The nature of the risks involved in the air ambulance sector mean that providers must take a proactive approach to safety, which can involve shifting the emphasis away from punishment for errors, instead treating mistakes as learning opportunities, as James Paul Wallis explainsAn air ambulance service is a hybrid beast that comes from the marriage of two separate industry sectors: aviation and medicine. At first glance, these sectors might seem to have little in common; medicine deals with the messy chemistry and biology of the human body, whereas aviation deals with the more sterile physics and mechanics of flight. However, they share a need for a proactive focus on safety, and the search for strategies to reduce risks is common to both fields. One such strategy is the adoption of the ‘Just Culture’ concept, wherein the reporting of errors and near-misses is encouraged so that systems can be improved, in the hope that this will reduce the likelihood of similar adverse events occurring in the future. Earlier this year, US-based international fixed-wing air ambulance provider Reva released a white paper in which Emma Roberts, Director of Safety, discussed Just Culture and the steps the firm takes to ensure it operates with a high degree of safety. Some of the aspects of reporting and accountability might seem counter-intuitive to those who enjoy the comfort of an office-based environment, where even the worst of bad days may end in nothing worse than bankruptcy. In an air ambulance mission, the stakes are higher – to put it bluntly, the worst-case scenario with a medical flight is not loss of earnings, but loss of life.
Lives on the lineRoberts told ITIJ why it’s important for air ambulance providers to take positive steps to improve safety: “The air ambulance business is comprised of two of the most highly regulated, high-risk industries – aviation and healthcare. Actively focusing on safety isn’t a choice, it is the way we do business. We focus on being proactive to avoid incidents before they occur, because our people and our patients’ lives are on the line.” Explaining the Just Culture concept in the white paper, Roberts wrote: “A Just Culture is a culture in which front-line operators and others are not punished for actions, omissions or decisions taken by them that are commensurate with their experience and training.” At the same time, though, ‘gross negligence, wilful violations and destructive acts are not tolerated’, she added.
the reporting of errors and near-misses is encouraged so that systems can be improvedThe aim of Just Culture, then, is to create an environment in which employees feel comfortable reporting issues so that improvements can be made. Roberts said in the white paper: “Nobody wants to tell on his colleague, but if that ‘don’t-tell-the-teacher’ pressure doesn’t exist, then reporting becomes a necessary step rather than a threat of ‘I’m going to get you in trouble’. That comes with the feeling company management is looking out for workers, not looking over their shoulders while tapping feet.” Key to this system is the reporting of hazards, so that steps can be taken to prevent accidents from developing in the future. Thus, improving safety becomes a proactive, rather than reactive, task. To promote a ‘free exchange of safety information between employee and management’ at Reva, employees can report hazards through a web-based system, through a telephone hotline or via email. Roberts noted in the white paper: “The most important piece is trust in the system. People have to know they’re in no jeopardy when reporting. We do everything we can to maintain confidentiality. And we get back to them. We let them know they’re making a difference.” Paul Scott, Safety and Compliance Manager at European Air Ambulance (EAA), agreed that confidentiality is prime importance in such a system: “The person reporting is not revealed in any of our reports.” He added that steps are also taken to avoid potential conflict between the person being reported, and the person reported on: “In a case where a conflict between personnel would arise, we would encourage the other person to report their point of view in a formalised way.” Scott also reflected on how staff attitudes can develop over time once a Just Culture model is introduced: “As [a Just Culture] evolves within the organisation, personnel will realise that the punitive attitude is not applicable to errors, mistakes or even, in some cases, a system-induced violation. As such, this will contribute to an increased reporting culture.”
Learning vs punishmentAir Alliance, which offers fixed-wing air ambulance services from bases in Germany, Austria and the UK under the Air Alliance Medflight brand, recently shared its approach to safety. Chief Operating Officer (COO) Captain Joachim Wirths explained how safety is embedded in a ‘learning organisation’ at the company. He noted that the International Civil Aviation Organization (ICAO), a UN specialised agency, published its Annex 19 in 2013, which describes bow organisations should implement Safety Management Systems (SMSs). He commented: “What is unique about this is the fact that reporting is non-punitive. This was a culture shock for some nations and companies who are less tolerant to mistakes.” He continued: “You only become better by analysing mistakes and by learning from them.” Emphasising the value of reporting, Roberts told ITIJ: “Employee hazard reporting is one of the most valuable safety programmes because it brings to light concerns and issues before they become an incident.” David Quayle is Clinical Services Manager at Air Alliance Medflight and a site surveyor for accrediting body CAMTS EU (the European arm of the US-based Commission on Accreditation of Medical Transport Systems). Writing on the benefits of following Just Culture in AirMed&Rescue Magazine (Issue 86, October/November 2017), he clarified how an organisation should respond when errors are identified: “In my experience of some 28 years as a registered nurse, errors are often devastating to the individual [that makes them]. They do not require punishment, as they’re already punishing themselves rather harshly in any event (with a few world-renowned exceptions, healthcare professionals rarely intend to do harm to their patients). They are extremely likely to have already learnt a lesson from the experience and are the least likely people to make the same error again.” In Just Culture, said Quayle, consoling the staff member would be the correct course of action for a simple, one-off, error. This would be followed by a review of the organisation’s systems to see whether circumstances, policies or procedures made the error more likely to occur, and whether the systems require change. EAA’s Paul Scott suggested the following steps: “The improvement (mitigation) in cases where the behaviour can be categorised as negligent conduct or violations without involving personal gain, can range from training, to rewriting procedures to avoid making the same mistake.” Consider the words of Dr Lucien L. Leape of Harvard School of Public Health, who once stated: “Medical errors most often result from a complex interplay of multiple factors. Only rarely are they due to the carelessness or misconduct of single individuals.” That sentiment chimes with the idea that where problems are identified, it’s worth looking at what changes to procedures, training and so forth should be made, accepting that an error can be produced by the organisation, not just the individual. It also suggests a particular shortcoming of a ‘blame’ culture – if an error is rarely down just to the individual, then limiting the reaction to punishing the individual will rarely address the root cause. An example that would lead to a non-punitive result could be an aircraft having to divert and land as soon as possible due to a change in the patient’s condition, suggested Paul Scott of EAA. He said: “Having adjusted to the diversion with air traffic control, the flight crew receives priority routes and lands safely. During taxiing, it realises that the maximum landing mass was exceeded due to fuel that had not been consumed. Thereafter, the commander reports this fact and the maintenance staff carry out an overweight landing inspection.” Imagine the same scenario, said Scott, where the commander decides not to report the overweight landing: “This is an unacceptable behaviour where the Just Culture may well lead to disciplinary action. The Just Culture keeps a positive output by acting on the unwanted situation, treating it as a threat or a safety issue. No one wants to be working in an environment where threats exist. This also contributes to an increased reporting culture.”
Responsibility remainsThere is sometimes a misconception that under the Just Culture concept, employees don’t have to take responsibility for their actions. It’s worth asking whether the non-punitive aspects of Just Culture would make staff feel freer to commit errors without fearing disciplinary action. Roberts, however, explained that while a Just Culture is not a ‘blame’ culture, neither is it a ‘no-blame’ environment. She added: “The way I see it, there are three types of safety cultures typically seen in an organisation. A ‘punitive culture’ is dangerous because it drives employee reporting into the ground. If someone is afraid to speak up in fear of getting in trouble, we lose invaluable data from the front line and we lose the opportunity to learn from our mistakes. On the other side of the coin, a ‘no-blame’ culture allows individuals to be reckless without consequence. Every employee receives training and is aware of their responsibilities and we rely on them to act professionally. Not holding employees accountable can be just as dangerous as creating fear of disciplinary action.” As part of a Just Culture, there must be a line in the sand between acceptable and unacceptable behaviour, said Roberts.
gross negligence, wilful violations and destructive acts are not toleratedAsked whether, following a Just Culture model makes staff feel less responsible in practice, she told ITIJ: “I think the important key here is that a Just Culture does not come with ‘get out of jail free cards’. Instead, the goal of a Just Culture is to expect each and every employee to act professionally and in accordance with their training and responsibilities, but also to create an atmosphere of trust in which they feel comfortable raising their hand and stopping the operation when something doesn’t feel right.”