5 steps to create an EMS culture of continuous learning

By Sean Caffrey, NEMSMA

EMS is a practice of medicine. As a result, it doesn't matter if you are an EMT that graduated yesterday or a 20-year veteran of critical care transport, you are a medical professional and you have an obligation to provide the best care possible for your patients. To do so, you cannot simply rely on what you were taught in school. Practicing medicine involves constantly improving your practice, keeping up with the latest information and periodically refreshing your knowledge.

As an EMS leader, however, you have an added obligation to support the practice of the medical professionals within your organization. The quality of care your EMS providers deliver is dependent on you creating the systems and culture necessary to support the delivery of high-quality patient care, and the continuous improvement of that care. Here are five steps necessary to create a culture of continuous learning:

Step 1: Partner with your medical director

The highest-performing EMS organizations almost always have a well-established partnership between the head of the organization and their physician medical director. The role of the medical director is to lend their medical expertise and judgment to the development and implementation of the care protocols used by your organization. The medical director also has a lead role in supervising and monitoring the clinical practice of EMTs and paramedics. The best medical directors are also an accessible resource for provider questions, a mentor for the effective practice of medicine, a teacher and a partner in high-level patient care decision making.

While not every medical director has all of these traits, the more of them they have, and the less your medical director simply serves as a rubber stamp for clinical practice compliance, the better off your organization will be. The National Association of EMS Physicians has taken a strong leadership role with other physician organizations to develop the EMS subspecialty of emergency medicine with its own knowledge base, fellowship requirements and testing. Every year more and more physician EMS specialists become available. The advantages a physician board certified in EMS brings to your organization are:

• A thorough understanding of the application of emergency medicine in the field.
• A knowledge of EMS systems, operations and regulations.
• A strong background in EMS protocols and related research.
• An understanding of quality improvement methods.

EMS physicians come with 10 or more years of post-graduate training and experience in emergency medicine. If you can team one up with an experienced supervisory team, it's a combination that's hard to beat for creating a culture of continuous learning.

Step 2: Don't focus just on compliance

EMS operates through the use of protocol-based medicine. Hopefully, you hire well-qualified providers to deliver clinical care in an unpredictable and often difficult environment. If your providers go through their workday worrying about if they will get in trouble for not following the protocols, you have probably created the wrong culture.

Protocols are guidelines that help standardize the delivery of care. EMS providers are the skilled professionals employed to interpret them in highly dynamic and complex situations. On the whole, EMS should be celebrated among medical specialties for doing a great deal of protocol-based care in comparison to many other areas of medicine.

Your providers, however, must also exercise judgment in their application. Great leaders are always looking to improve their protocols and look for ways to improve them as tools that their providers can use to increase the quality of care. Failure to follow protocols can be a system, provider or even a protocol issue. Work to understand what is causing protocol compliance issues before you assume the provider is at fault.

Just culture principles offer a great set of tools to improve performance in your organization by better understanding the types of error and how to address them. Quality improvement methodologies, such as Lean and Six Sigma, further help you understand how your systems function and when they are working effectively.

Taken together, you will often find that improving the performance of your organization is often more about fixing systems and processes than it is about individual performance issues. It is likely the management team of an EMS organization that will have the most responsibility to improve clinical performance through optimization of policies, procedures and protocols.

Step 3: Choose your best personnel to lead QI efforts

The secret to an effective quality improvement program is understanding that providers want to do a better job of providing patient care. If your QI program works well, it will help your people recognize gaps in care and make them partners in addressing those gaps.

Of course, if you run a "gotcha" compliance program you can rest assured your clinicians will probably avoid giving you any feedback on what could be better for fear it will lead to punishment. As a general rule, if you have an angry and frustrated leader of your QI program, and your providers hate getting QI related messages, your QI program needs better leadership.

Tap your best clinicians to do QI, teach them about just culture, statistical process control, normal and special cause variation and other key improvement science concepts that make them well qualified and curious about how to improve care, and less likely to be cranky disciplinarians.

Step 4: Mistakes are your best opportunity to improve so don't waste them

Mistakes will be made in clinical care for a variety of reasons. Sometimes they are unavoidable due to circumstances or unclear information. Sometimes mistakes are the result of provider error, but most of them they are the result of poorly functioning systems. Don't waste the opportunity to learn from these mistakes.

A wasted mistake usually starts with the assumption that the mistake was due to a lazy or stupid provider. If you act on that assumption before digging deeper, then your providers will learn to effectively hide mistakes. Since the hiding will frequently work, you will no longer have frontline partners in solving problems and your systems will operate poorly. You will also have to spend a lot more time and effort finding problems.

Big mistakes are often the result of multiple smaller mistakes that go unrecognized or uncorrected. As a result, every mistake is an opportunity to fine tune systems and prevent catastrophes.

Don't waste mistakes by ignoring or hiding from them. Instead, use them as a tool to support learning throughout your organization in a non-punitive way. If you do it well, your team might even start telling you about problems and potential fixes even before you know the problem exists.

Step 5: Commit to communication and education

One of the biggest tragedies in modern organizations is that things go wrong or improvements are not realized because no one bothered to broadly communicate issues or changes. If you find problems, you need to communicate them to your team so they can have the benefit of heading them off where they can. Telling one person not to repeat a mistake is fine, but telling everyone how to anticipate, recognize and prevent one is much better.

Asking for help from field providers to evaluate and improve processes is also a critical feedback loop to managers responsible for how things are done. Develop good mechanisms to communicate in both directions.

Finally, continuing education is more than a requirement to maintain a certification. It is a benefit that employees and volunteers appreciate to help them do their jobs better. It is essential that EMS organizations offer some continuing education in-house or in partnership with other health care organizations. Ideally, continuing education should be tied back to gaps identified by quality improvement efforts. This could be topics that you don't encounter often, high-risk skills or known problem areas. Regardless, take steps to address these areas through education and training to constantly improve performance and to create a culture of continuous improvement.

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