Should EMS Adapt "Just Culture"? (Part 1 of 2)

We are witnessing a sharp uptick in unnecessary, damaging, and costly investigations into emergency medical care provided by emergency medical services (EMS) professionals. In response, EMS providers must begin emphasizing the need for "continuous quality improvement" (CQI) and promote its critical components for ensuring provider and patient safety. A part of this is developing a "Just Culture." This approach has organizations look into the root causes of problems instead of pointing the finger at somebody to blame the problem on them.

We must always work to be as effective as organizations as possible. We need to have a consistent, practical, and fair way to ensure that we are on a mission to be the best EMS providers we can be. We must also accept that it is human to error. Only an unrealistic provider or supervisor would think otherwise (one caveat to "Just Culture" is that it's not meant as a remedy for willful recklessness).

So, how do we do all this? How do we see the provider and supervisor walk away from a meeting confident that progress was made? That the provider was appropriately led through education and confidence building by a supervisor or mentor, and that the provider walks away feeling the same way?

For CQI to be meaningful, it must be a process that the medical director, department administration, and providers believe in. For this to happen, CQI processes must be applied equally and fairly. All parties must be trained on these processes together. There must be no surprises or fear when a member is notified that an incident they were involved in will be reviewed. If you believe that you operate in a fear-based culture versus an education-based culture, there is a high likelihood that your CQI policy needs immediate attention.

As you review these concepts, please consider how they might apply to many issues we face in emergency services. Almost no one comes to work to do a lousy job. When emergency responders error, it's almost always unintentional. Most firefighters, EMS professionals, and police officers tend to beat themselves up if they know they made a mistake.

These moments give leaders chances for positive learning opportunities. However, given the gap in age and experience that can exist between supervisors and subordinates, we must be mindful of how generational differences may impact life skills and knowledge, learning styles, and leadership philosophy. For a "Just Culture" approach to work, we may need to consider where we can meet the members where they are at versus where we want them to be. After all, an organization's culture impacts the ability to recruit and retain high-quality members, something many agencies are at critical points with.‍

Is "Just Culture" a Good Fit?

First, evaluate how your organization currently mitigates EMS errors. For example, no GPS or app can tell you how to get somewhere without first knowing where you now are. This may be a bit painful because we may realize that we've handled some events wrong or that we have a lot of work to do.

This retrospection is part of the CQI process. Own it! It's beneficial for everyone to realize that we could do better and fix something, rather than repeating the same errors and for past adverse preventable outcomes to be in vain. It's never the wrong time to do the right thing!

Next, determine where you'd like to take the organization. Ultimately, we want members to feel comfortable and safe from formal discipline when they self-report errors. We also need supervisors to feel safe bringing issues or errors up after a call with the EMS provider(s) involved. This is the hardest part in many organizations because it's not the existing culture.

Critiquing a member's actions on a call, especially if you weren't there, has historically been viewed as unfavorable. And culturally, these things can quickly become a hot potato! But this is what must change!

After 22 years as a paramedic instructor, I've found that people learn from and enjoy case-based scenario discussions. That's essentially all this is. It just happens to be their own case study that we are learning from and implementing an educational plan to avoid repeating potential medical errors.

To show our commitment to maintaining a culture of high-quality EMS care, we must foster an environment for safe discussion and collaboration. A place where supervisors and members may speak freely but professionally. Where all data is managed sensitively and compliant with HIPAA, all stakeholders have accountability, and input is welcome through defined ground rules. 

As a firefighter and paramedic with Milwaukee County Emergency Medical Services(MCEMS), I will build this article from our system's plan. But, of course, this plan can be modified as needed for your agency, provided the fundamentals remain intact.

Our system believes that delivering EMS care is challenging given the dynamics, austerity, lack of resources, and myriad other factors. But when errors occur, they are almost always the result of systems and environments. They are rarely the choice of the provider. To that end, MCEMS focuses on using error as anopportunity to continually improve the delivery of our EMS care.

(Part 1 of 2)

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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.