Editor’s note: Our Safety Leadership column is written by experts Michael Greene, Blair Bigham and Daniel Patterson. Following is part seven of a 12-part series.
The author Barry Lopez said, “The storyteller is the person who creates the atmosphere in which wisdom reveals itself.” I couldn’t agree more, and when working at a helicopter EMS service, I would tell a story—several stories, in fact—at every new employee orientation. During the first hour, the first day of every staff member’s employment, I promoted safety and set the tone for the organization’s culture. I told stories of the successes, challenges and mistakes that team members made—that I made—and how the organization learned from those mistakes. Here’s one of the stories I liked to tell:
Jules was a tenured member of the team who took a break from EMS to earn a master’s degree and try a stint in leadership. She was a great student, leader and manager, but even the banker’s hours, higher pay and 12-step program couldn’t cure her EMS addiction.
When she returned to EMS, she received an abbreviated orientation and field training because, as the field training officers explained, “She was our preceptor when we started and she taught us. What can we teach her?!” Jules was respected as kind and compassionate and an extremely safe team member.
Fresh out of re-orientation, she ran a call on a motor vehicle accident where she and her partner, “Iron Man,” transported a critical trauma by air to the regional trauma center. While conducting a “hot” offload with the helicopter still running, the locking mechanism on the stretcher jammed, resisting the combined efforts of Jules, Iron Man and the pilot to get the patient out of the helicopter. In an effort to release the stretcher, Jules climbed into the cockpit of the idling aircraft and inadvertently rolled the throttle, causing a momentary “run up” of the engine. The pilot calmly reached across the patient and returned the throttle to idle while Jules, wide-eyed and red-faced, exited the aircraft.
Within hours of this incident I heard stories of the aircraft leaping up into the air with Iron Man clinging to his life holding one skid, the pilot frozen in disbelief, as the helicopter spun overhead, out of control, the trauma surgeon armless and the aircraft crashing to the ground à la an episode of the TV show “ER.”
I pause here in the story to ask, “What do you think happened with Jules after the incident was reported to leadership?” “Fired” is the most common answer I received, but that wasn’t the outcome of this error, nor was it a case of “blame-shame-retrain.”
I go on to ask, “Who reported this incident?” and then tell the orientees that Jules did, adding that I didn’t have to fire her because she immediately offered her resignation—though (pausing for effect in my story) I refused to take it. Yes, I tell them, she did get the rest of the day off, and there was a comprehensive investigation with processes and procedures instituted to prevent future occurrences, but what she did, anyone else could have done. Terminating her would have done more damage to our carefully cultivated safety culture than the damage that occurred when the embellished stories of Jules “piloting” circulated among her peers.
The basics of safety promotion
The International Helicopter Safety Team’s safety management system (SMS) toolkit lists the following methods of promoting safety:
- Publish a statement of management’s commitment to the SMS.
- Management should demonstrate their commitment to SMS by example.
- Communicate the output of the SMS to all employees.
- Provide training for personnel commensurate with their level of responsibility.
- Define competency requirements for individuals in key positions.
- Document, review and update training requirements.
- Share “lessons learned” that promote improvement of the SMS. (This is where effective storytelling comes in.)
- Have a safety feedback system with appropriate levels of confidentiality that promotes participation by all personnel in the identification of hazards.
- Implement a “just culture” process, as first championed by David Marx, that ensures fairness and open reporting in dealing with human error.
The first and possibly most important step in promoting a safe culture is the establishment of justice. In other words, you want to establish a just culture that includes a system of shared accountability in which the organization is responsible for safe system and process design, and employees are responsible for safe choices and behaviors. This shifts an organization away from a “blame” culture. Why? Because to design safety, the organization needs feedback from users (employees). To give feedback, employees need trust. An organization can establish this trust through a consistent and fair approach to managing employee behaviors.
Let’s admit it, we’ve all made mistakes in EMS: drug errors, failing to remove a shore power cord, mislabeling something—simple human errors, even when trying to do our best. Not only do humans make mistakes, but we drift away from safe behaviors. I liken drift to practical joking (or worse, hazing) between individuals where as the jokes go on, perceptions of risk fade, each tries to “one-up” the other and then, as Mom said, someone gets hurt. A strong safety culture will anticipate and catch human error and drift, then design systems, processes and barriers to prevent them. Occasionally individuals place self-interest before others where they knowingly create an unsafe situation. Reckless behavior, unlike the first two, is addressed with a strong remedial or punitive response.
Assume, for the sake of argument, your organization has designed the perfect system and process for safety. Beyond safe choices, employees, staff, the “humans in the system can be expected to exhibit the three behaviors listed above; human error, at-risk (drift) or reckless behavior. Outcome Engineering of Plato, Texas defines these three behaviors as follows:
- Human Error: an inadvertent action; inadvertently doing other that what should have been done; slip, lapse, mistake. Product of current system design and behavioral choices
- At-Risk Behavior: a behavioral choice that increases risk where risk is not recognized, or is mistakenly believed to be justified. A choice, risk believed Insignificant or justified
- Reckless Behavior: a behavioral choice to consciously disregard a substantial and unjustifiable risk.
Your response as the leader depends on your analysis of the behavior, and the “prescribed or suggested” just culture response. A simple design for “justice” is illustrated below.
Establishment of a Just Culture
The benefit of this approach to managing behavior is that the process is up-front and transparent to the staff, which helps to achieve trust. Risks become identified, reckless behavior isn’t tolerated, and ultimately the organization is safer. The implementation of a safe and just culture in aviation has been credited with a significant decline in aviation accidents, incidents and deaths over the past 30 years. In practical terms, today you are three times more likely to be involved in a motor vehicle crash, and 1,000 times more likely to be involved in a medical error, than in an aviation-related incident due in part to this cultural shift.
Another best practice in safety promotion is to involve employees’ families and/or significant others in the safety program. Police, fire and EMS agencies have recognized the importance and upside to promoting safety through formal and informal demonstrations or presentations on the SMS.
I recently learned of a law enforcement agency that presented an eight-hour course on stress recognition and management to family members of new police recruits during the academy and field training period as part of its safety promotion plan. I’ve had family members attend emergency vehicle operations training alongside staff. There is a profound (albeit unquantifiable) effect on a staff member’s driving after being strapped in the patient stretcher during a run around the obstacle course in an ambulance operated by one’s spouse or teenaged driver!
So what happened to Jules? Well, Jules, Iron Man and the pilot took this incident with the seriousness and attention it deserved, standing in front of their peers to explain the incident and new safety measures, thus stifling conjecture or rumors. Jules suffered the kidding, ribbing and joking with grace while promoting safety with a vengeance. In the end she received greater respect for her humility, transparency and humor than she may have received under a less just and trusting approach. I still chuckle at the memory of the program’s aviators having her stand up at a staff meeting to present her with a Photoshopped pilot’s license with big red letters spelling “REVOKED.”
So what are your stories? Use them to create the atmosphere and wisdom for safety promotion in your organization!
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, county EMS director and 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.
