Editor’s note: Our Safety Leadership column is written by experts Michael Greene, Blair Bigham and Daniel Patterson. Following is
Wpart four of a 12-part series.
What a pain. It’s just paper-pushing, pencil-whipping BS! Have you ever uttered these words when writing a new policy or document- ing an organizational practice? Chances are you have—maybe even something a bit more colorful.
As a safety advocate and consultant, I often see organizations operate by “common practice.” The premise goes something like this: We don’t have a policy or procedure for that; it’s a common practice.
More often than not, common practice is the tacit (implied but not expressed) guideline for organizational activity, as opposed to explicit written documentation of corporate philosophy that leads to policies and procedures and drives organizational behavior. Often the common-practice argument becomes a conve- nient reason not to capture institutional knowledge and experience on paper. (I can just hear a collective sigh as you read these words.) In regard to patient care documentation it’s been said, “If it isn’t written down, it wasn’t done.” The same rule applies with a safety management system (SMS): It needs to be written down.
Why is it necessary to have so much documentation? The answer is fairly straightforward: An SMS must include policies and procedures that explicitly describe responsibility, authority, accountability and expectations. Documentation should answer simple questions like: “Who is responsible for [insert duty here]?” and “What do we do if ...?”
Before we explore specific elements of policy-making, I’d like to introduce the simple idea of “P to the fifth power,” or P5. A model developed by Fitch & Associates, P5 is a template for organizational processes.
- Philosophy P5 begins with philosophy. For example, an organization’s safety philosophy may be safety first; zero errors of consequence; accidents and injuries are preventable; or the classic first do no harm.
- Policies and procedures Philosophy is translated into actionable policies and procedures (e.g., risk assessment, fatigue management, stop-work authority). These documents, paper or electronic, define and guide expectations for behavior in the organization.
- Practice The preceding P’s (philosophy, policies and procedures) are demonstrated within the organization by the observable practice of the employees. Safety audits, random spot checks or “leadership by walking around” are good tools for observing what people in the organization actually do.
- Paperwork As always,the job isn’t done until the paperwork is complete. In other words, documentation of the actual practice or behavior in following the policies and procedures that codified the safety philosophy must be completed.
P to the Fifth Power
As shown above, P5 is a circular or closed-loop approach to all organizational activities, a process many accrediting bodies use to evaluate the extent to which a standard or standards are achieved. I’d hypothesize that P5 is the organizational equivalent of the Krebs cycle: It’s how an organization lives, breathes and acts.
Necessary elements of a safety policy
1. Keep it simple
One might argue that having to write policies and procedures is the major cause of lactic acidosis in safety lead- ers. But it doesn’t have to be painful—in fact, the simpler, the better. The best safety manual isn’t one that creates muscle strain when you lift it to the top shelf, where it will sit and gather dust; it’s the type that staff members can (and do) quote in a few simple words, like “Our policy is to make a full stop at intersections.
The U.S. Forest Service (USFS), a visibly large and bureaucratic organization, documents its “Safety Management System Guide and Aviation Safety Plan” in a scant 73 pages! And it’s quotable: “Our number one job is to protect our most valuable resource— our employees.” The principles outlined by the USFS codify the safety philosophy across hundreds of employees, over thousands of square miles, as evidenced by a December 2010 SAFECOM Survey Report that found 82 percent of federal, state and vendor respondents agreed with the statement, “Safety is a core value in the Federal land management aviation program.”
2. Identify and recognize key safety leaders and managers
The sentinel 2000 Institute of Medicine report, “To Err is Human,” stated, “Safety should be an explicit organizational goal that is demonstrated by strong leadership on the part of clinicians, executives, and governing bodies.” Yet five years later, safety researcher Donald Berwick, now administrator of the U.S. Centers for Medicare and Medicaid Services, implied that few health care leaders have made safety a priority or committed resources toward safety improvement.
What commitments to safety leadership and improvement have you and your organization made? Formal or informal, you need to have safety leaders in your organization. The takehome message, if you want to value your SMS, is to empower your staff and man- agers by calling them out, formally and informally, with responsibilities, rewards and credit where due for supporting safety.
3. Make documentation and record-keeping a priority
Argumentum ad nondocumentus, the argument that policies, behaviors or practices don’t need to be written down because “it’s always been done that way,” is most organizations’ Achilles heel. I don’t mean to rant here, but I do intend to repeat this message: Documentation is the greatest area for improvement in virtually any organization. Furthermore, it’s absolutely essential, for without it the organizational Krebs cycle fails.
I can almost guarantee that without comprehensive organizational documentation you’ll feel the pain at some point, be it through a governing body, an accrediting organization or legal action. With today’s technology and information systems, comprehensive documentation should be an Argumentum ad nonignorantiam (a no-brainer).
4. Include a specific emergency response plan
Winston Churchill was quoted during World War II as saying, “He who fails to plan is planning to fail.” In the crusade for safety, a specific emergency response plan (ERP) provides an organization a plan that addresses what to do in an emergency, and who is responsible for each action. Stated differently, an ERP is bringing the future into the present so you can do something about it now. An ERP isn’t just about accidents or incidents; it should address utility failures, natural disasters, influenza outbreaks, bomb threats, workplace violence—in other words, it should be a “what do we do if ” guide.
A high-reliability organization operates on a continuum from day-to-day routine, to once-in-a-year or once-in-a-lifetime events. This element of your SMS goes beyond what you engage in daily regarding safety management; it’s an insurance policy, a “Plan B” when extraordinary events exceed the organization’s capacity.
Don’t believe it works? Consider this
It may be difficult to believe that this first pillar of an SMS can lead to a system that will improve safety, but I am mindful of a World Health Organization-sponsored study on morbidity and mortality following the introduction of a simple checklist. The Safe Surgery Saves Lives Study Group hypothesized that a surgical checklist would reduce complications and deaths associated with surgery. The results: “The rate of death was 1.5% before the checklist was introduced and declined to 0.8% afterward (P=0.003). Inpatient complications occurred in 11.0% of patients at baseline and in 7.0% after introduction of the checklist (P<0.001).” The conclusion: “Implementation of the checklist was associated with concomitant reductions in the rates of death and complications...” This example illustrates safety management in action and the power of P5!
So far, my colleagues and I have shown you the blueprint of an SMS and laid the foundation for a strong SMS through safety culture assessment and development. This month, we’ve helped you understand the elements of the first pillar of an EMS: policy. Now the heavy lifting—and leading—is up to you.
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, as a paramedic, a county EMS director, and as 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.
