How to Build the Crew Chain of Safety
Introduction and Overview
Richmond Ambulance Authority (RAA) is an organization embracing the EMS culture of safety in every department, from field staff to administrative office. New employees are told by everyone from the CEO to their field training officer (FTO) how our desire for them to be able to go home at the end of the shift is our inspiration. When it comes to vehicle operations, RAA takes its task to provide both safe crews in safe vehicles very seriously. Hard to believe, but statistically an ambulance in the wrong or poorly trained hands can become a weapon of mass destruction. Statistics have proven EMS workers in the United States are a “high-risk” population and have a fatality rate of 6.3 per 100,000 workers, 1.4% greater than the national average. Among the 65 fatalities for EMTs between 2003 and 2007, emergency medical technicians and paramedics accounted for 60 deaths, while “ambulance drivers” and attendants accounted for the remaining five deaths.1
In addition to fatal injuries, around 19,900 nonfatal injuries requiring treatment occur to EMS workers each year.2 Against this backdrop, the RAA leadership team is committed to a “crew chain of success,” establishing a level of safe and skilled vehicle operations. They are developed and sustained while also being measured and managed. The “crew chain of success” (CSS) is very similar to the American Heart Association’s Chain of Survival. Each link, although distinct and specific in nature, is only as effective as the next one. Their collaborative and overlapping efforts are what create the ultimate success. RAA’s CSS has a minimum of nine links. Each one contributes specific content; however, none is mutually exclusive of another (see Figure 1: CSS diagram).
The process begins before any potential employee begins the first day of new employee orientation (NEO). The initial selection process for RAA recruitment begins with an application evaluation. RAA has taken the proactive position by instituting a set of parameters by which potential candidates are compared. Experience, provider development, driving record and criminal history are just a few of the factors considered to offer an applicant an interview. The safety and risk director (SRD) takes a lead role in considering the applicants. There is an adage stating “past behavior is a predictor of future performance.” If the applicant has significant vehicle operating infractions such as speeding, improper driving or accidents, then the process stops. RAA knows the mission cannot be completed if vehicle operators make poor decisions and cause accidents. RAA’s vehicle liability insurance carrier has repeatedly mentioned this as a best practice among its customers.
Members of management from the operations and clinical departments meet with human resources staff to review information on the applicant and make certain candidates meet our required standards. The next step is having the candidate come in for an interview. This is also done in a team approach with staff from operations, clinical and human resources conducting the question period. The candidate is then sent to an operations supervisor for a critical thinking exercise. The interview team then tabulates the results and makes a determination on whether or not the candidate will be a proper fit for the organization.
Emergency Vehicle Operator Course (EVOC)
Previous driver education notwithstanding, all new employees are required to complete the RAA Emergency Vehicle Operators Course during the first week of their employment. This is the first phase of virtually continuous monitoring and assessment throughout the operator’s employment at RAA. This course is based on national curriculum and enhanced to meet RAA’s expectations. Recently, one of the FTOs took on the task of updating and personalizing the presentation. RAA EVOC has been approved by the Commonwealth of Virginia, Department of Health, Office of Emergency Medical Services. Classroom didactic sessions in conjunction with cone course sessions are just one phase of the program.
New employees also spend time doing a “road rally,” giving them an opportunity to become familiar with the vehicles, city and each other. This combined learning experience benefits them before being placed in more stressful actual call situations. We also stress the 12 standards of vehicle operations adopted from the Allsafe Driving System. These 12 basic principles augment the basic EVOC information and improve the overall program.
Preception/Vehicle Operator Training
Upon completion of the classroom phase, the employee is placed with an FTO for 22 shifts. The preception period equates to 264 hours of learning the “RAA way” and being monitored on success. The candidates spend more time in preception than in initial EMT training! During this time vehicle operations is an integral part of being “cleared” to operate in the system. In simple terms the reinforcement of driver safety does not end with a lecture and a trip round the cone course. Once this initial training is completed the new employee is transformed from an “ambulance driver” to a “vehicle operator.” There is so much more to ambulance operations than driving and RAA wants to recognize these efforts by addressing the position in a more appropriate and dignified manner.
RAA uses the ZOLL Road Safety System to alert drivers in the live environment. The interactive feedback alerts vehicle operators they may be exceeding the specified safety parameters of the vehicle. The system records driver behavior data/force and vehicle operating information. RAA was one of the first EMS systems to introduce this technology. For almost 20 years RAA has assisted in the growth and development of this product. Road Safety has been integral in both vehicle operation and fleet maintenance successes. Each week the SRD reviews the overall performance of the employees. Any significant deviations from the standard are analyzed, keeping in mind anyone can have a bad day or one-time increase in points causing an issue with the week’s score. The key determination to overall vehicle operation behavior is the six-week performance score. If a trend is seen in force points, speed points or unsafe reverses, the employee receives notice from the SRD of the problem and a plan for improvement is considered.
From the first time the employee comes in contact with this system RAA management emphasizes that the black box is not there for a punitive means. The vehicle operator monitoring system as a whole is designed to create safer vehicle movements. Accrued points are not a bad thing in all cases. New employees are told points are an acceptable alternative to not stopping hard for the red light and then hitting a van full of nuns taking the orphans to Christmas dinner. Employees are quick to report any significant point accruals. They often are self reporting the problem before any corrective actions are taken. Another positive aspect is in case of a vehicle contact the system is the only contemporaneous witness. RAA is able to rapidly retrieve information about how the ambulance was performing at the moment of impact. The capacity to retrieve telemetry from the vehicles at any time has been beneficial. For example, there was one vehicle contact where the ambulance and a second vehicle struck during a call. The driver of the other vehicle claimed there were no turn signals activated. The police officer was in the process of citing the RAA operator when a report showing the fact all lights were activated was produced. The driver of the car was then cited.
CRM Safe Vehicle Operation
RAA operates under the notion that an ambulance is a crew-served vehicle. Using principles of crew resource management, both employees are required to be active participants. The topic of distracted driving has grown significantly over the past few years. The primary concern is texting or cell phone usage. However, there have been distractions since Henry Ford started mass producing the automobile. Drivers are distracted by the weather, other people in the vehicle, children in the back seat arguing, consumption of food—the list goes on. Society tells people these distractions are dangerous and yet EMS adds more distractions and then mandates safe vehicle operations. Adrenalin added to lights and sirens, radio traffic, GPS, patient care and other vehicle actions are certainly a recipe for disaster. Using the aviation industry standard of a sterile cockpit RAA encourages 100% concentration by the crew. This dictates that the crew is not allowed to have non-task oriented conversation or activity during the response phase. They are also encouraged to actively use this concept in all stages of vehicle movement.
After Action Review/Root Cause Analysis
Each vehicle contact is investigated and analyzed with a goal of determining the root cause of the event. This means RAA is looking for the ultimate reason the incident has occurred. A common type of contact is the mirror tap. The streets of Richmond, VA, are not conducive to parked vehicles on each side with two-way traffic passing in between. Mirrors stick out the farthest and are the most susceptible to damage. The root cause is not the narrow street. The root cause is one vehicle failed to stop so the other could pass. These root causes help management determine if there is an issue with training, equipment, processes or personnel so corrective actions can be taken.
Employees are encouraged to participate in the self reporting program for any unexpected event. This includes vehicle problems and equipment issues, in addition to clinical performance and operational problems. Self reporting is a good sign of a progressive organization. Fostering an environment where management demonstrates problems are opportunities to learn and improve from versus issuing punishment and cover up should be encouraged. The RAA system is derived from the Aviation Safety Reporting System (ASRS), which itself was based on the NASA system where voluntarily submitted incident reports are collected and analyzed from dispatchers, pilots, flight attendants, maintenance technicians and others related to unsafe practices, occurrences and hazardous situations.3
Continuous reinforcement is a feature to RAA operations. Many agencies put out information about “safe driving” during inclement weather. RAA regularly reinforces the importance of “safe vehicle operation.” The use of field operation supervisor talking points, SRD e-mail updates, EPRO login messages, RAA’s daily news item Word on The Street, and daily operational coordination messages contribute to management’s support of the concept.
Maintenance and Truck Design
RAA views the ambulance as the providers’ “office” for at least 12 hours a day. Employees need to be comfortable and happy—along with safe and skilled—while they provide world class EMS. The fleet maintenance section’s primary objective is to supply field crews a mechanically sound and mission ready vehicle. Regular preventative maintenance and prompt repairs keep the fleet readiness at optimal levels. Having a ready fleet allows the vehicle operator to concentrate on getting to a call instead of worrying if the brakes are going to work. Each vehicle is on a miles-based maintenance schedule based on engine type. Diesel units are serviced at 5,000 miles and gasoline units at 4,000 miles respectively.
Routine service includes a standard oil and filter change. The mechanics also do a comprehensive bumper-to-bumper inspection looking for any unusual wear and tear. Major component replacement is done at the first sign of any issue. Not all vehicles wear or age at the same rate and this is why problems should be identified in the shop and not while the ambulance is on duty.
Employees are encouraged to participate in committees created to benefit aspects of their job. Vehicle design and layout is no exception. The fleet manager has used information solicited from field crews in the design and retrofit of RAA vehicles. The end user has a loud and important voice in this matter and this is taken into consideration. The fleet manager and SRD are constantly looking at vehicle design and industry changes to see what may be beneficial to RAA. There are always new tools, designs and ideas claiming to be safer; however, they are not always safer for RAA. Excellance, Inc. is the ambulance manufacturer chosen to provide Type III units. The standard construction has proven to be truly crash-worthy.
In one case a RAA unit was struck in the patient compartment by a vehicle running a red light. The other vehicle went under the ambulance and came out from the rear. The ambulance was already due for refurbishment and sent to Excellance for work. During the process of repair and re-chassis, the manufacturer found all original welds to be intact. This is a testament to the compartment integrity and construction. Their ability to adapt to RAA unique specifications turns a committee vision into everyday reality. The customization and design-specific construction provides a fit for purpose RAA vehicle meeting the needs of a high performance, system status managed EMS environment.
Two parallel tracts of thought are occurring. One tract has to do with accident prevention and includes human factors engineering. The vehicle operator is the only one in control of the ambulance. Identifying the right candidate to hire and train to understand the dynamics of how to manage an ambulance in all conditions and situations is the initial link in the CSS.
The complimentary tract is based on surviving the accident and has experts working to create a more efficient and safe vehicle. This is equally as important and hopefully one day a new design will be an ambulance manufacturing industry standard. Meanwhile, replacing an entire fleet of vehicles would be extremely cost prohibitive and potentially create a new problem. If you use a fleet replacement plan then how do you tell crews they have to use the less safe vehicle until all units are replaced?
While the overall program is successful for RAA, each agency must look at the topics and make decisions based on their own organization. Safe vehicle operation should not be based on budget constraints! Developing basic educational guidelines, routine monitoring, proper vehicle maintenance and purposeful change are great preliminary starting points in designing a similarly successful program in your agency.
- U.S. Department of Labor, Bureau of Labor Statistics. Injuries, Illnesses and Fatalities, www.bls.gov/iif
- U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Emergency Medical Services Workers: Injury and Illness Data, www.cdc.gov/niosh/topics/ems/data.html.
- NASA. Aviation Safety Reporting System (ASRS), http://asrs.arc.nasa.gov.
Bryan S. McRay has been involved in EMS for 24 years. He graduated Cum Laude from the University of Richmond with a degree in emergency services management and a minor in emergency management and homeland security. He has a master’s degree in business administration–public administration from Columbia Southern University. He spent 13 ½ years volunteering at Tuckahoe Volunteer Rescue Squad in Henrico County, VA, and served on the board of directors in various offices for 5 years. He went on to be president of the Henrico County Association of Volunteer Rescue Squads for two terms as well. He was a supervisor for a private ambulance service in Virginia for 11 ½ years. From there he went on to use his formal education in emergency management to become the emergency management coordinator for a local hospital. He is now the safety and risk director for Richmond Ambulance Authority. He continues to serve on numerous local, regional and state committees dedicated to EMS and disaster planning.
Rob Lawrence is chief operating officer of the Richmond Ambulance Authority. Before coming to the U.S. in 2008 to work with RAA, he held the same position with the English county of Suffolk as part of the East of England Ambulance Service. He is a graduate of the Royal Military Academy Sandhurst and served in the Royal Army Medical Corps. After a 22-year military career in many prehospital and evacuation leadership roles, Rob joined the National Health Service, initially as the commissioner of ambulance services in the East of England. He later served with the East Anglian Ambulance Service as director of operations. He is also a member of the EMS World editorial advisory board.
Dan Fellows, who has served 17 years with the Richmond Ambulance Authority, has accumulated 24 years of emergency vehicle maintenance and design experience. In his tenure at RAA he has designed and implemented solar panel systems for fleet ambulances as well as re-engineered the idle-off heat and air conditioning system. He is also a licensed Virginia state inspector, Stryker, Excellance and Ford factory-certified technician. In his spare time, Dan is a published fiction author and author of the Common Sense EMS Fleet Maintenance Guide.