Building Accountability in EMS

Accountability can be a loaded word.

According to the dictionary, accountable means a person, organization or institution required or expected to justify actions or decisions. Accountable can also be described as being reasponsible and transparent. Ideally, accountability also includes a willingness to admit to and learn from mistakes. Unfortunately, however, our culture has mostly turned accountability into a description of punishment.

In many contexts, when someone “needs to be held accountable,” it’s code for someone who needs to be fired as the result of a bad outcome. The challenge EMS leaders face is how to orient their organizations to use accountability as a tool for improvement, while avoiding the pitfalls of an organizational culture based on blame and punishment.

Accountability Building Blocks

The exercise of personal responsibility by individual practitioners and their leaders is the foundation of professionalism, trust and credibility that is needed to allow for organizational accountability. Therefore all practitioners must recognize their duty to be skilled in prehospital care and to learn and follow clinical care and operational rules. This commitment demonstrates  professionalism.  

Managers must recognize that they are accountable to those they lead to ensure the systems they develop and the rules they create are logical, well communicated and practical for team members to implement.

Furthermore, all members of an organization must be open to examining their actions, admitting their mistakes and working to continuously improve systems. To the extent possible, organizations should screen for these characteristics when hiring new members and promoting individuals to leadership positions.
Building a governance structure of transparency  is a cornerstone of organizational accountability. Transparency, however, can be difficult in public safety organizations. EMS services in particular have a broad responsibility to keep the public safe and have significant authority to violate traffic laws, enter people’s personal spaces and provide invasive medical procedures, often at some risk of injury. It is critical, however, that EMS systems do not view themselves as detached or above the public they serve. Accountability, including regular and accurate reporting to the public, should be built into oversight structures. EMS organizations should report to external authorities outside of public safety that are representative of the community, which  may include an independent board of directors, elected officials or a parent organization.

A Just Culture

With individual responsibility and organizational transparency in place, the true value of accountability within an organization becomes the ability to recognize and learn from mistakes. To accomplish this, however, requires a recognition by leadership that mistakes, sometimes with bad outcomes, will happen in all organizations. These mistakes will have a variety of causes. In many cases, errors will be attributable to the systems and procedures put in place by management. If managers punish individuals for bad outcomes as a matter of course, they will destroy trust within the organization, discourage team members from reporting mistakes and create a blame-shifting culture that will inhibit organizational learning, improvement and excellence.

Creating a Just Culture environment is perhaps the best approach currently available to understand errors, treat team members fairly and improve organizational performance. The concept has received much attention in EMS and been widely utilized in a variety of high-consequence industries such as aviation and healthcare. The newly released Strategy for a National EMS Culture of Safety document recognized the concept as the first of six core elements of a national EMS safety strategy. The National Association of EMTs further endorsed Just Culture in a position statement in 2012.

At its most basic, Just Culture is about accountability and fairness. It recognizes that the reporting of errors offers a better opportunity to improve systems. It further recognizes that errors occur and those errors may fall into the categories of simple human error, at-risk behaviors or unjustifiable and reckless behavior. Errors are addressed differently based on their origin and regardless of their outcome. The system only strives to blame or punish when reckless behavior or unjustifiable risk taking is the origin of the problem.

Inherent in accountability is the leader’s responsibility for setting expectations and managing systems. As mentioned above, team members have a duty to follow procedural rules. Team members, however, must be provided with an explanation of why these rules exist and proper training on how to carry them out. EMS managers must understand that they bear the responsibility for how things work or don’t within an organization. Leaders must ensure that their expectations are reasonable and effectively communicated. As a practical matter they must also ensure it is possible to follow the rules that are created. Failure to expend effort on well-constructed, reasonable and easy-to-follow rules will not go unnoticed and will cause teams to become resistant and dysfunctional.

For example, it is always a danger sign to find an organization that requires its employees to sign for a 300-page policy or protocol manual without an extensive orientation and/or field-training program. Even more concerning are organizations without established policies or procedures that expect new members to simply figure things out based on informal or nonexistent orientation programs and traditions. Volunteer organizations are particularly at risk for these scenarios based on the limited time and resources available to members and leaders.  

Ideally members of the organization, practitioners and leaders alike, should be held accountable for their portion of any particular error. This accountability should lead to a collective desire to understand and correct the causes of the mistake. This desire, however, can be easily stifled if the fear of punishment replaces the curiosity and trust needed to be critical of individual and team performance.

As you can see from this overview, accountability is a complex topic made up of individual responsibility, effective and enlightened leadership, and organizational culture. At the end of the day, a healthy EMS organization will leverage the professionalism of its team members and the fairness of its leadership to learn from its mistakes, improve its processes and continuously strive for excellence. The best way to start down this path is to model accountable behavior, be answerable to external authority and manage in a responsible, equitable and just manner. Tools to accomplish this include effective screening of employees and leaders, accountable governance structures, high-quality orientation programs and the use of Just Culture methodologies.

Sean Caffrey, MBA, CEMSO, NRP, is a 25-year EMS professional currently managing the Colorado EMS for Children Program. He also serves as a board member of the National EMS Management Association and remains active part-time as a paramedic in Grand County, CO.