Editor’s note: Last issue we introduced you to our new Safety Leadership column, written by noted experts Michael Greene, Blair Bigham and Daniel Patterson. Following is part two of a 12-part series.
Sometimes I sleep during air travel, especially at the end of the day after crossing multiple time zones. Not so on a recent return to my home airport: Before boarding, it was announced that a diversion to an alternative airport was possible due to fog at our destination. My fellow passengers openly complained about another night away from their destination, while I cringed at the thought of a “bonus night” in a hotel bed.
The captain left the cockpit to address the possible diversion face to face with the cabin full of grumbling holiday travelers. “Here’s the story,” he said. “To land at our destination, visibility—ceiling and distance—must be at certain minimums per FARs (Federal Aviation Regulations), the rules and procedures we follow. Now I won’t bore you with the details, but here’s the bottom line: I want to make it home to my family, and you to yours. That’s my goal, regardless of our destination this evening.”
Rules, policies and procedures, along with a good dose of attitude, behavior and ownership, got me safely home to my family. Most aboard that flight did not consider the magnitude of what had occurred; they simply, and instinctively, trusted the system and the crew. Passengers expected a safe flight home—and that’s what they got.
Do we think our patients expect any less than a safe transport to the hospital? Without thinking or verbalizing it, the general public expects their EMS organization—its policies and procedures, staff and culture—to deliver. Figuratively and literally, the public expects EMS to be highly reliable and safe. And how do we make sure we fulfill that expectation?
Building a strong safety foundation
Last month I introduced the concept of a high reliability organization (HRO) and the toolkit of an HRO: a safety management system (SMS). The design of an SMS is like that of a house: a strong foundation (the organization’s safety culture); four corners or pillars (policy, risk management, assurance and promotion); the internal contents (11 elements of SMS); and a roof (leadership).
While SMSs are designed around the “four pillars” concept, I believe a truly effective SMS can only be built on a solid safety culture, shielded and insulated by leadership, and connected and supported by the four pillars. In other words, culture and leadership deserve (and demand) special emphasis.
Now let’s start at the top and work our way down.
The roof (aka leadership): What does a roof do? It shields, protects and insulates the occupants and contents of the house. This, too, is the fundamental job of leadership: To protect employees and the organization from harm. An SMS requires unwavering commitment on the part of leadership, in addition to a commitment to safe system design and a “just (open) culture.”
At a recent conference, I asked a group of 50 or so EMS leaders if they give their employees “stop work authority” if conditions are unsafe or “timeouts” if workers are fatigued, key elements of leadership in an SMS. The response was mediocre at best. This is indeed unfortunate and means that our EMS workers continue to demonstrate risky behavior, such as working beyond the point of fatigue and falling asleep at the wheel. My advice to this group and you: Don’t let tragedy become your wake-up call.
Holding up the “roof” of the SMS are four pillars: policy, risk management, assurance and promotion. Each pillar contains key elements that define the overall system.
The first pillar: An SMS must have written, accessible policies and procedures in place: the first pillar. These policies must explicitly describe responsibility, authority, accountability and expectations within the organization. All job descriptions must include these elements. Key safety personnel are identified and described with commensurate scope and authority. Emergency preparedness and response is preplanned, known to all staff and practiced through regular emergency drills. And the most important aspect to safety policy, documentation and record keeping? Documentation. As the old proverb says, “The job isn’t done until the paperwork is done.” Documentation captures organizational knowledge, activity and behavior consigned not only to posterity, but also as evidence to an accrediting organization or a legal inquiry.
The second pillar: Risk management, the second pillar, is deliberate early recognition and management of potential problems. Risk management is a formal system of hazard identification and management and fundamental in controlling an acceptable level of risk. A risk management system describes operational processes across department and organizational boundaries; identifies key hazards and measures them; methodically assesses risk; and implements controls to mitigate that risk. A fatigue risk matrix and assessment, periodically applied during a work shift, is an example of risk management.
The third pillar: With policies, measurements, assessments and controls in place, the organization must incorporate regular data collection, analysis, assessment and review to ensure that safety goals are achieved—assurance, the third pillar of an SMS. Key elements within safety assurance are safety performance management (monitoring, audits, evaluations, investigations, RCA, employee reporting, data analysis, assessment, and preventive and corrective actions), a defined change management process and continual improvement.
The fourth pillar: To promote safety—the fourth and final pillar—an organization must train and communicate safety as a core value. Safety promotion begins early with employee recruitment and selection, and continues from Day One with explicit competencies, training and personnel expectations in regard to safety. New employees must be socialized into the safety culture early on. Safety is then promoted through communication and awareness.
Don’t forget, a safe workplace culture is the foundation of an SMS. Culture is the undercurrent or underpinning that defines an organization and “how things get done around here … or over there.” The importance of having a workplace safety culture cannot be overstated. The literature is replete with the message that safety can only exist within a strong culture. Daniel Patterson, one of my co-authors, has said, “You’ll never get all EMS staff to drink the ‘SMS Kool-Aid’ without a strong safety culture.” Safety culture is a, if not the, vital component of an SMS.
Michael Greene, R.N., MBA/MSHA, is a senior associate at Fitch & Associates. He has served in numerous front-line and leadership positions throughout his career, working in volunteer and paid search and rescue and as a paramedic, a county EMS director and an air medical/critical care transport director. He is the author of numerous articles and chapters on EMS and air medical transport topics. He can be reached via e-mail at mgreene@fitchassoc.com or by phone at 816-431-2600.
