Over the last several years, many articles have been written about the benefits of implementing Just Culture in EMS. Speakers at various conferences have presented lectures about Just Culture, and described how it can transform organizations into safer, more cohesive and more reliable entities.
These articles and presentations have done a great job of explaining the benefits of Just Culture, but the practical application and organizational integration have remained elusive.
This article details how an organization successfully integrated Just Culture and sustained success for more than seven years and counting.
What is Just Culture?
Before we share our story, we need to first explain what Just Culture is. Traditionally, many EMS cultures have been relatively punitive, holding individuals accountable for all errors or mishaps that occur. An organization that employs Just Culture recognizes that individuals shouldn’t be held accountable for system failings over which they have no control.
A Just Culture organization recognizes that many errors represent predictable interactions between human operators and the systems in which they work. It recognizes that competent professionals make mistakes, and acknowledges that even highly skilled individuals will develop unhealthy norms by taking shortcuts or committing routine rule violations.
Just Culture is a values-supportive system of shared accountability, where organizations are accountable for the systems they designed, and for their fair and just responses to the behaviors and performance of their staff. Just Culture is the blood that runs through the veins of my agency, but it wasn’t always that way.
In September 2010, I was celebrating my 18-year anniversary at my organization. My employer offers a 30-day paid sabbatical after 15 years of employment and again every five years thereafter. It was three more years before I was able to actually pry myself away from the job and take my sabbatical.
After a few days away from the daily stresses of a high performance ambulance service, I realized that I was still struggling to relax. I felt uneasy every time I thought about my agency and the endless employee complaints, high attrition, strained relationships and pervasive feelings of negativity and hopelessness.
Communication between employees and management was minimal, and when conversations did occur, they were full of tension and mistrust. Employees were issued disciplinary actions without consistency and, in some cases, without justification.
Concepts such as near-miss reporting, mindfulness and risk mitigation were nonexistent. Our organizational culture was sick, and at risk to significant adverse events.
Spending time away from the day-to-day operations gave me the opportunity to reflect on the type of organization I was leading, and the fear-driven, blame-saturated, reactive and inconsistent environment I worked in.
I began to look for solutions and ways to turn our toxic work environment around. I scoured through my personal library of leadership and business books, but nothing really popped out as helpful.
Then it hit me. I had a good friend who, for the last several months, had been telling me about High Reliability practices, including Just Culture, and how he used it within his fire district as well as the local public safety answering point center.
Paul LeSage was about to retire as the assistant chief of operations at Tualatin Valley (Ore.) Fire Rescue, and was taking a new position as director of Oregon’s second-largest 9-1-1 emergency dispatch center. I immediately called him and arranged for us to meet.
Humans are fallible, and often the least reliable component of larger systems—but they can also be an organization’s greatest asset.
A Turning Point
Between the time I called Paul and the day of our meeting, a significant event occurred with one of our ambulance crews, resulting in the immediate termination of both crew members.
The crew was transporting a patient on continuous positive airway pressure (CPAP) and ran out of oxygen. The paramedic attending to the patient panicked and yelled to his EMT partner to drive faster. When the call was over, both crew members were terminated for violating rules associated with excessive speed and non-standard patient care.
Even though I was on my sabbatical, I was notified of the event and the turbulent impact it was having on the workforce.
A few days later, I met with Paul and asked him to help our company. I described the current state of our organization and told him about the CPAP call. Paul agreed to assist and coach us, with one condition: We would have to agree to analyze the CPAP call using a Just Culture systems and behaviors approach, and commit to the findings, even if it meant reversing the employment termination decision.
To be successful, we would need buy-in from all levels of management, and we would need to agree to hold mandatory all-hands meetings every quarter, where all employees were in the same room, at the same time, hearing the same information.
One week later, I had an encouraging meeting with the president of the company. He was intrigued by the possibilities and wanted to learn more.
A few days later, the three of us met, and Paul went into detail about Just Culture, High Reliability and the benefits it would have for our company. The president pledged his support and the integration process began.
The Journey Begins
When I returned to work, I met with the management team to discuss my new perspective on our company’s existing, toxic culture.
Some members of the team nodded their heads in agreement. We were in a “doom-loop” where our responses to negative events were actually increasing risk, worsening the rift between employees and management.
I explained High Reliability approaches, Just Culture and the impact it had on other organizations. I told them about Paul, our conversations, as well as the president’s support for this approach.
I also explained that it wouldn’t be easy. There would be setbacks, and the transformation would take at least two years.
Responses were mixed. Some agreed that this approach was needed, others were noncommittal, and some team members expressed their disapproval, stating that the program wasn’t sustainable and they weren’t interested in a “blameless” culture.
After clarifying that the process wasn’t focused on blame, but rather analyzing systems, performance, behavior, and properly assigning responsibility and accountability, I asked them to be open-minded and inquisitive. I reminded them that we couldn’t move forward until every management team member was fully committed.
Over the course of the next three months, Paul led several classes for our leadership team. Those who were still uncertain were encouraged to do their own research and initiate private meetings with Paul to help them make the commitment.
Analyzing the Call
After the first few sessions, we were ready to analyze the CPAP call. This was our first experience using the systems and behaviors approach. The management team participated in a probability analysis. This is similar to root cause analysis, but it uses more advanced technology. We thoroughly reviewed the details of the call.
The team identified risks inherent in the system and in the behavioral choices made by the crew. We reviewed the system components (e.g., policies, equipment, protocols and procedures) in place to mitigate risk. We discussed the potential for competing priorities faced by front-line employees using system components. We discussed human error associated with the event, as well as the quality of the choices that were made, and any personal performance limitations.
We’d performed such a thorough review of a single event. It was clear that, prior to learning Just Culture, we were in a dark room with only a flashlight to illuminate small areas.
The analysis showed us how to turn on all the lights and see the entire room, every space and all the contents at the same time. At the end of the analysis, the management team was fully committed.
All Hands On Deck
By the second week in January of 2011, with a fully engaged management team, we were ready to introduce Just Culture to our workforce at the first all-hands meeting.
I began the session by acknowledging how unhealthy our existing culture was. It was the first time our employees had heard a manager describe in detail what they were experiencing.
I introduced Paul, who spent the rest of the session explaining what Just Culture was all about, the challenges of integrating highly reliable practices and what everyone would be asked to do for the concepts to take hold.
The entire process, Paul explained, was about finding risk, rather than finding fault. Undesired outcomes are often the result of the systems we work in (or our own personal systems), human performance and human behavioral choices.
To mitigate risk, the organization’s systems, performance and behaviors must be analyzed, and, when necessary, properly managed. Humans are fallible, and often the least reliable component of larger systems, but they can also be an organization’s greatest asset.
Just Culture helps to draw the line between unacceptable behavior and unsafe acts. Fear of random, inconsistent punitive action impedes open conversations about errors and at-risk choices, and often leads to underreporting risk and the inability to improve or correct.
The entire group learned to avoid outcome bias. One of Paul’s favorite messages was that “we can’t be curious and angry at the same time.” If an event causes you stress or anger, take a step back, and engage with curiosity. We discussed the power of stories and gossip, and how much they can damage organizational culture. I knew we were on our way to creating a safer, more collaborative work environment.
Just Culture in Action
Over the next several months, education continued for our leadership team. They acquired additional knowledge and skills, and communicated with their employees in a more confident and consistent manner.
They came to recognize that open communication with staff shouldn’t be underestimated. The new approach improved employee engagement and created an appreciation for learning within the organization.
The learning process extended beyond the leadership team. We created a robust quality improvement committee and an operations advisory committee (OAC). We also spent time strengthening the existing safety committee.
While the committees were analyzing events and near misses, they were also looking for patterns in systems, processes and behaviors to identify areas where our agency might proactively manage risk to avoid future problems.
This committee has been instrumental in minimizing medication administration errors, enhancing protocols and recommending training based on their analytical findings. Committee members are appointed by the clinical manager and their scope and term are memorialized in a committee charter.
The OAC’s primary function is to inform management of policies and procedures that no longer serve in the best interest of the employees and customers. They also alert management to conflicting requirements, such as, “Make sure that you appropriately document all activities related to patient care,” and, “Make sure that you keep the patient satisfied at all times, even though your back is to them and you can’t pay attention to them because you are typing.”
They also report on equipment issues and outdated operational practices that pose potential hazards. This type of environment allows learning to flourish, and, in most cases, the managers are the students.
The safety committee, which was in existence prior to the integration of Just Culture, received a much-needed boost in the way of training and event investigation. The committee consists of managers and frontline personnel. Using a structured approach, the committee reviews in detail every accident and on-the-job injury. They also track and trend their findings and identify patterns that might lead to adverse events.
These important committees significantly improve the employee experience and employee engagement. They also create vital communication channels between frontline employees and management.
While the committees were analyzing events and near misses, they were also looking for patterns in systems, processes and behaviors—and identifying areas where our agency might proactively manage risk to avoid future problems.
A Culture Healed
It’s been more than seven years since we first introduced Just Culture to our organization. The fear-based culture has been replaced with one that is positive and focused on safety, effective communications and the overall health of our company.
When asked what the best part of our Just Culture is, I have a difficult time pointing to a single component. However, in our quarterly all-hands meetings, it’s very satisfying to hear the committees share their efforts to improve quality, safety and productivity of the organization with their co-workers.
Terms such as human error, at-risk and reckless behavior are now part of a common language used throughout the organization.
Employees now proactively work to identify risks within our organization’s systems and pinpoint the best ways to mitigate potential issues.
These face-to-face sessions, like the quarterly all-hands meetings, give us the ability to deliver the same message to everyone, without information becoming diluted or distorted in the rumor mill.
The return on investment has been exceptional. In 2012, we had 40 on-the-job injuries; in 2016, we reduced that number to 22. Not only was the reduction significant, but it was accomplished while we added 67 new employees to the team.
Furthermore, medication errors decreased by 85%, backing accidents reduced by 55% and employee attrition increased by 23%.
Integrating Just Culture into an organization is always a work in progress. Although it can be complicated and, at times, messy, Just Culture represents a fundamental shift that can be infused throughout an organization.
Employee engagement is vital and leads to employees caring about their jobs, their employer, their co-workers and their patients.
Our Just Culture program changed the “feel” of our company. We transitioned into a workplace focused on safety and high reliability, with heightened levels of system effectiveness and individual performance.
Now, we’re a learning and teaching organization where everyone—regardless of rank—has the opportunity to teach and learn, and these elements are built into the fabric of our day-to-day activities.
Each organization’s use of Just Culture principles may be different, depending on regulating bodies, union presence and participation, size, ability to collaborate, organizational readiness and geographic location, among other possible variables. Each organization must embrace the tenets of Just Culture in the way that’s most successful for them.
This article is the first in a four-part series on Just Culture. The remaining three will be featured exclusively in our monthly EMS Insider Newsletter. Sign up at www.jems.com/enewsletters.
Part 2: The Initial Approach: Buy-in, commitment and trust In our next article, we’ll discuss the challenge of introducing workplace justice and reliability concepts, and how to gain buy-in and commitment from the top management team to the newest employee. we’ll walkthrough the steps needed to build a culture of trust and reliability. We’ll emphasize the importance and the pitfalls of retrospective incident review, and how collaboration and careful instruction can mitigate the impact of bias and other factors that affect our ability to think proactively.
Part 3: The Journey Starts: Steps toward a more reliable organization A bad thing happens. We investigate. Someone is held accountable. We write some new policies. Promise on the news that this “will never happen again.” Rinse. Repeat. The third article in this series will address some of the fundamental problems we face when integrating safety culture and reliability concepts into the fabric of the organization. We’ll discuss where you might start, realistic timeframes and potential opportunities. This article will use specific case examples to show how a safety culture and eventual high reliability is achieved over time, with effort and with a forgiving attitude for the times you’ll drift from the mission.
Part 4: Advanced Concepts: Where do we go from here? Return on investment (ROI) is a seemingly simple phrase that seems to be the lead-in any time a new initiative is proposed. “What’s the ROI? When will we see fewer accidents? When will quality improve? When do we get reliable?” Our final article will address the importance of having a vision as well as a plan to achieve high reliability and foster a safety culture. We’ll discuss how your current programs might align with this long-term plan, and how your team should assess new proposals designed to improve operational efficiency, teamwork, reliability, quality and other foundational aspects of your business..