In EMS, we must strive to be accountable to our customers in every action we take. This accountability creates a culture of trust. From the patient’s perspective, if we’re accountable for the care we provide then the patient is able to trust that we know what we’re doing, and no matter the situation, we’ll arrive trained and ready to perform to the best of our ability. From the employee’s perspective, if we work for an EMS organization that’s accountable for its actions to both the employee and the patients, there’s a culture of trust and pride built into that organization.
The presence or lack of competition shouldn’t be the determining factor of accountability. Developing, nurturing and listening to the voice of the customer are the first of many steps of any EMS organization’s implementation of accountability. The basic understanding of who a customer is will start the process of structure development to meet the needs of those customers. Whether an agency serves large or small communities, is for profit or not, or is private or public in any form, their core customers are essentially the same. Customer satisfaction starts with the employees and encompasses their interactions and contacts with the patients, their families, community members and other health care providers in the continuum of care.
Providers are taught early on the need for developing rapport with patients. It gains trust, respect and open lines of communication that allow for appropriate patient care and management. The business model for an organization still falls under this pretext as well. Without the faith, trust and respect of an organization’s customers, the purpose of business is lost.
Employers have a responsibility to establish expectations of and for employees no matter their position. That responsibility revolves around accountability and the function of achieving it. Ultimately, when accountability is broken down to its most miniscule aspect, it’s found to be synonymous with transparency. Clear-cut expectations of employees through a thorough policy and procedure manual are essential. Honest communication must be established with any outside organization, peer group, governing body, or to the population your organization serves. This may be in regard to response times, noncompliance areas, public information releases or even strategic outlook.
So how do you build a foundation of success? Multiple realms of the organization must be strengthened, secured and rooted as a part of the organization’s daily function and model. The model starts from the inside by establishing a work environment of “just culture.” This allows an employee the opportunity to perform their duties without fearing repercussions for their mistakes, such as the use of open-door policies to instill the freedom of information exchange. Empowering employees with knowledge, ability and rules includes the appropriate quality assurance/quality improvement (QA/QI) policy and procedures and customer service focus. It continues with outward growth, development and appropriate, honest communication with city councils, organizational boards and public informational releases that strengthen the organizational roots in the community.
Board meetings, health group coalitions and Local Emergency Planning Committee (LEPC) meetings all have important community members who may not know the daily details of what’s going on in their EMS organizations. Knowing this, a representative from EMS must have the appropriate attitude that ensures their agencies are viewed in a positive light. This will encourage optimistic progression in an ever-changing EMS culture.
LEPC meetings deal mainly with hazmat incidents. As scenarios are discussed, it’s vital that accurate information is released so the community is aware of the resources and manpower that can be expected. Training should be performed to ensure that what was reported can be realistically matched. Utilizing incident command system (ICS) forms fosters accountability by ensuring the proper steps are taken.
EMS committee meetings are made of local responders, physicians and city council members who review protocols, happenings and developments in the field. These individuals count on accurate information and follow-through. Discussions can be about revising protocols, concerns with EMS and hospital operations, or allocating grant monies. This group collectively approves items with a majority voting, and each member has the accountability to provide input from within.
Healthcare coalition meetings consist of hospital administrators, health department employees, care center owners and first responders. These personnel discuss what resources could be available in the event of a disaster. They deal mainly with logistics; for example, if one facility is unable handle a large patient volume, solutions of how and where these patients are transferred are established. Emergency operation plans (EOPs) are crucial to allow for fluid, operational function.
A challenge for many rural governments is the blatant ignorance and complete lack of oversight that elected officials put toward providing a quality EMS service. It’s an even greater dilemma when the government entity provides an EMS service that’s staffed solely by volunteers.1
This obvious lack of concern characteristically starts at the top of the administrative food chain and rolls all the way down. An elected official, such as a county commissioner or mayor, is a major stakeholder in the delivery of that government’s critical services; yet in rural America, how often does an elected official have any knowledge or background of such a vital service?
As with most politics, a race for commissioner or mayor is a popularity contest. Within a rural community, it often comes down to which candidate has more family and close friends showing up at voting booths. Some of these elected officials come into office with their own agenda and EMS is just another assignment on their “to do” list, like overseeing the road department or mosquito abatement. A slothful commissioner or an apathetic mayor may think a successful ambulance service means someone shows up every time the pager goes off, regardless of the competencies, or the lack thereof, of the personnel responding to the call.
In the state of Utah, approximately 80% of all prehospital care is provided by volunteer EMS agencies.2 Many of these volunteer agencies are administratively and financially supported through their local governments. The elected officials of these governments, most with no knowledge of the profession whatsoever, may hire a person to be the EMS director who may, or may not, have general experience as a provider.2 In addition, the director may have no management experience or skills at all. This individual may have been chosen because they were the only one willing to take the job or because the elected official believed they could help them accomplish their personal agenda. Elected officials of many rural governments provide little to no oversight for their EMS services. They display a cute little mission statement on their website, issue tacky T-shirts to their volunteers that were bought on clearance from the last EMS conference, and call themselves EMTs.1
Until the constituents of governments with EMS services demand competent oversight of their service by their elected officials and/or stakeholders, it’s believed that many jurisdictions across the country will continue to administer second-rate EMS services. Most citizens won’t question if a local service is substandard until there’s a death and/or lawsuit.
Policies & Procedures
EMS organizations should develop structured policies and procedures (P&Ps) in order to assure accountability throughout an organization. Why and how they do this will dictate the success, growth and efficiency of all of their members. EMS organizations should consider the importance of accreditation in P&P development and the pitfalls that can limit their effectiveness.
The importance of efficient and appropriate P&P development has been explained and justified over a wide variety of both public and private industries. P&Ps provide a means to mitigate risk/liability, promote compliance, establish expectations, provide clarity, define commitments, provide direction, define responsibility, monitor actions and ultimately assure the growth and accountability of an organization.3-6
P&P development and implementation needs to be structured to account for the changing needs of an organization. They must maintain and assure consistency, enable ownership, provide a means of enforcement and enable growth and maintenance.
Changing Needs & Regulations
P&P development should directly correlate to the evolving needs of an EMS organization and the environment it must operate in. Understanding the regulations that affect an organization, and monitoring how they change annually, should be a primary focus. There should be a specific model for monitoring this change with an individual or group responsible for the consistent acquisition and dissemination of information. This holds organizations accountable to stakeholders and the community’s expectations.
Other needs within an organization can and should dictate the need for drafting additional P&Ps. These needs will likely originate from departmental committees (including field crews), operational needs, existing liability issues, executive oversight, board oversight, accreditation requirements, performance needs and accountability tracking. Multi-departmental involvement in P&P development builds a foundation for organizational accountability. Additionally, using evidence-based information during development will enhance P&P legitimacy.4,6-9
Consistency & Ownership
P&Ps must have a consistent, easy-to-understand format to ensure compliance and accessibility. Having diverse groups of people or committees responsible for the implementation and development of specific P&Ps promotes involvement by imposing accountability among all departments.3,4,7,8
To hold employees accountable for P&Ps, they need to be trained specifically on each P&P that affects them and their support staff. Having employees sign a receipt of acknowledgement, and maintaining records of that acknowledgement, ensures employees can be held personally accountable in the future. Supervisors, clinical department staff, human resources (HR) personnel and other stakeholders must spend time and effort enforcing these P&Ps. Without enforcement, true accountability can’t be achieved.3,4,6-9 “What you permit, you promote.”4
Growth, Maintenance & Accreditation
P&Ps are often written and put aside without consideration of changing needs, new regulations and relevancy. Accountable organizations review the P&Ps annually (or on a cycle) to assess additional needs, reduce liability, encourage growth and monitor effectiveness.3,6-8
Accreditation is obtained through various organizations dependent on department type. Accrediting organizations include: the Commission on Accreditation of Ambulance Services (CAAS), the Commission on Accreditation of Medical Transport Systems (CAMTS), the Center for Public Safety Excellence (CPSE)/Commission on Fire Accreditation International (CFAI), the Continuing Education Coordinating Board for Emergency Medical Services (CECBEMS), the Commission on Accreditation of Allied Health Education Programs (CAAHEP) and others. Each accrediting agency provides guidelines that will dictate appropriate and necessary P&Ps that reflect the ongoing drive for accountability in the prehospital community.
Accredited education programs have proven effective in producing higher-performing paramedics.10 CAAS- and CAMTS-accredited organizations have established themselves as leaders in the EMS industry. Voluntary accreditation also implies organizational accountability by being held to third party standards governed by diverse boards.5 Additionally, the accountability provided by accreditation may dictate Medicare reimbursement rates in the future, and help instill trust within our communities.10,11
P&Ps can easily lose, or never attain, an acceptable level of accountability without proper development. It’s important to maintain the transparency of P&Ps across organizational departments so that P&P development doesn’t take place outside the organization’s goals-as a whole, or in direct opposition to an existing P&P. This is usually caused by a lack of technology that enables accessibility, tracking and change. Developers of P&P should avoid inconsistent formatting. The lack of periodic review will cause an inability to adapt to change. More importantly, P&Ps must be diligently taught to employees and attested to so that organizations can build a culture of accountability.3,5,9
An effective QA/QI program will ensure the highest quality of education and patient care are provided to customers both internally and externally. When a QA/QI program is driven by a just culture mentality, it strengthens the foundation of the organization by changing the culture from one that’s historically punitive to one that’s transparent and designed to meet the customer’s needs. One study found, “Quality improvement programs assume that all EMTs … want to do the best they can for every patient and, given the proper tools and training, EMS personnel will provide high quality care.”12
This culture of trust, once created, becomes the expectation and no longer a delegation of duties. A good QA/QI establishes a standard of care that’s clear and measurable. Once in place, it’s reinforced through ongoing education and the development of a continuous feedback loop: from the customer to the organization, from the organization to the employee, from the employee back to the organization, then from the organization back to the customer. With this information, an organization is able to develop performance standards to continuously strive to improve the services provided.
Customer Service & Accountability
Customer service starts with the call-taker. They should use a scripted sentence to answer the call that’s both professional and helpful. EMS usage can facilitate ED overcrowding, such as low-priority calls triaged to urgent care facilities. An organization needs to monitor out of chute and response times to maintain benchmarked minimums, if possible.
Crews need to be caring and professional when they arrive and take time to explain procedures to the patient and family. When the patient is experiencing significant pain, crews should attempt to relieve it by repositioning and using padding or pharmaceuticals.
If ED overcrowding is known by the crews, a single-page scripted document should be used to inform the patient and allow them to make an informed decision on where to be transported. The patient can initial the document after it’s read to them, if time and call type permits.
EMS crews should leave a business card, if possible, with a link to a satisfaction survey. Develop a survey with Survey Monkey (or similar program) and trend results. This can include all departments involved from the call-taker to the first responders, the crew, the vehicle and the billing department. Correct any deficiencies and trend and monitor for improvement. By leaving the web information, the survey will yield a random sampling, as not all customers will return results. After trending and getting information back, deficiencies can be corrected first by the department involved, and then by the individual employee involved.
Implementing a Just Culture
A just culture protects people’s honest mistakes from being seen as culpable. But what’s an honest mistake, or rather, when is a mistake no longer honest?
It’s too simple to assert that there should be consequences for those who cross the line. Lines don’t just exist out there, ready to be crossed or obeyed. We construct those lines and redraw them differently all the time-depending on the language we use to describe the mistake on hindsight, history, tradition and a host of other factors.
What matters isn’t where the line goes, but who gets to draw it. If we leave that responsibility to chance, or to prosecutors, or fail to tell operators honestly about who may end up drawing the line, then a just culture may be very difficult to achieve. The absence of a just culture in an organization, a country or an industry hurts both justice and safety. Responses to incidents and accidents that are seen as unjust can impede safety investigations, promote fear rather than mindfulness in people who do safety oriented critical work, make organizations more bureaucratic rather than more careful, and cultivate professional secrecy, evasion and self-protection. A just culture is critical for the creation of a safety culture. Without the reporting of failures and problems, with openness and information sharing, a safety culture can’t flourish.
To collect productive investigative data, we must promote a culture in which employees are willing to come forward in the interest of system safety. Yet, no one can afford to offer a “blame-free” system in which all conduct has impunity-society rightly requires that some actions warrant disciplinary or enforcement action. It’s the balancing of the need to learn from our mistakes and the need to take disciplinary action that motivates the adoption of a just culture.
A just culture recognizes that competent professionals can make mistakes and develop unhealthy norms (i.e., shortcuts or routine rule violations), but has zero tolerance for reckless behavior.
Just Culture Algorithm
There are three basic duties in a just culture:
- Duty to produce an outcome. If an individual knows the desired outcome and is able to produce it (e.g., safe removal of an inflamed appendix), failure to do so represents breach of this duty;
- Duty to follow a procedural rule. If the individual knows the proper procedure and it’s possible to follow the rule (e.g., the procedure for inserting a central venous catheter), failure to do so represents a breach of this duty; and
- Duty to avoid causing unjustifiable risk or harm. Breach of this duty occurs when an individual intentionally harms the patient or acts recklessly.
If a duty has been breached, then the mechanism of the breach can be identified. There are three identified causes:
- Human error: This is an inadvertent act (e.g., a slip, lapse or mistake).
- At-risk behavior: Typically, this is a conscious drift from safe behavior, occurring when an individual believes that the drift doesn’t cause any harm. An everyday example is the willingness of some drivers to roll through stop signs. Those drivers don’t see it as risk-taking because there have been no negative consequences.
- Reckless behavior: In this case, the individual has chosen conduct that he/she knows poses a substantial and unjustifiable risk.
The response to an event is tied to the mechanism of error. An isolated human error is an opportunity to correct system weaknesses (e.g., confusing drug labels). The individual making the error should be consoled, rather than disciplined. At-risk behavior may also indicate a system vulnerability that should be fixed. However, the individual should be coached so that they understand the risks they’ve taken. Reckless behavior may be grounds for disciplinary action. The intent is to reduce the risk of future reckless conduct, and may include removing the individual from the organization.
The term “just culture” refers to a values-supportive system of shared accountability where healthcare organizations are accountable for the systems they’ve designed. This includes responding to the behaviors of their staff in a fair and just manner. Staff, in turn, are accountable for the quality of their choices and reporting both errors and system vulnerabilities.
In a just culture, boards and councils must recognize that EMS practitioners are faced with a diverse and difficult work environment on a daily basis. They must recognize that this requires dedicated, loyal employees who strive to be the best through constant training. Their goal is to provide the most accurate, mistake-free care in what are often very stressful situations. They must understand that medical errors occur when providing emergency care. Further, that most errors occur because of a system and/or a training problem. Sometimes an error can be, and most likely should be, a learning experience.
Repetitive problems are often caused by system weaknesses, but are sometimes individual performance issues-particularly when coaching or additional training has not improved the problem. For example, repetitive human errors may be an indication that the individual isn’t capable of performing safely in their current job. Repetitive at-risk behaviors may be due to impairment (e.g., drug abuse) or unwillingness to follow proper protocols.
A way to reinforce systems that are effective in accountability is the utilization of open door policies. Such policies give the employees the opportunity to discuss issues that they’re having with the organization with any level of management. Open door policies empower employees and assist with holding all levels of the organization accountable through an increased communication process.
Developing an organization that relies on accountability is important. EMS organizations have organizations that they’re responsible for and to: community, hospital and other local boards. EMS organizations need to develop P&Ps that form a roadmap of where an organization can operate in the future. An organization that develops a just culture and understands accountability will be prepared to move forward with an assurance of appropriate, quality care and understanding.
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12. American College of Emergency Physicians, SS Polsky, JC Johnson: Principles of EMS systems. Dallas, 291-331, 1994.