From Airplanes to Ambulances

Terms like “Just Culture” and “Crew Resource Management” aren’t completely foreign to EMS. They originated in the aviation industry and have been adopted in principle across the healthcare spectrum. But are they properly understood by EMS agencies and providers? More important, are they being deployed properly—or at all?

From the late 1970s through the mid 1980s, the aviation industry was growing exponentially. More planes were in the air with more people on them. And aviation experts—from the FAA, National Transportation Safety Board (NTSB) and even NASA—started to ask themselves, can we sustain the accident rates we have now with the projected increase in airline travel? In other words, if the accident rates of the 1960s, ’70s and ’80s were applied to the expected dramatic increase in air travel, how many people would die?

“The answer, for industry experts, was unacceptable,” says Capt. Stephen W. Harden, a former TOPGUN instructor and president of LifeWings, a team of physicians, nurses, former NASA astronauts, former military flight surgeons, pilots, flight crew, former military officers and healthcare risk managers who have melded and adapted the best practices of their respective industries for use in healthcare organizations. “If we continued to kill the number of people we killed in airline accidents at that increased rate, nobody would get on an airplane. That really was the catalyst behind change.”

The root cause of most airline accidents, Harden says, was a breakdown in teamwork, communication and collaboration. “It was not because people couldn’t physically or technically fly the airplane where it was supposed to go, and not because the airplanes and engines weren’t reliable,” he says. “It was because of the introduction of some sort of error that wasn’t caught, detected or corrected because of a lack of communication and teamwork. Up to 80% of the accident rate really related to the failure to work together and follow standardized processes. You put those two together, and a lot of people die.”

The aviation and EMS industries aren’t as different as they seem. For one thing, people trust complete strangers—with their lives—to get them safely from point A to point B. So there’s a lot about safety and working together that EMS agencies and providers can learn from the aviation industry.

For starters, Just Culture is the idea that a problem is seldom the fault of an individual; it is the fault of the system. Rather than punishing someone for making a mistake, it’s better to look at the flaws in the system that allowed the mistake to be made in the first place.

Crew Resource Management (CRM) is a formalized system focused on communication, collaboration and teamwork. CRM holds that functioning as an effective team is just as important as technical knowledge and expertise.

Harden offers some simple lessons from the aviation industry that can be carried over to EMS.

  1. Look at the way you do business and figure out what can be standardized. “Clearly, EMS providers can’t always predict what they’re going to see, but what can be standardized should be,” he says. That means putting standards in writing and training providers accordingly.
  2. You won’t get the results you want in terms of safety and quality unless you have world-class teamwork. Harden says having expert EMS providers is great, but only if they function as an expert team. That’s not a trait people are born with, but it is one that can and should be taught to all providers. An analogy from sports would be the idea of a “dream team.” All-star teams may look great on paper, but if none of those stars understands how to truly function as a team, that “dream team” may end up a nightmare.
  3. You won’t get either standardized work or expert teamwork without the direct intervention, oversight and follow-up of EMS leadership. “Leaders have to be persistent at providing training, insisting standardized work be done, getting it into policies and procedures, checking competency based on standardized work and teamwork skills, and rewarding behavior and holding people accountable for failure to use those skill sets. There’s a direct correlation between the degree to which you make it mandatory and how successful you are in permanently changing your culture,” Harden says.

Dick Blanchet, a paramedic and pilot, gets even more specific when discussing things EMS can adopt from the aviation industry.

“What can EMS learn from the aviation industry to improve safety?” Blanchet asks. “A lot more than you might suspect:

  1. A federal EMS agency that has equal status with fire and law enforcement.
  2. Develop a program of best practices that fit for EMS.
  3. A culture through leadership, not management, of CRM.
  4. A non-punitive system of reporting errors and omissions.
  5. A non-punitive system of reporting fatigue-related problems.”

Both Blanchet and Harden agree there should be a universal set of standards for EMS. And following standards for teamwork and CRM must be mandatory for all EMS agencies and providers if the industry as a whole is to become safer for patients and providers. But that’s not an easy task.

“There was great fear and reluctance to adopt CRM in the aviation industry, because those with authority were afraid they would lose that authority,” Blanchet says. “This turned out not to be the case, because CRM was implemented through federal legislation for all airlines. But there is no central authority for EMS, and this will be the single point of failure for its implementation and standardization.”

“Of course there was resistance” when CRM was adopted by airlines, explains Harden. “There were a lot of old-time, authoritarian captains who said, ‘I’ve made it this far, had a fabulous career and never been involved in an accident. I don’t see why I need to do this. If I want to hear what you have to say, I’ll ask you; if I want you to do something, I’ll tell you. Otherwise, sit there and shut up.’ That pretty much was the culture of the airline business: I talk, you listen. But it’s since dramatically and fundamentally changed.”

One important factor in that change was crew members were able to see how CRM and a culture of teamwork would be to their benefit. “We know what’s in it for the industry and the organization, but what’s in it for the individual practitioner?” Harden says. “We found it made our day more efficient. There were fewer hiccups, fewer disruptions to our schedule, fewer things that cropped up that hadn’t been considered, fewer run-ins with the FAA where we made some sort of legal mistake—all the way around it just made for greater peace of mind and a more efficient and productive way to operate.”

Blanchet adds programs like the Aviation Safety Action Program (ASAP), a system where errors can be admitted without identifying oneself and management is not allowed to punish employees based on the information, allow employees to submit significant safety concerns, issues, operational deficiencies, noncompliance with regulations or deviations from company policies and procedures without fear of reprisal. Fatigue Risk Management Plan, or FRMP, also established an open reporting process, allowing crew members—from dispatchers to flight and cabin crews—to report fatigue that would affect safety. Both programs would be welcome changes to EMS.

The bottom line if you’re running an EMS agency, says Harden, is not only that creating an environment for teamwork is the right thing for your patients, it’s the right thing for your business. “It saves money, and for the individual EMS responder, just like we’ve found for pilots and surgeons, it makes your day more efficient, there are fewer communication mistakes, less frustration and hassle, less ‘rework’ when your work is standardized, and you’re doing it with a group of people with expert teamwork and communication.”

Harden adds he actively checks with his local healthcare providers—doctors, clinics and hospitals—to ensure they have a solid framework for teaching teamwork and collaboration. If they don’t, he won’t go there.

But the stakes are higher for patients seen by EMS. “I can choose which hospital I go to,” Harden says. “But someone calling 9-1-1 can’t choose the EMS provider who comes to their door. For EMS, it’s even more important to teach and practice expert teamwork, because those patients are depending entirely on you.”

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