SafetyMatters

JULY-SEPT 2013
SafetyMatters
A quarterly, collaborative Newsletter
from MedFlight and HealthNet
Aeromedical Services
As recognized leaders in the critical care transport industry, MedFlight and HealthNet Aeromedical
Services look for new ways to approach common challenges. By sharing information and expertise,
both programs are made stronger. Operational safety is a preeminent concern and is no exception.
Through the consolidation of the MedFlight and HealthNet safety departments we are given the unique
opportunity to learn more, share more and experience more and both programs will benefit. One of the
first tangible signs of this process is the fresh look and reach of the quarterly SafetyMatters newsletter.
each issue will be distributed to both programs as well as to peer programs across the nation. In this
regard, our focus on safety will extend well beyond the reach of our respective service areas.
Working together for common good is simply the right thing to do. we are pleased that MedFlight and
HealthNet collectively set a high bar for others to reach for.
Rod Crane, President and CEO
MedFlight
Clinton Burley, President and CEO
HealthNet Aeromedical Services
The State of HEMS
By Colin Henry
Vice President of Safety
MedFlight
Since December 2012, there have been 11
Helicopter Emergency Medical Services (HEMS)
related accidents in North America. Of the 11
HEMS accidents, 6 were fatal and 16 persons
perished.
From year to year the amount of accidents and
fatalities have varied. Some years have been better
than others.
However, for the past 20 years the amount
of fatal HEMS accidents have been on the rise if
you separate the accidents in 5-year increment
periods. If 2013 continues its trend we could
surpass the last 5-year period 2004 – 2008. As
of June 2013, the period 2009 – 2013 has had 16
fatal accidents.
Since December 2012
THIS ISSUE INCLUDES:
Since 2006
• The State of HEMS
• Using “Soft Skills” to Manage
Risk in EMS Operations
• Beware “Early Commitment”
• Material Safety Datasheet Information
• Safety Communication
Contact Information
• Managing Risk When Faced with Management of Change
Fatal Accidents from 1989-2008
Using “Soft Skills” to
Manage Risk in
EMS Operations
By Colin Henry
Vice President of Safety
MedFlight
Impact of Safety Measures 1989-2008
To date the aircraft Part 135 operators have done a great job in
implementing these systems and recommendations in their companies. We
however still have a long way to go for the accident count has not reduced. I
am intentionally not using a rate, but a count. We must design a strategy and set SMART goals to reduce this fatal
accident count. A true Safety Management System (SMS) that is working at
the “sharp end” should show signs of an engaged safety culture, a thorough
understanding of human factors, some form of flight data monitoring and the
implementation of lessons learned derived from data-driven safety cases.
These true cases can then be used in simulator-derived scenario-based
training that includes all crewmembers, pilots and medical crew members. HEMS Safety extends to on scene operations
In this article the term “soft skills” refers to the use of Air Medical Resource
Management (AMRM)/Crew Resource Management (CRM), Threat and Error
Management (TEM), Risk Assessment and Culture. The day-to-day safe
operations of emergency medical transports are dependent on these skills.
We spend significant time teaching pilots on the skills required to fly aircraft,
and
medical
crew members
on the clinical
skills required
to perform their
jobs.
These
are necessary
skills that are
required to be
met in order
to function in
our positions.
We do not however spend as much time on “soft skills” training. These are
the skills that we should have that are not directly required in order for us to
function in our positions. In these “soft skills” we will find those incidents and
accidents that have a human factor relationship. These are errors that have
occurred because one forgot about a procedure or process that they know,
have blatantly disregarded a procedure, or did not have the knowledge to
handle the task at hand safely. Sometimes these appear in a National Transport
Safety Board (NTSB) final report as controlled flight into terrain (CFIT), loss of
control (LOC), pilot error, pilot failed to ….. etc. These accidents all have some
elements of human factors that were never known or understood by those
who were affected. Air ambulance accident statistics from 1988 to 2000
have shown that 64.7% were pilot/human related. Experts say that today this
number is around 90% in the air medical transport industry. This is an attempt
to show that the skills mentioned are very important to the safe outcome of
emergency medical service (EMS) operations.
AMRM is a derivative of CRM that gained momentum in the air medical
industry around the mid-nineties. It is defined as a method of making optimum
use of the capability of the individuals and the systems in an aircraft to achieve
the safest and most efficient completion of a flight. Air medical companies felt
that there was something missing from their training curricula after there were
some accidents with very experienced and highly trained pilots. Although
some companies brought some form of aeronautical decision-making
training to their pilots, that information was usually not shared with medical
crewmembers and communications specialists. The EMS industry knew that
there was something missing that did not require solely flying the aircraft.
Some EMS operators researched practices at airlines to see what they were
doing differently. We found out that some had an active CRM process in place.
© Mark Mennie
Through these years the NTSB probable causes and recommendations
have introduced to HEMS: Night Vision Goggles (NVGs), Helicopter Terrain
and Awareness Warning Systems (HTAWS), Safety Management Systems
(SMS), Autopilots, Simulator Training, Traffic Alert and Collision Avoidances
Systems (TCAS).
© Mark Mennie
The CRM training
in the classroom
had transferred
into the cockpit.
CRM
was
a
working tool that
was
standard
practice. Some
air
medical
companies even
sent
personnel
to the airlines
to learn about
CRM. After some
years of use in the air medical industry by both pilots and medical crew
members, an advisory circular was published in 2005. This was the Federal
Aviation Administration’s attempt to focus this training for all air medical
service operation team members such as pilots, medical crew members,
communications specialists and maintenance technicians. The air medical
industry was introduced to human factors related training at all levels. The
AMRM training covered several human factors related accidents and spent
time discussing assertiveness, communication, team building and situational
awareness. We now recognize the importance of reinforcing these principles
through recurrent training and feedback. Some later training modules of
AMRM have introduced other subjects such as complacency, stress and
management of change.
Around the mid-nineties Delta Airlines collaborated with University of
Texas to study the effectiveness of their CRM process. This collaboration
was instrumental in the introduction of threat and error management (TEM)
principles in the airlines and the introduction of a line operations safety
audit process. Some airlines and some hospital systems have actively
employed TEM since it is a countermeasure for AMRM/CRM. The TEM
countermeasures are planning, execution, and review/modify. For example,
these countermeasures can be used
to evaluate effective communications
in flight. The skills learned in
Helicopter
AMRM training can now be more
Emergency
recognized and any inherent threats
Medical Services
and errors managed effectively.
This is done by using threat/error
(HEMS) operate
management tools and procedures
in a demanding
to prevent active failures and latent
environment.
conditions. We want to employ hard
and soft safeguards such as night
vision goggles, helicopter terrain awareness warning systems, checklists,
standard operating procedures, etc. We must take these safeguards that are
put in place and effectively manage their inherent threats and errors using
the principles of anticipation, recognition, and recovery that are thought in
TEM training. MedFlight has actively employed these principles in its day-to
-day operations and HealthNet is beginning to do the same. We have been
teaching the importance of hard and soft safeguards and the recognition of
mistakes (skilled-based, rule-based and knowledge-based) that all humans
make. Our reporting system allows for threats and errors to be reported and
to be effectively managed and shared with all partners through cases and
lessons learned. We have expanded AMRM theories into workplace realities
with emphasis on our human characteristics. We are also now in a position
to audit and measure significant threats and errors in the workplace. This is
accomplished through the line operations safety audit (LOSA) process.
In 2006 the FAA published a notice that addressed risk assessment.
They established the fact that “helicopter emergency medical services
operate in a demanding environment.” They went on to say in their FAA
Inspector Handbook that “risks must be identified, assessed, and managed
to ensure that they are mitigated, deferred, or accepted according to the
operator’s ability to do so within the regulations and standards appropriate
to the operation.” This concept has forced Part 135 operators to implement
some form of risk assessment/risk intervention procedure. MedFlight and
HealthNet use a risk assessment tool for both ground and air transportation.
We are offering a contingency management plan to our partners so that
transport strategies can be proactively accounted for and anticipated threats
better managed. Research and experience has shown that these types of
contingency planning can account for fewer errors and in some cases even
fewer mismanaged errors. Used effectively the tool also allows any program
to effectively manage and measure risk in their day-to-day operations. This
process has been around for years in U.S. military operations.
None of the items mentioned will work unless your company/program has
the right safety culture in place. Dr. Robert L. Helmreich, a well known human
factors expert says, that “culture represents the values, beliefs, and behaviors
that are shared by members of a group.” Without the right culture, people will
never hear the message nor will they be willing to comply with procedures
or practices. This is where a company will see a large amount of procedural/
rules-based mistakes. For example, checklists will not be used effectively
nor will standard operating procedures be followed. The company’s Chief
Executive must set the stage for the right safety culture by first establishing
a Corporate Safety Culture Commitment policy. This message has to be
communicated effectively to all personnel in order to lay the foundation for
any specific safety culture such as a “just culture.”
“Just culture” is an environment/culture/understanding of how acceptability
of individual behavior is to be determined and how accountability is evaluated.
It is shared responsibility and a balance between human factors, individual
practices and system issues.
“
Some advantages of a “Just Culture” are:
•
•
•
•
•
Its value to both justice and safety.
It is good for company morale.
It shows how people are committed to the organization.
It gives people job satisfaction.
It allows those persons who are willing to do that little extra to step inside that role.
“Just culture” adapts a systems view to errors and mistakes:
• It sees human error as a symptom, not a cause.
• It sees human error as an effect of trouble deeper inside the system.
• It turns to the system in which people work. For example, the design of equipment, the usefulness of policies and procedures, the existence of goal conflicts and production pressures.
Collectively we strive for a “Just Culture” and have implemented this
culture in a Safety Management System. We measure the progress of this
culture annually for it is very important for the success of safe outcomes.
“Just Culture” and TEM has had increased popularity in both aviation and
healthcare. All of these “soft skills” mentioned should be a part of a company’s
SMS in order to manage risk at the highest possible level.
“
Beware
“Early Commitment”
By Tony Kern
This article first appeared and is published with permission by Vertical Magazine
BEFORE I START a
gender war with the title for
this column, let me briefly
explain what I’m talking
about. First responders are
notorious for their drive to
accomplish the mission.
Normally, this is a good thing,
but not always. As missionoriented professionals, we
can be at risk of succumbing
to a nasty little gremlin
called completed bias, the
overwhelming drive to “finish
the job.” While maintaining a
forward leaning posture, we
must recognize and counter one of most dangerous hazard attitudes first
responders face every day – impulsiveness.
Impulsiveness is when a situation (or person) urges action before collection
and analysis of all available and useful information. When we make an early
decision to commit to a specific course of action, we cut our interval for input
and analysis, and thus short circuit our risk management logic. By committing
too soon, we may not have time to fully understand and analyze the scope
of the challenges we may face. Examples include decisions to take off, to
continue into deteriorating weather, or accepting a marginal landing site.
Often, impulsiveness strikes when we want to exert influence on a situation
that is spinning out of our understanding and/or control. But there are a
few things we can do. The following list is modified from a column by Mark
Dykeman, an IT professional and blogger at thoughtwrestling.com
Before you pull the pin, before you leap off the cliff before you charge into
battle, before you commit to an irreversible course of action…think again and
ask yourself the following questions:
1. Do you understand the situation as well as you should to do what you are about to do?
2. Are you reacting emotionally instead of logically or
professionally?
3. Do you understand the possible unintended consequences of your proposed course of action?
4. Have you told the people who need to know what’s about to happen? Are they fully briefed and in agreement?
5. Is this something you need to do – or simply want to do?
6. Is there a better way?
If you answer “no” to any of questions 1-5 and “yes” to question 6, maybe
you’d better stop and think again.
There are many problems associated with premature commitment.
Depending on your level of familiarity with the task at hand, you may not
have adequate experience or knowledge to support reliable intuitive decisionmaking. Your premature actions may proceed through a one-way decision
gate with no “out.” Don’t put yourself into a self-induced time-pressure event,
which research indicates is one of the first steps in lost situational awareness
and controlled flight into terrain mishaps. Finally, an early decision to “go for
it” negates team inputs and supervisory or peer intervention or assistance.
CHECKLIST FOR RECOGNITION AND
PREVENTION OF IMPULSIVENESS
•
•
•
•
•
Keep a “beginner’s mindset,” by respecting all situations as potentially risk-laden, no matter how routine they seem. Evaluate multiple options as a matter of routine.
Ensure adequate planning time to think through and brief multiple scenarios.
Encourage actions that will “buy time” instead of reduce it.
Seek all available information before deciding on a course of action.
Stay in a conservative mindset until planning and analysis are complete.
To a certain extent, managing hazardous attitudes like impulsiveness is a
skill like any other, and the more you practice, the better you become, You
may not be able to control many things in your first responder mission, but
you can control your attitude and account for personal bias. Armed with this
skill set, you will make fewer errors in the heat of the moment. You will work
smarter and fly safer.
In the never ending battle against human error, it is not always external
factors or mission demands that cause us to err, but rather an internal mindset
that turns us into our own worst enemy. As we go through our daily workplace
challenges, our attitudes change based on our experiences, training, the
situation and the people we live and work with. With some introspection and
insight, we can teach ourselves how we, as individuals, recognize and react
to various high-risk situations and scenarios. Remember, the only decision
that is ever truly final is the one that puts you in the grave. Let’s not be too
impulsive and delay that one as long as we can.
HealthNet Aeromedical Services and MedFlight jointly maintain
an online database of Material Safety Datasheet information.
Here is how you can access it:
HealthNet access instructions:
•
•
•
•
•
•
Log into HealthNet WorkPlace
Click on Document Room
Click on Safety
There you will find a link to 3eonline
Log onto 3eonline – username: mfoo, password: msds1
(both all lowercase)
Once in, select your base and then enter a search for the name of a specific chemical or browse entire MSDS list.
MedFlight access instructions:
•
•
•
•
Log into MedFlight intranet
Click on safety tab
Find “msds lookup” on left hand side of page and click the link
Log into 3eonline – username: mfoo, password: msds1
(both all lowercase)
Once in, select your base and then you can enter a search for the name
of a specific chemical or browse entire MSDS list.
Managing Risk When
Faced With Management
of Change
By Colin Henry
Vice President of Safety
MedFlight
Management of Change (MOC) is a system for managing operational,
organizational and installation changes that require effective communication
with the personnel affected. A systemic approach should be implemented
in order to efficiently identify safety issues that can cause inherent risk in an
organization. It is essential to identify goals, objectives and the nature of the
proposed change and to gather the right personnel in place for your task
force. This will help you determine how the proposed change will be screened,
reviewed, approved, and implemented.
Changes that need
to be reviewed
Screening Process
Approval Team
Do work under
normal authority
No
Initiate MoC
procedure?
Yes
Proposed Change
No
Do work under
normal authority
Yes
Analyze for MoC
change effect
No
Yes
New Type Vehicle
Task Force/Exec. Com./Board
Design Change
Task Force/Exec. Com./Board
New Equipment
Task Force/Exec. Com./Board
New Operations
Task Force/Exec. Com./Board
Change in Operations
Exec. Com./Board
Facility Change
Exec. Com./Board
Geographic Loc. Change
Exec. Com./Board
Do work under
normal authority
To further break it down, organizations may also have a MOC
experience if:
•
•
•
•
•
•
•
•
They have a change in vendor, i.e. Part 135 operator;
There are aircraft or ground vehicle changes;
The current software and electronic systems have changed;
The current staffing levels have changed;
There are changes in some operating limitations in the workplace;
Procedures change;
Changes occurring in the facilities/infrastructure: or
When an acquisition or merger takes place.
The “naysayer” may say such things as; we tried that before, our place is
different, it cost too much, we don’t have the time, it’s too radical a change, the
staff will never buy it, etc. This behavior is attributable to the significant emotional
experience that MOC brings with it. It is not uncommon for employees to
experience shock/denial, anger, grief, and have a hard time experiencing this
change intellectually or emotionally. Employees may even want to bargain and
prove why the change is not necessary. Executive leadership must then seize
the opportunity to establish a sense of urgency by forming a guiding coalition
such as a task force to help create and communicate the company’s vision to
the workforce. If this is a major project, we may just be able to achieve short
term wins but we must plan for them. Modifications may have to be made
after improvements are consolidated. Sometimes new approaches may be
required. During this MOC experience the “door is open” for certain business risks
due to technology changes, competitor actions, material shortages, health
issues, safety issues and environmental issues, etc. On the insurable side
there could be property damage, indirect consequential loss, legal liability and
personnel injury. So we must proactively design a risk management approach
to minimize and manage risk during MOC. Our risk management approach
should look at the reason for the change in order to determine what safeguards
need to be in place in order to minimize risk. It is very important to identify the
stakeholders or parties affected by the plan early. These stakeholders may
include EMS, hospitals, employees, suppliers, vendors (Part 135 operator),
management and the community (neighborhoods affected, etc.). Always
involve representatives from all work groups such as task forces/transition
committees in the risk assessment of the changes. Lastly, develop a written
work plan/project management plan that clearly specifies the timeline for the
change and the control measures to be implemented.
The written work plan/project management plan should be reviewed
and special attention given to its:
Implement Work
Processes
Organizations may experience MOC because of strategy, technology,
structure or personnel. For example:
• Strategic changes occur when the company shifts its direction and
resources toward new businesses or markets;
• Technological changes occur when the company decides that
automation or modernization of key processes are essential for
overall competitiveness;
• Structural changes occur when the company undergoes a management
de-layering process, or goes from a functional structure to a product
structure; and
• Personnel changes occur when the attitudes and behaviors of
personnel are undertaken through organizational development
techniques.
•
•
•
•
•
•
Work Breakdown Structure
Communications Plan
Risk Plan
Stakeholder Register
Resource Calendar
Gant Chart/Activity Schedule
This will give you a good feel for the set plan including the schedule/timeline
and the initial risk identified. The communications plan will help us design a
plan to communicate with our stakeholders and thus make this a true quality
process. We have to assume that this is a major change for all stakeholders
including employees. The risk plan is comprised of a risk register that lists all
of the inherent risk identified and its impact in term of high, medium or low.
This risk can then be computed using a risk assessment matrix (RAM) and the
project risk factor can be computed as the sum of all risk factors Σ{(probability
of occurrence) x (severity of risk)}. The mean, median and mode of the project
risk factor should be reported at every task force/transition meeting in order
to get a feel for the current risk at stake.
The risk management process is not over after the project is completed.
We are now subjected to practical drift! This is a deviation from the intended
baseline performance of our system due to the changes that were made.
We have changed some ways so we have to make adjustments for those
changes. Policies, procedures, training and equipment may tend to deviate
form their intended functions/objectives. It is expected! Going forward, we
must now identify any new threats due to these deviations and mitigate them
by using problem solving, process development and process improvement
techniques. Some areas that may need to be investigated are:
•
•
•
•
•
•
•
Safety Culture
Has your culture changed from the normal custom?
Safety Standards
Are these still safe or have these created unsafe conditions?
Policies and Procedures
Are some policies and procedures now obsolete, irrelevant or
hazardous?
Operating Requirements
Are some operating requirements now above limitations, no longer
within limitations or just hazardous?
Human Resource Requirements
Are there any restrictions or personnel requirements that need to be
addressed?
Marketing Requirements
Are there any new requirements on our external customers?
Training
Identify and conduct the required training generated
from the change!
Most of these threats can be identified through the Safety Reporting system
and Internal Evaluation Program (IEP)/audit system of an effective Safety
Management System. A threat register can then be compiled and most of
these threats can then be managed or mitigated. However, in order for risk to
be managed effectively when faced with MOC, your Safety Culture, Reporting
System and IEP must be continuously working and active. As a general rule,
audits should start as soon as possible after a project is completed. The intent
is to identify any practical drift and to proactively identify any deviations that
are hazardous or could eventually become hazardous. We must be cognizant
of the fact that sometimes an unrealistic timeline may cause deviations. We
must also be aware of the importance of maintaining the Safety Space.
We must balance production and protection and continuously navigate
in the Safety Space by using reactive and proactive measures. It will take
commitment, competence and cognizance by all stakeholders involved in the
MOC experience. Lastly, communicate the changes to all stakeholders!
QuickQuote
By Jeff White, BA, MCCP
Safety Officer
HealthNet Inc.
Safety
Communication
Contact Information
MedFlight
1. VP of Safety
2. VP of Risk
3. Infection Control Officer
866-745-2445, 614-734-8047 or
chenry@medflight.com
614-734-8027 or lhines@medflight.com
614-734-8041 or
jhedderman@medflight.com
Intranet Website Resources:
• Safety Awareness Form – the link to the form is located under the
Safety section
• Unusual Occurrence Form – the link to the form is located under the Forms section then under Crew resources
• MedDebrief system – the link is found under the quick links on the intranet and is automatically activated after a medical transport HealthNet
1. Safety Director
2. Safety Officer
3. Infection Control Officer
614-204-1265 or
colin.henry@healthnetcct.com
304-610-3666 or
Jeffrey.white@healthnetcct.com
304-553-5274 or
amee.douglas@healthnetcct.com
Intranet Website Resources:
TAMMA – the link is found on the portal under Flight Team/ Communicators
As HealthNet and MedFlight journey through this first year of combined safety operations, we struggle with change
and challenge. I ask everyone to remember the great Alabama coach Paul “Bear” Bryant. Bear is now known as one
of the greatest coaches in college football history; many coaches try to follow standards he set. Bear’s first season
at Texas A&M he went 1-9, his first season he went 5-4-1 with a team, that of the 58 on the roster 13 went to the
NFL Pro-Bowl and/or Hall of Fame. This seems pretty dismal for one of the greatest coaches in history, how did he
achieve this?
He achieved it with this simple philosophy: “We will relentlessly pursue perfection, knowing we will never reach it,
we will relentlessly pursue perfection and find excellence along the way!”
SafetyMatters
Do you have any ideas for SafetyMatters?
Let us know by emailing colin.henry@healthnetcct.com or chenry@medflight.com