Editor’s Note: Chris Cebollero, BS, CCEMT-P, is the President and CEO of Cebollero & Associates Consulting Group. He has served as a paramedic for over 20 years, and in his last operational role he was the Chief of EMS at Christian Hospital in North St. Louis. We spoke with him about the status of safety culture in EMS and challenge associated with safety event reporting.

Kendall Hall: Could you please introduce yourself and your current position to our audience?

Chris Cebollero: I am Chris Cebollero, and I've been a paramedic since the mid-eighties. I've had the opportunity to work in a lot of different EMS [emergency medical services] systems throughout my career, but in my last operational role I was the Chief of EMS at Christian Hospital in North St. Louis County. I held that position for about five years. Presently, I'm the President and CEO of my own consulting firm. I work mostly in the transformation of EMS and the community paramedicine space, but part of my business is also in leadership development and organizational process improvement.

KH: As you know, our conversation today is around Just Culture and thinking about it in the context of EMS. For our audience who might not know what Just Culture is, can you just briefly describe that, and then talk about what it means to you in the context of emergency medical systems?

CC: Culture really is the behavior of the organization and the approach to reaching a vision of that organization. When we think about Just Culture, it's really kind of giving the workforce clear expectations and the tools that they need to be successful when it comes to safety, as well as accountability across the system to ensure that we are staying safe. That's kind of it in a nutshell from my side.

KH: I think one of the big components of Just Culture in other settings is the tracking and reporting of safety events to learn from them and identify areas for improvement. Do you think that is an element present within EMS? 

CC: I think it really depends on the organization and how much this idea of a Just Culture has taken hold. It's there as a model, but I think there needs to be consistency in how it is incorporated throughout the career field. We're able to, like you mentioned, track and record things like falls in EMS, a patient falling from the stretcher, for example. Can we put our finger on a number to say, “this is an issue that we really need to address?” I don't think that we have that data.

KH: Having the ability to openly report events is part of this good safety culture, right? So, do you think that is something embraced by EMS?  

CC: You know, again, I think that it depends on the organization, what the culture of the organization is. If we're developing a culture and an organization that's allowing people to hide their mistakes, we've got a bigger issue than patient safety and employee safety, right? We need to be able to address the fact that we should not be a “one mistake and you’re out” organization, and if somebody is having a challenge with the fact that they can’t come forward, there's a bigger issue here. There are organizations where I’ve had a patient fall in my care and the first thing I had to do was not only put it in my patient care report, but I had to bring it to the people who might have to defend my behavior later on, right? Because this could be a legality for the organization and, of course, if I'm not forthcoming with that information, I've now put my organization in a horrible place, but number two is, I’ve probably put my position in jeopardy as well. You set the expectation that if anything happens with a patient on the call, that's your responsibility, I'm going to hold you accountable to make sure you're sharing that information.

KH: It sounds like you have experienced cultures where you’re coming from a defensive stance—you are reporting, but it is to protect you and the organization, as opposed to coming from a place of learning from events. How do we shift the thinking to the idea that these are harms that may happen to the patient, be it a fall, medication safety error, etc., that we need to prevent, and that that is the primary reason for reporting?

CC: I think that that's a great point, and I don't know that there's any healthcare provider who's going to set out to hurt a patient. I mean, we all believe in the do no harm [principle], but if we calculate the medication the wrong way, if a patient trips because we're walking them to the ambulance instead of putting them on the stretcher, if we're trying to move them from bed to from stretcher to bed in the hospital and they fall between the cracks, we've got to be able to be responsible for those actions. I think that people are actually more apt to hide that the vehicle was damaged than they are to hide a patient error. But to your point, it's developing the culture to say, “you know what, we've all done it.” I've had a patient fall. I've dropped a patient trying to pick them up and put them on the stretcher. I've had a medication error. It's just the nature of the beast and you've got to know that experience comes from mistakes, and mistakes come from lack of experience. It is one of my rules for success and you’ve just got to know that you learn from those errors.

KH: And I also think it’s not just learning from errors, right? It's learning what needs to change in the system in order to prevent those errors from occurring again. With error reporting in the EMS space, do people feel comfortable reporting from the perspective that it will improve the system?

CC: I think a lot of the organizations, especially the ones that I've worked [with], always set up the opportunity to report—and not just on challenges with patient care but also things like poor equipment or equipment that doesn't work, which does actually feed into poor patient care. Confidentiality in reporting really is important for a couple reasons. One, you don't know what retaliation is going to be from an organizational standpoint. It's a horrible thing for me to have to sit here and say that an organization is going to retaliate against a member of the workforce for bringing something forward that only makes the organization better, but unfortunately that does happen. But more importantly, it's the perception that you could be snitching on your peer. I know that I need to do the right thing, but I don't want to be seen as not trustworthy to my crewmates and I need to keep my own integrity with my peers that I work with on a daily basis. One of the big issues that we deal with in EMS is that our workforce is primarily young. Sometimes it's an entry-level job when we see EMTs [emergency medical technicians] and paramedics in the workforce and we have to teach them the maturity to say, okay let's talk about mistakes, let's talk about fair, let's talk about your responsibility in helping us to reach the “excellent” part of our vision. I don't know if that part is really [at] the forefront of many organizations.

KH: So how do we get it to be at the forefront? How do we teach this younger generation? It almost seems like they need to be indoctrinated right from the get-go, right in training when they're taking their classes to go and get their license. Is that feasible?

CC: Yeah, I think that the purposes of reporting could be a part of the initial education. I think that's a great way to start but more importantly, the challenge is with the caliber of leadership that we see in organizations presently. We’ve got to be able to change the mentality that the days of command and control, and leading from a position of authority, are over. As leaders, we have to shift the mentality from the idea that the workforce works for me, to the idea that I work for them. We've got to change the mentality of the leadership to say we've got to give the tools to the people who are in our organizations to help us be successful. And when we change that mentality, we're also developing a respectful rapport, almost a personal but professional rapport, with those people who are in the field. Fear is not a way to run an organization. If there is fear, I’m not going to come forward with a medication error. I'm afraid I'm going to lose my job. I'm afraid that my reputation is going to be tarnished. I'm afraid that I won't be allowed to work as a paramedic. So, while I love the idea of initial education to talk about the importance of reporting, the leaders have to be able to ingratiate themselves with the workforce to let them feel comfortable coming to their office and saying, “I think I just gave a patient the wrong medication, or too much medication, or not enough medication.” When you talk about Just Culture and we talk about culture as defining behavior, we've got to change the behavior of the whole organization as well.

KH: With that concept of bringing the leadership to the front lines and maybe integrating them more, we talk about leadership rounds in the hospital. Is there an equivalent in EMS or is there a potential for an equivalent? Does leadership get a chance to ride on the ambulance, go on calls, see what's really happening? What the struggles are?

CC: A lot of the people who are in EMS leadership are EMS-certified, and they've had their time in the field. But, [in my experience], I'm going to say that there is a small percentage of the people who are in management, supervision, senior leadership don't have EMS certifications or some type of related background. I think for EMS leaders, one of the challenges is that there are so few places to get true leadership training. And then a lot of the leadership training is antiquated as well, because a lot of EMS leaders feel that, “this is my organization, I'm the chief of this organization, the buck stops here” kind of thing. Whereas when you take a servant leadership mentality, you take the viewpoint that you’re there to serve the workforce because they’re the biggest component of our success. If you think about a true measurement of leadership success, it's how engaged, satisfied, and productive the workforce is. We have to get work done through other people and we have to get the very best out of those people so we can ensure that we reach the vision of the organization. The job of the leader is to get your workforce to be the very best that it can be, and I think we are still really transitioning to that viewpoint as a field.

KH: Part of it might be that you have to wait until this next generation is in leadership positions, right? And that's where starting from day one and training becomes so important, because eventually these folks that are on the front line will become the leaders of tomorrow. And it's going to take time for that culture shift.

CC: Well, to say that we have to wait for the next generation to move into leadership puts us in a deficit of what? Five to seven to 10 years? We don't have that time. You know, EMS is beginning to transform into a broader model of care: community paramedicine. In this model, we've got to make sure that the transformation is whole. We can’t transform, but not grow, our leaders, or not change our workflow processes, or not make sure that we have great patient safety, employee satisfaction, patient satisfaction. It's all got to move together or you're just going to limp your way into what you think success should be.

KH: How do you do that?

CC: I think there really has to be a separate model. I mean, if you think about trying to change the structure of an organization, it's a daunting task. For example, if I'm going to separate community paramedicine from the rest of my EMS business, it at least gives me an opportunity to build the model that needs to be built. And then, hopefully, from the best practices of that model, some of that will bleed through into the organization. If people don't want to take that route, they can look at their vision statement and think about what they want their vision to look like for the future. The vision statement is the most important component of any organization: if we don't know where we're going, we certainly don't know how we're going to get there. So, this may be the time to change the focus of the vision of the organization, to build goals around the vision, plans to reach the goals, and then to train everybody as to what their responsibility is in reaching those goals. To me, that is the path to move forward.

KH: I'd like to get back to error reporting because I think that's something that's consistent across all of the parts of the continuum we touch. What, right now, is this state of how errors are reported and used in emergency medical services? I know there’s variability but is there any generalizability?

CC: Right now the process would be that, if you have an error or if you have a safety issue, you need to contact your field supervisor as soon as possible. Your first call is always your field supervisor. Then it's going to be the responsibility of the supervisor to take those next steps. Some of those next steps are to get the employee into the organization so they can write a detailed statement while it's fresh in their mind and then there might be an investigation. Usually the supervisor will take it to the next level of the organization, whether it's the operations manager, clinical manager, or if there's a safety manager. The next level of EMS leader will do that investigation as part of that process of reporting.

KH: Do you have the equivalent of “never events” in the hospital that automatically trigger more scrutiny or a root-cause analysis?

CC: You know, I think that depends on the organization and what they're looking at. I believe in the root cause and process improvement methodology of quality control. Why did this error happen? Because if one person can do it, is it something that another person could do as well? I don't know that this is global systems thinking and it’s really going to be down to the individuals in those leadership positions. I learned root-cause analysis when I was the Director of Clinical Services at MedStar (Mobile Healthcare) in Fort Worth, Texas. Whether you call it root-cause analysis, whether you call it five whys, whether you call it seven deep, you've got to be able to figure out the “why” when you’re looking at errors in clinical care to ensure that we can teach what happened and determine if we need to tweak our processes. Remember, we develop processes, but we don't really know how they're going to work in the field until they work. And then when an incident happens, we don’t know if that's a one in a million occurrence or if it is something that happens one every hundred times. All that’s to say there's nothing in EMS, in general, that says that you should use a root-cause analysis and then a process improvement when such and such an error occurs. Leadership may be assessing challenges in their processes every year to 18 months, but a lot of the time the mentality will be, “if it’s not broke, don’t fix it.” To make sure that we do have those best practices in place, I think that that's where process improvement should come in. But again, it's not global.

KH: Are there any specific types of event reporting systems that are used uniformly across EMS?

CC: Really there's not and there needs to be. Not only, as I mentioned earlier, do I have to make sure that members of my organization are tracking any patient safety errors, but I would like to know what the percentage of falls are in my career field, what the percentage of medication errors are in my career field. What is an average rate? Right now, it's hard for me to transform my organization into a culture that is going to report, but it’s even harder to transform a whole career field. I think that it really has to be a third-party reporting system because we just can't pull that data. There are some states that may have some type of trauma reporting, maybe it could be part of that same system?

KH: Like a registry-type system? Are trauma registries or any registries that may interface with EMS used for looking back at care?

CC: Usually the trauma registries are really just to determine the amount of trauma and what's being done to treat the patient. I think what that does is push a care plan if there are state protocols in place. It also allows the people that are in lawmaking positions, for EMS, for example, the state Office of EMS Management, to look at that data and say, “how do we need to change?” But these registries could and should capture everything for EMS, not just trauma. It should include employee and patient safety issues. But then if you have too many registries, is it just going to lead to that complacency of people not wanting to get involved in that process? But it has to be done.

KH: What do you see as next steps for this area, whether it's the Just Culture or reporting as a way to support the Just Culture, or vice versa?

CC: I think that there really has to be some globalization with EMS associations and EMS state officials. Over the past year, one of the great things that this pandemic has done is it has brought continuity between all the associations in wanting to make a difference in working within the pandemic. For the first time that I can remember in, you know, 30-some years, the leaders of those associations are actually at the table together and working on issues that affect EMS in this time of pandemic. That relationship needs to continue. This was a great lesson for all EMS associations and all EMS leaders, and it enables us to say that we need to be at the table to talk about things like patient falls, and employee safety, and assaults, and we need to work together to fix these issues. Until there's some type of EMS entity that is going to move globally, it's really going to be organization-dependent, or state-dependent, and that's really not what we need. We need it really to be a global movement. Until somebody with a big network can come and lead the charge for working out how we track data and then develop that tool, it’s going to be hard to change. However, that's the thing too—just because you develop a tool, you’ve still got to get people to use it, to use the reporting system. That's where the education comes in.