Editor’s note: Our Safety Leadership column is written by experts Michael Greene, Blair Bigham and Daniel Patterson. Following is part three of a 12-part series.
Those of us with a few years under our belts probably remember our early days in EMS, when the thrill of a good call far outweighed any concern of safety issues. Young, immortal and reckless, many of us were—let’s face it—the safety manager’s worst nightmare. And where is your organization’s safety culture today, given the youth, mindset and adventure that each day in EMS brings? It may be high time you gave it some serious thought.
What is a safety culture?
Safety culture has been described as the shared beliefs that an organization’s employees hold relative to workplace safety. Personally, I like how Terry Mathis of ProAct Safety described it in the October 2010 edition of the EMS Agency Research Network (EMSARN) podcast series: Safety culture is not only the actions and what we do when we’re being watched at work … but also the reason why we behave in a particular way. Said differently, behavior is the foundation of a successful safety management system (SMS), based on shared beliefs that safety is a priority.
Ask any engineer or architect how to build a sturdy, long-lasting bridge, building or highway—the answer you’ll undoubtedly get is to start with a strong foundation. Similarly, the “weight” of an SMS is built on, and supported by, a positive and proactive foundation of safety culture.
I operationalize safety culture by thinking about first impressions, recalling the first few days of work at prior and current places of employment. I think about the way the workplace appeared on the outside. Was it run-down or well-kept? Was the inside neat or messy? I think about how I was greeted by employees: Were they nice? Did they smile, and were they generally in good spirits? Did the representatives of the organization look me in the eye or avoid such contact?
We all do it: We have gut reactions in which we establish long-lasting opinions of new acquaintances or new places based solely on first impressions. They stick with us. They shape our thinking, perceptions and, yes, our behavior.
For instance, I believe that if an organization is lax in its appearance, it may lead to a culture of low expectations and thus lower employees’ defenses against error, adverse events and accidents. In contrast, an organization that values adherence to protocols and communication with patients, partners and leadership—one that values a kept and tidy station and ambulance—I believe those standards impact employees’ behavior and beliefs to be positive, thwarting the threats to poor safety outcomes.
Safety culture vs. safety climate
While the terms “safety culture” and “safety climate” are used interchangeably, their meanings differ slightly. Safety culture references deep-seated patterns, core beliefs and behaviors, while safety climate refers to the current perceptions (status) of safety in the workplace.
Surveys are the most common way to measure safety culture and safety climate. Their utility is analogous to the oil-stick in our car’s engine: Periodically we need to check the oil in our car. Low levels indicate a potential problem; oil levels at or slightly above the full line indicate that the engine is most likely working properly. Safety culture surveys serve as an “oil-stick” check of the overall workplace engine.
As an investigator, I am not too concerned with how different people define or describe safety culture or if they prefer to use the term safety climate. What worries me is measurement—the oil stick. To gain reassurance that our workplace is working properly, we need reliable and valid measurement. To compare and contrast our measurements over time or to other organizations, we need reliable and valid measurement.
Does the proposed tool for measurement actually measure what it is intended to measure? If not, the tool is not valid and of no use to anyone! Can the survey tool be used over and over again in different settings and produce a set of measurements as intended? If yes, then the tool is reliable.
In 2007 we set out to develop the EMS Safety Attitudes Questionnaire (EMS-SAQ) to measure safety culture in the EMS setting. First, we evaluated the multitude of published safety culture survey tools. Surveys were developed for the hospital, long-term care, ambulatory care and other settings. We focused our attention on the ICU version of the questionnaire, as it had been widely used and had positive indicators of reliability and validity, and data for benchmarking EMS against other settings was readily available.
Next, our team developed and tested a pilot version of the EMS-SAQ in three EMS agencies. This first study was designed to test acceptance of the survey among EMS personnel, answer questions about feasibility in administering, and test the psychometric properties of reliability and validity. The results: The tool is easy to administer, EMS personnel interpreted the survey items with no trouble, and psychometric analyses determined the tool is reliable and valid in the EMS population.
We conducted additional psychometric tests in a second study that was primarily focused on establishing benchmarking data for EMS agencies. That study was recently published in the Prehospital Emergency Care Journal and identified wide variations in safety culture scores.
While prescriptive safety culture interventions can be employed following the survey, there are no known evaluations of interventions based on EMS-SAQ scores. Ideally, safety interventions should tie back to the elements of your SMS. Several hospital-based safety programs have been researched, implemented and validated. If you are interested in these, head to the Internet and use the key words “comprehensive unit-based safety program,” or CUSP, to find more information.
Regardless of the specific interventions, the first step toward a culture of safety is strong leadership.
A few take-away points
- Start with a strong foundation for your SMS: Find out what your safety culture looks like.
- A positive safety culture requires strong leadership.
- Don’t worry about how you define or describe safety culture. There are many useful descriptions and definitions.
- Surveys are the most commonly used tools for measuring safety culture in any organization.
- Be wary of tools untested in the EMS setting. The ambulatory care setting is different from the ICU, which is different from the long-term care environment. Questions developed for these settings are specific to the workers, actions and behaviors in those environments.
- We have tested the EMS-SAQ in more than 80 different EMS organizations. Test after test reveal positive psychometric properties of reliability and validity.
- An EMS-specific CUSP has not been developed or published. Be the first!
Finally, remember that the safety culture of a workplace is the foundation for good or bad behaviors among workers and contributes to safe or poor outcomes for patients and providers. One cornerstone of any safety program should be confidence in reliable and valid measurement.
Daniel Patterson, Ph.D., MPH, EMT-B, is an EMS researcher and assistant professor in the Department of Emergency Medicine at the University of Pittsburgh School of Medicine. He is also a principal investigator at EMSARN.
