Administration and Leadership, EMS Insider

Just Culture & High Reliability: Where Do We Go From Here?

In our previous article, we addressed some of the fundamental problems we face when integrating safety culture and reliability concepts into the fabric of the organization.

Our final article in this series will address the importance of having a vision and a plan to achieve high reliability and foster a safety culture. We will discuss some key components for this long-term plan, and also discuss the concept of return on investment – ROI.

A Vision to Sustain

The fact is, success in developing a systematic approach starts with a vision of sustainment. Many organizations launch initiatives with what we call a “one and done” mentality. Recall we discussed this problem at the very beginning – what keeps this from becoming the flavor-of-the-month? The executives have to buy in to the fact that sustaining high reliability is an ongoing journey – not a destination. There needs to be a commitment to changing the way your organization looks at risk, develops systems, and matures people. 

The primary starting point is seeing that managing risk with your employees, systems, operations, administration, finance, and logistics needs to be an integrated effort. An exercise we commonly undertake when organizations first start the journey to high reliability is that we try to identify all the different ways that the organization sees risk. Commonly, there are more than 70 different inputs—for example, provider complaints, near-miss reports, clinical misadventures, safety and injury reports, etc. Once these are identified, it becomes clear that a systematic approach is needed—a common taxonomy and method for the organization to separate the signal from the noise, to analyze risk, and to develop risk mitigation plans.

Subject Matter Experts

One initial priority is the formation of a core team of individuals who will become the organization’s subject matter experts. This Reliability Management Team will become the backbone for evaluating risk inputs, providing new supervisor scenario training, ensuring that systems are resilient, and for analyzing incident and near-miss events.

From here forward, contributors to risk will be stratified into system issues, personal performance factors and behavioral choices. Frontline supervisors and managers will manage their own staff, making certain they develop appropriate remediation plans for personal performance (knowledge, skill and ability) issues, they will coach or use corrective action to address behavioral choices that increased risk, and they will identify and forward to the Reliability Management Team any system components that need to be made more resilient.

A reliability management plan that’s sustainable also includes a process for new employees so that when they’re on-boarded, they have an orientation around their responsibilities within a high reliability system, particularly when it comes to identifying and reporting risk. 

Developing New Leaders

Another critical component of any high reliability plan is a method for developing newly promoted supervisors and managers. Within 30-60 days of promotion, these new leaders should be trained in how to properly identify risk, detect competing priorities that drive employee behavior, and recognize non-resilient systems. 

Supervisors and managers also need to be trained on how to effectively build remedial plans when employees are not meeting minimum performance standards, how to coach and appropriately use corrective action, how to manage conflict, and how to be a good team leader.

It’s amazing that before we allow our employees to touch a single patient, they have to receive schooling, obtain a certificate after testing that proves competence, and then spend time with a mentor or training officer—but we will promote someone to supervisor and hand them the responsibility of 20-40 (or more) individuals with absolutely no training! There’s no way to be reliable without setting clear standards and expectations for our leaders.

Now that we have some idea that a reliability management plan is a long-term investment (like anything that involves the successful development of people), we should address the often-asked question, “Is it worth the investment? What is the ROI?”

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?” For this, I will defer to Larry, and let him discuss his experience.

Attaining the Elusive Intangible

Many people believe that the ROI of culture is an intangible. It’s elusive, difficult to define, and even more difficult to quantify. For some, culture isn’t something that can be seen or measured; rather it’s something that can only be felt. And we all know how executives feel about investing in the touchy-feely. Although it may make some leaders cringe to talk about feelings, there’s truth to them and ignoring them won’t negate the fact that culture influences performance.

As for my company, the ROI of our reliability journey is undeniable. We thoroughly understand the impact that our Just Culture and reliability management systems have had on elements such as safety, cost savings, recruiting, customer service, employee motivation, responsiveness to change, leadership, teamwork, injuries, insurance rates and employee satisfaction. 

For example, our task times (measured from the time a crew receives a call until the time they clear the hospital) averaged 67 minutes prior to Just Culture and our reliability journey. The increase in frontline employee engagement around our response systems decreased average task times to 58 minutes. Reducing task times by nine minutes improved overall response time performance, as well as netted a savings of more than $21,000 per week in unit hour costs.

Another example of cost savings and safety improvements is the fact that in 2012, my organization experienced 40 on-the-job injuries (OJIs). At the time, we had 314 employees.

In 2017, our OJIs decreased to 22 for the year, and the number of employees increased to 381. Our workers compensation experience modifier remains extremely low and has resulted in cost savings of our insurance premiums of $1,296,461 since 2013.

In addition to the direct cost savings, there are numerous indirect costs that are saved by having fewer claims. Some experts estimate the indirect costs to be as high as 5-10 times the actual cost of the claim. In carefully reviewing our experience, we attribute much of this to our organization’s new ability to proactively see, understand and manage risk.

In addition, the ROI of employee satisfaction is extraordinary.  Our employees are our greatest recruitment assets.  They brag to their friends about our collaborative workplace and they help us attract top candidates.  When employees urge their friends to join us, they are typically highly selective, inviting only people they know will excel. This has become a chain reaction making our agency that much stronger.

The leadership roles that our employees participate in such as the safety, OAC and QI committees launched the development of future leaders. Many of our current supervisors and managers actively participated on these committees when they were frontline employees and have stated that their experiences gave them a clearer sense of purpose and was one of the most important experiences in their careers.

As our Just Culture and our Reliability Management Systems evolved, so did the service we deliver to the customer. We have been better at managing everyone’s experience inside the company which improved relationships with outsiders such as patients, customers, regulators and other healthcare providers. Most outside associates are highly attuned to our culture. They can easily tell when things are working well by the way they are treated by our employees. We measure customer satisfaction on a monthly bases and continuously score in the mid-to-high 90th percentile.

Another great benefit from our investment in Just Culture is our responsive to change. We recently experienced the need to make some significant changes to our health insurance benefits. Even though the cost of health insurance increases every year, we have been able to absorb those increases as an organization and not pass them along to the employees.

After 10 years of increases, it got to the point that we needed to ask the employees to share the burden. Due to our communication channels, such as the OAC and our All-Hands sessions and the trust we have built over time with our employees, we were able to explain the adjustments and quickly implement the changes without negativity or backlash.

Thriving on Teamwork and Cooperative Problem-Solving

There are few things more satisfying than being part of a well-developed culture that embraces reliability practices. It’s a real pleasure working in an organization where people enjoy each other, thrive on teamwork and where they enthusiastically cooperate around problem-solving and where people sincerely recognize each other for their special contributions and the agency’s success.  

And because this is a journey, not a destination, we expect there to be inevitable bumps in the road. We will slip, miss an important signal now and then, and need to continually invest in developing our people and systems. 

Hopefully, this short series has given you some insight into the risks and rewards of integrating Just Culture and High Reliability practices. Importantly, the concepts always sound great in theory – so we wanted to show you that they can be operationalized, and that they can definitely make a positive difference.

This article is the fourth in a four-part series on Just Culture 

Part 1: Just Culture & High Reliability: Learn more about two concepts that can improve your agency while reducing injuries, accidents & cost.

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.