Steps to Designing a Safety Management System

EMS agencies have protocols and policies in place to ensure proper care and safety of patients. Agencies can also include programs that make EMS providers more mindful of their own safety and the behaviors that impact that safety. Developing a safety management system (SMS) can assist field providers and their supervisors in being proactive, and possibly even predictive, instead of reactive, to the hazardous situations they face in the field.

The creation of an SMS can become an integral part of the agency’s operational procedures, but it takes a commitment from leadership to administrative staff says Ron Thackery, senior vice president of professional services & integration for American Medical Response (AMR). During the recent EMS World Expo held September 15–19 in Las Vegas, NV, Thackery and others presented ways to create an SMS as part of the EMS Safety Officer workshop that debuted this year.

According to Thackery everyone in an agency must understand the role of safety in order to implement and manage a program. He cautions, however, that one size does not fit all. Leadership, with strong input from employees, must analyze individual agency needs and prioritize based on what is realistic to implement.

“You can’t boil the ocean,” says Thackery. “You might have a list of 10 things you want to do but realistically, you can’t do all of them. You have to boil it down to something manageable. Agencies have to pick their top needs and be committed to implementing the most important ones.”

Thackery and his colleagues at AMR have extensive knowledge in integrating safety into every aspect of providers’ duties. Thackery is responsible for risk management and safety, with previous executive oversight for fleet administration and clinical services. He serves on the board of directors for the National Safety Council and chairs the Professional Standards and Research Committee of the American Ambulance Association.

“There are four components to a safety management system,” says Thackery. “The three primary ones are safety risk management, safety leadership and safety assurance. The fourth is safety promotion, which is the glue that holds it all together. That part is how you communicate to the people in the field to behave safely. If you remember the TV show Hill Street Blues, at the end of every roll call they were told, ‘Let’s be careful out there.’ That built a culture of safety in every show. That kind of culture can be built within any agency.”

Thackery says the message can vary. In some places the chief or board president signs a mission statement or pledge that the agency is committed to safety. Others may have the entire staff sign the pledge. The statement may be framed and placed in a heavily traveled area of the agency.

“It’s a pledge saying, ‘This is why I work safe,’” he says. “Another idea is to have the staff provide photos of whatever is important to them in life–a spouse, kids, a pet. It sends a message that they are committed to work safely because of the reminders that are posted. It helps build a culture among the staff because people also learn things about each other. Then it is up to leadership to develop policies and programs of what they expect them to do to behave safely.”

Thackery says that the message needs to be changed on a regular basis: “People might become numb to the message. Some organizations update the photos every six months or every year. I try to push people to have something personal and to update with new photos all the time. And really, people who are committed will keep updating it, and leadership must make sure it happens.”

Thackery says the aviation industry implemented safety management systems in the 1970s. The EMS industry is mimicking the aviation industry’s research and policies for its programming.

“It became popular in the EMS profession in the past decade because the air-med side kept having crashes,” says Thackery. “We decided we needed to have a framework with a tie to EMS. Agencies have a process and policies, a way to manage their dispatching, billing, etc. It makes sense to include a program and policies for safety. When they do it, it just becomes a part of the overall way they run and operate the agency.”

The concept is rooted in behavior-based safety and relies heavily on Herbert Heinrich’s Pyramid of Safety. Heinrich was an industrial safety pioneer from the 1930s who worked for Travelers Insurance Co. Heinrich's research is claimed as the basis for the theory of behavior-based safety, which holds that as many as 95% of all workplace accidents are caused by unsafe acts. Heinrich came to this conclusion after reviewing thousands of accident reports.

According to Thackery, changing behaviors to create a culture of safety in the EMS industry requires a commitment to improve provider safety, which results in improved patient safety and, ultimately, improved community safety. The foundation of an SMS includes fostering a culture of safety, coordinated support and resources, safety data, education initiatives, safety standards and requirements for reporting and investigating incidents that affect safety.

An SMS should examine how paramedics are lifting patients, driving ambulances, fatigue levels (analyzing hours of service), infection control protocols, hazmat responses, machinery operations and workspace ergonomics. Thackery also says an SMS can focus on environmental sustainment, contractor safety, off-duty safety, fitness for duty, physical agility testing, drug/alcohol testing and medical monitoring (of employees, but also communicable diseases in the community, such as Ebola).

Thackery says there are three approaches to managing safety issues:

• Reactive (past): Respond to events that have already occurred, such as incidents and accidents;
• Proactive (present): Actively identify hazards through the analysis of the organization’s processes;
• Predictive (future): Analyze system processes and current environment to identify potential future problems.

“A lot of agencies manage safety in a reactive mode,” says Thackery. “An employee gets injured and the agency reacts. But they can develop systems to be proactive or even predictive.”

However, that requires leadership to be more in tune with what is affecting safety within the agency. Thackery said that in most agencies, the paramedics and EMTs have 100% knowledge of problems and safety issues; supervisors have 74% knowledge; mid-level management has just 9% knowledge; and top management has just 4% knowledge.

So how does an EMS agency go about analyzing its needs and then implementing and maintaining a safety management system? Thackery says agencies should follow the ideas in the four pillars of an SMS:

Safety Policy: Establishes senior management’s commitment to continually improve safety, defining the methods, processes and organizational structure needed to meet safety goals. It requires:

• Commitment of the team to achieve high standards and compliance. This also involves ethical decision-making and promoting a culture of safety.
• Transparency in managing safety.
• Documented policies/processes.
• Open reporting.
• Any policy, program or initiative must pass two tests: Will it mitigate risk if used as designed, and will the system adversely impact productivity, safety, efficiency and privacy?

Safety Risk Management: Determines the need for, and adequacy of, new or revised risk controls. The agency must identify hazards and assess, analyze and control the risks.

Safety Assurance: Evaluates the continued effectiveness of implemented risk control strategies and supports the identification of new hazards. This ensures results meet expectations and compliance, and facilitates information gathering (via audits/evaluations, employee reporting and data analysis). Periodic assessment of the system is required.

Safety Promotion: Includes training, communication and other actions to create a positive safety culture within all levels of the workforce. This phase is the glue that “bonds” all safety activities. It involves advocating for a strong safety culture; communication (includes awareness, lessons learned, social media); training and education; and eliciting input, ideas and feedback from everyone.

“The four categories give agencies the ability to put together their own SMS,” says Thackery. “They need to think about what they want to do in their own agencies. They also have to build a process so that people are willing to come forward about things they see and get employees to become engaged in order for it to work.”

AMR Safety and Skills Competition

AMR holds an annual event in Denver where providers compete in a safety and skills competition that simulates situations EMS professionals encounter every day. “The AMR National Safety Competition is not only a very prestigious event for our caregivers, it also instills a culture of safety and an emphasis on clinical excellence,” says Thackery.

“The competition includes a timed driving course that measures their abilities to safely and efficiently operate an ambulance, two very difficult patient encounters and a clinical skills section.” While the crews have a lot of fun and truly enjoy the competition, they also understand the importance of focusing on safety and clinical excellence. “The crews all take home something they have learned and then they pass it on to the other team members in their local operation,” says Thackery. “It’s that type of commitment to learning and excellence that ensures our crews provide outstanding patient care every day.”

Susan E. Sagarra is a writer, editor and book author based in St. Louis, MO.