Richmond Ambulance Authority Creates EMS Safety Culture

The Institutes of Medicine’s landmark publication To Err is Human estimates that at least 44,000 and perhaps as many as 98,000 Americans die in hospitals each year as a result of medical errors.1 And hospital patient safety incidents account for $6 billion in extra costs annually in the U.S.(2) Is EMS any different?

In a 2002 Prehospital Emergency Care study, the authors wrote a consensus statement that represented the views of several respected operational medical directors regarding the national state of EMS safety.(3) The group identified common EMS errors and concluded, “Standard operating procedures to prevent and recover from such errors in the field are in their infancy.”

Shortly thereafter, several researchers conducted a survey of 283 EMS providers attending a North Carolina EMS conference and found that one or more errors had occurred during the previous year in 44% of those surveyed.(4) However, only half of the errors were reported to their supervisor or medical director.

In 2008, two authors wrote an editorial calling for the establishment of a national center for EMS provider and patient safety.(5) A national center doesn’t exist yet. However, a number of local and state initiatives, such as the Missouri Center for Patient Safety, are beginning to focus on at least some aspects of safety in EMS. This article describes the comprehensive, multi-dimensional safety program developed and implemented at the Richmond Ambulance Authority (RAA), a high-performance EMS system serving Richmond, Va.

Transformation to An EMS Culture of Safety
RAA is a self-operated public utility model EMS system employing a system status management approach to its deployment, command, control and communications. It’s a member of the Coalition of Advanced EMS Systems and is accredited by both the Commission on the Accreditation of Ambulance Services and the National Academy of Emergency Medical Dispatch as an Accredited Center of Excellence.

RAA employs unit hour utilization (UHU) as its currency to ensure that all available income is transformed into helping deliver world-class EMS. A unit hour is equal to one hour of service by a fully equipped and staffed ambulance available for dispatch or assigned to a call. UHU is a measure of productivity, which compares the available resources (i.e., unit hours) with the actual amount of time those units being used for patient treatment and transport or productive activity. UHU is the measurement of unit hours “consumed” in productivity compared with the total staffed unit hours. In simple terms, UHU monitors the provision of resources available in the right quantity, at the right time and in the right place to perform, treat and transport efficiently.

Conceptually, RAA operates within a total quality and safety bubble, employing lessons learned from other high-quality, safety-oriented industries, such as nuclear and aviation.

In 2008, RAA’s operational medical director, a pilot with firsthand experience in how aviation has achieved a high level of safety, instigated a successful error self-reporting program patterned after the Aviation Safety Reporting System (ASRS) developed by the National Aeronautics and Space Administration (NASA). The NASA system was designed to detect all near misses and to translate lessons learned into operational process changes rather than blaming individuals for human errors.

RAA’s approach to safety pervades all levels and departments, from the frontline to the back office. This starts in the pre-hire phase. Conceptually, RAA also looks ahead to plan and anticipate the next set of safety issues that may arise.

Pre-Hire Process
RAA’s approach to safety begins even before the employees receive an offer letter. RAA contracts with an occupational health service that conducts a pre-hire physical agility test (PAT) on all field operations candidates to determine their existing muscular skeletal strength, which is often predictive of future physical problems, such as a back injury. The computer-based system RAA has used for the past two years has proven to be an effective predictive tool.

For example, RAA now factors the PAT results into its decision whether to offer employment to an applicant. Some highly qualified candidates have failed to make it to the initial New Entry Orientation because they haven’t met the PAT requirements. As a prudent risk-reduction measure, staff members who have suffered either work or non-work related injuries and miss 10 shifts or more must pass the PAT before they’re cleared to permanently return to work.

Induction to the Organization
Introducing, developing and embedding a culture of safety are core functions of the new employee orientation program. The initial classroom-based induction covers scene safety, the operating principles of all of RAA’s key pieces of equipment, safe and skilled operation of vehicles, and correct appropriate patient transfer techniques.

All new employees are immersed in safety from orientation through field preception. For 26 shifts, RAA’s field training officers carry on where the classroom left off, providing practical instruction and leadership by example in a controlled environment, ensuring that providers are prepared to operate safely as RAA crew members. RAA instructors also teach the National Association of EMTs’ safety course to its employees.

Safe Driving
New hires are required to be emergency vehicle operator course (EVOC) qualified prior to employment at RAA. From this baseline, safe and skilled vehicle handling is built on with the successful completion of the in-house driver training program. This program includes a review of EVOC material, state laws governing emergency driving and RAA’s 12 standards of driving adopted from the Allsafe Driving System.

Focus on safe vehicle operation is maintained through consistent reiteration of the 12 standards of driving via periodic safety campaigns as well as safety talking points highlighted by field providers and safety and risk staff during everyday operations. Checks and balances are kept on drivers via an on-board road safety system. The “black box technology” interactively monitors preset driving parameters, giving the vehicle operator immediate feedback through the use of audible tones. Monitored parameters include seatbelt compliance, lights and sirens usage, acceleration and deceleration forces, turn signals and safe vehicle reversing. The latter feature also requires the use of a spotter who activates a reverse button located in the rear of the vehicle to alert the driver of any hazards.

A weekly league table of emergency and non-emergency driving that scores vehicle operators is produced. In the rare event of a vehicle collision, road safety data is downloaded to analyze the activity of the vehicle at the time of the incident. This ability to instantly review the incident helps create a clear picture of what occurred, which allows RAA to fully understand the root cause of the incident so the operational changes can be made to prevent a recurrence.

Self-Reporting Program
The RAA self-reporting program provides an employee who makes a mistake the opportunity to report that incident without fear of punitive action, as long as it’s not a criminal act. Once reported, an investigation and root cause analysis are conducted by the clinical safety review committee, which is chaired by the operational medical director and attended by the chief operating officer, chief clinical officer and director of safety and risk.

The goal is to identify whether a systemic issue needs to be addressed. As in the ASRS, an individual who self-reports is deemed to have an appropriate, positive attitude regarding safety and won’t have punitive action (including termination) taken against them provided the action:

>> Was reported promptly;
>> Was inadvertent and not deliberate;
>> Wasn’t a criminal offense;
>> Wasn’t due to a substantial lack of qualification or competency; and
>> Wasn’t repetitive.
Training, remediation and changes in protocols, processes and procedures typically result from self-reports to minimize the likelihood that a similar incident will occur involving any provider in the future.

Reducing Risks
The greatest risk and exposure to fatal vehicular accidents occurs during the response phase of any call. The team effort to deliver each vehicle and its crew to a call safely is of paramount importance. RAA emphasizes crew resource management (CRM) in its training and operations, not just regarding patient care but also regarding vehicular safety.

The driver and the paramedic crew member are both responsible for the vehicle’s safety. They must work as a team to coordinate navigating to calls, obtain additional information from the mobile data terminals, work the siren and communicate on the radio. The single most important thing employees can do for their patients and for themselves is to have both sets of eyes looking outside the unit as much as possible.

Crews are discouraged from performing any tasks during the response phase that aren’t absolutely critical to the current call. This is similar to the “sterile cockpit” rule used in aviation, which dictates that a crew isn’t allowed to have non-task critical conversation or distracting activity during the takeoff, approach and landing phases of flight.

Safety All Day & Every Day
RAA’s operations are designed with efficiency and effective response in mind. The by-product of this planning is safety. We’re convinced that lights and sirens responses should be used sparingly–and only when medically justified–to reduce the risk of vehicular accidents. Instead of basing units at fixed locations and requiring fast driving, RAA uses system status management to place units to post locations throughout the city dynamically based on computer predictions of where the next most likely life-or-death calls will occur. This has proven to be highly accurate using historical data factoring in the time of day, day of the week, and month.

The result is that RAA’s ALS units arrive on scene in less than or equal to eight minutes from the time of the call receipt 93—96% of the time in all sectors of its service area on life-threatening calls, despite the fact that our average fleet speeds aren’t much different between emergency and non-emergency responses (see Table 1 ).

A response to calls in which dangerous activity is suspected enacts the call staging safety procedure. Crews are required to wait off scene until the area is cleared and deemed safe by police. Similarly, a crew on scene potentially compromising their safety has the discretion to evacuate and await further back up. All crew members have personal radios equipped with mayday buttons that issue a silent alarm to dispatch and place the radio into continuous transmit mode.

A mayday triggers an immediate top priority police response to the ambulance location, which is constantly monitored in dispatch using RAA’s automatic vehicle locator system. Regarding the more common situations of lifting and moving a patient, RAA is always looking for better devices and techniques to reduce musculoskeletal injuries. An outward success in the past year has been the purchase of pneumatic lifting cushions.

Patients are placed and then elevated by compressed air to a sitting position, from which they can be assisted to their feet. RAA is currently equipping its entire fleet with powered stretchers to reduce the amount of lifting required. Better back care is an issue RAA takes seriously in its effort to reduce staff injuries and attrition. One role of RAA’s operational team is to keep the workforce rested and prepared for the rigors of busy shifts, so RAA’s scheduling and shift-building rules prevent a member of staff from returning to work within eight hours of their last shift.

RAA’s philosophy is that communication isn’t a skill reserved for the radio. Root cause analysis in aviation as well as EMS frequently identifies a lack of communication between crew members on a day-to-day basis as a significant contributory factor to safety incidents. RAA’s supervisors and managers train crews to have open, frank and honest dialogue with each other any time any issues–even seemingly minor ones–occur.

We also stress the importance of CRM, making it clear that each crew member has the responsibility to speak up promptly within the chain of command whenever they have a concern that something isn’t quite right. This is especially true if it might constitute a safety risk to the patient or responding personnel.

Measuring Safety Success
RAA’s transformation to a culture of safety culture is an ongoing journey. Its mission is to provide world-class EMS, and we recognize we can’t do that without striving to be among the safest EMS agencies in the world. Success must be measured on multiple dimensions, both for employees and patients.

RAA has reduced worker’s compensation injury claims since it began a “culture change,” which reduced our NCCI experience modification factor (an insurance premium adjustment that recognized the merits or demerits of individual risks) from 1.04 to 0.83. This translates into a 20% premium reduction. RAA’s insurance carriers use RAA as a model of a best practice, and they refer clients with similar operations to RAA for information.

Finally, for RAA, overall success is defined by keeping the promises we make to employees during orientation: “Our primary goal is to get you home in the same way you came to work. No injuries and no illnesses. You may be sore and tired, but you aren’t hurt or sick.” We work hard each day to meet or exceed this challenge. This article originally appeared in June 2012 JEMS as “Net of Protection: Richmond Ambulance Authority creates comprehensive culture of safety model.”

1. Institute of Medicine. To Err is Human: Building a safer health system. Washington, D.C.: The National Academies Press, 2000.
2. Levenson D. Hospital patient safety incidents account for $6 billion in extra costs annually. Rep Med Guidel Outcomes Res. 2004;15(16):1—2,6—7.
3. O’Connor RE, Slovis CM, Hunt RC, et al. Eliminating errors in emergency medical services: Realities and recommendations. Prehosp Emerg Care. 2002;6(1):107—113.
4. Hobgood C, Bowen JB, Brice JH, et al. Do EMS personnel identify, report and disclose medical errors? Prehosp Emerg Care. 2006;10(1):21—27.
5. Paris PM, O’Connor RE. A National Center for EMS provider and patient safety: Helping EMS providers help us. Prehosp Emerg Care. 2008;12(1):92—94.

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