An Overview of "Just Culture" in EMS (Part 2 of 2)

Jerry Biggart

August 11, 2022

MCEMS adopts a "Just Culture" approach for patient safety. This is to ensure the agency can support and coach EMS providers in making safe choices, understanding at-risk behavior, and reducing the rate of human error. A" Just Culture" algorithm also ensures a consistent process in which providers can understand, feel is just, and have confidence.

"Just Culture" identifies three duties of EMS providers: 

1) Duty to avoid causing unjustifiable risk or harm 

2) Duty to follow a procedural rule 

3) Duty to produce an outcome

The product of the "Just Culture" algorithm produces four outcomes: 

1) Support the provider (ensure compassion and empathy) 

2) Coach the provider (values-supportive discussion on the need to engage in better choices; targeted educational remediation likely) 

3) Counsel the provider (notice that performance is unacceptable; an action plan for improvement) 

4) Discipline the provider (punitive such as clinical privilege suspension or revocation) 

The overwhelming outcome of this "Just Culture" algorithm focuses on the support and coaching of the provider, improving the tools providers need to perform their jobs, minimizing "second victim" phenomena when a patient safety event occurs, and justly balancing the mission to deliver excellent care. Additionally, whenever a patient safety event occurs, any "Just Culture" outcome (support, coaching, counseling, or discipline) is delivered in collaboration between the EMS provider(s), medical director, employer, and other critical "continuous quality improvement program"(CQIP) members. 

Targeted education remediation should be developed and overseen by the organization's EMS education manager in cooperation with the medical director and provider employer. Counseling, a corrective action plan, or punitive actions should be developed by the medical director in collaboration with the provider's employer, including labor representation, if applicable.

Formal discipline should be extremely rare and reserved for outcomes that show reckless, preventable action. The discipline should be measured, progressive, proportional, and fair when that occurs. Ultimately, we are trying to correct behavior, and the discipline necessary to achieve that result should be the focus.

After an error, the member must still make critical decisions for the duration of their shift. However, an error shouldn't plague them beyond the meeting if the process is done correctly. While we can't make everyone happy and let errors go unaddressed and expect a different outcome the next time, we can handle issues in ways that won't leave the provider second-guessing themselves out of the fear of discipline if an error occurs.

This process may start out rough and challenge your culture. But members need to see it in action. They need to know that it's happening regularly and that the rules of "Just Culture" are being followed by all involved. For culture change to occur, one must know that either side can call the other out if the process is not applied appropriately. These are safe discussions and far better than a grievance or hearing related to an unintentional medical error.

I have been the Chairman of the State of Wisconsin's EMS Board for over a decade. Since we began actively rolling out "Just Culture," we have seen a significant and positive change in the outcomes for providers. There's been much less formal discipline and action against their ability to practice. I have never been told that we shouldn't have tried "Just Culture," but I have seen a lot of money spent and relationships ruined by not trying it.

It's also important to remember that the severity of the adverse event is not proportional to the severity of discipline; they are independent. If using a "Just Culture" approach, formal discipline is almost exclusively reserved for choices or behaviors that knowingly cause harm.

It's mission-critical to have a labor-management initiative that produces a top-notch CQI program. We need all members of the organization to fully embrace it. If it's done correctly, everyone wins. If we can embrace these concepts when fires don't go as planned, we can do it for EMS events that don't go as planned.

Reporting and learning from "near-misses" must be as commonplace in EMS as firefighting. If we can openly self-report and critique an attic fire that doesn't go right, we can do it for a patient in respiratory distress that doesn't go right. It's how we learn. It's how we get better.

We owe this to our members on the front line and to our citizens. This will prevent errors and save the culture at the same time. After years of doing this, I am confident in that. 

Classification and Taxonomy Categories:

Patient Safety Event Classification & Adverse Event Reporting Policy of EMS Agency: Sentinel, Serious, Safety, Precursor, Serious Circumstances

Safety Event Taxonomy: Procedural, Environmental, Patient Protection, Care Management, Device, Criminal

Individual Error Taxonomy: Competency, Consciousness, Communication, Critical Thinking,Compliance

System Error Taxonomy: Structure, Culture, Process, Policy or Protocol, Technology, or Environment


MilwaukeeCounty EMS, OEM-EMS CQIP Revised 5-9-2018


Jerry Biggart is a Fire Lieutenant, Paramedic, and the Local President with the Oak Creek Professional Fire Fighters, Local 1848. Jerry oversees EMS and Education as an Executive Board Member with the Professional Fire Fighters of Wisconsin, and Chairs the Governor’s EMS Board. Jerry is an IAFF 5th District Field Service Representative and has been in Field Services for 16 years. Jerry has a Bachelor’s Degree in Fire Department Administration and instructs paramedics at Milwaukee Area Technical College.