,” she says. A good first step is to identify low hanging fruit to achieve early success.

Of course, implementing change isn’t without its challenges. “The good part about being with an agency that’s been around for 35 years is that there’s a lot of tradition. The bad part is that there’s a lot of tradition,” she says. What the Culture of Safety approach has done, she notes, is help refocus everyone within the agency on what is truly important—promoting patient outcomes, not necessarily arriving on scene in eight minutes or less.

She also recommends informing the public about the agency’s efforts. “There needs to be a public relations side when you make these changes. Tell your community and elected officials,” she says.

Given the chance, Braithwaite says she would do it again. “It’s been nice. It’s almost invigorating,” she says.

Envisioning a cultural change in EMS on a national scale has been a monumental task. The EMS community owes a debt of gratitude to the 18 individuals who dedicated three years of their lives to seeing this project to a successful completion.

Braithwaite notes that the work started by the EMS Culture of Safety team does not end when the final document is published. Further efforts are needed, especially in the area of research. NHTSA has committed some funding. Efforts to educate others outside of the EMS community must also be addressed. “It’s clear that there is little-to-no-understanding of the realities [of] EMS [among] the rest of the world,” she says.

By supporting and enhancing the work already completed or in the works and connecting the strategy to solid science and best practices, the recommendations of this document can be an invaluable guide for EMS agencies that wish to employ strategies to mitigate risk to providers, patients and the public.

A complete copy of the draft EMS Culture of Safety document is available at www.emscultureofsafety.org.


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