Highly Reliable

I decided to change the opening to this blog after flying this week and experiencing probably the worst commercial flight I have ever had the opportunity to participate in. It got me thinking more about this blog- systems thinking, resiliency, and working to create highly reliable organizations must be the standard in any 24/7 operations these days. One minor issue led to another, creating more and more problems during my failed attempt to fly back to the East coast this weekend. One person getting angry leads to another getting angry, and while there may be some entertainment in watching polite society breakdown via multiple systematic failures converging upon one another…I don’t want to be trapped on a plane with those folks when it happens. There are just too many variables at play; staffing and supply chain issues seem worse than ever, on top of COVID and all the havoc that is causing. Getting back on topic, I had the idea for this conversation before my flight experience after running a call that was based on our county’s worst response fears, which had wild success due to planning and the concept of a highly reliable organization 

Safe operations are a social construct. To me, that means we either go out of our way to make that cultural change, grow it, feed it, and demand it… or we don’t (Rochlin, 2010)

The Black Canyon of Gunnison is known for its deep, near-vertical walls, with depths ranging from 1820 to 2,722 feet deep at Warner point. The Gunnison River runs through the middle of the canyon and is known worldwide for its gold-medal waters full of trout. Tourism is a key industry here and brings inexperienced mountain drivers, trailers, and a vacation mindset. It is a risk factor that those of us who work in public safety here locally really consider a risk factor here. Being in vacation mode is probably something I am just as equally as guilty of being in, so don’t take anything I’m saying too personally. To compound the potential nightmares of the folks driving off the highway that rims the Black Canyon, major construction on Highway 50 for the next few years, thus forcing more drivers onto the narrow, curvy, two-lane highway. 

This past summer, we had the event we knew was coming, and luckily, we have embraced the concept of being a Highly Reliable Organization (HRO) and had prepared for a similar event. I was on my way home from my part-time job. I happened to get roped into responding as the EMS supervisor to a vehicle over the edge, with entrapment, at the bottom of the canyon, with the added element that all the sagebrush was on fire around the car. Fire and EMS responded from town, and it takes a solid 20-25 minutes going emergent to get to the location.  We are lucky to work side-by-side with the National Park Service, and their LEO and climbing Rangers repeatedly make hugely positive impacts on calls we run with them. 

A long-story-short, we eventually got short-haul assets moving to make the framework for the safest response possible (to include CO Helitack assets, Federal short-haul capable platforms, and our local HEMS agency) local and federal wildland fire, NPS Ranger, and our EMS team were able to abseil to the vehicle. We even had boats in the river to provide additional intelligence gathering, safety, and a means of rescue/retrieval from the Park service. Our preplan worked so well, CDOT showed up to direct traffic on that narrow, curvy road, which was full of campers and RVs. The plan worked out well, and, probably for one of the first times ever in my career, the after-action included documentation that communications between all teams with ICS went well. How often is that the first thing noted as not happening during a hot wash or after-action post a call? I’ll put money on that communication breakdowns are top items brought up during an after-action. 

Highly Reliable Organizations and the concepts and framework behind the title are not new. They were new to me when I first started with my current agency, and I think many other pre-hospital providers have not heard of this concept. I truly believe that embracing and applying it to the agency, or even yourself as an individual, can create vast amounts of positive change, systems thinking, and overall better operations. HROs operate under the concepts that systems thinking drives operations and how safety challenges are met: this can range from a complex, over the edge rescue to managing a vented patient during transport, to how we park our vehicles on scene. Safety issues are dynamic issues, new ones can emerge at any time, and no two things are alike… and failure to think this way embraces potential doom (High Reliability | PSNet, n.d.). 

Characteristics of HROs include the following concepts:

  • Preoccupation with Failure
    • I have long said our jobs in pre-hospital medicine set us up for failure, and we have to figure out how to come that set up over. 
    • Near-misses are chances to learn.
    • Lack of failures means we have the chance to look out for new and emerging threats.
    • Minor issues are watched and discussed, so they don’t lead to larger ones.
  • There is a reluctance to simplify.
    • Systems thinking is applied to everything. Nothing happens in a vacuum.
    • The complex nature of pre-hospital medicine is embraced: teams, systems, networks, and how dynamic their processes are all come into decision-making processes. 
    • Standardization in work processes and equipment is embraced because of the acceptance of the dynamic nature of pre-hospital care. 
  • High awareness/Sensitivity to Operations
    • The idea of Big Picture, Situational Awareness, or the Context of the matter of the operational situation 
    • When making safety or operational decisions, seeking to understand how the context of the issue fits with the bigger picture or other systems is always considered.
  • Experts Matter
    • The people closest to work know the work the best
    • The person who knows the subject/risk/issue the best may not be high ranking or even new to the agency. 
    • Everyone is expected to share concerns, and all team members are expected to be concerned about potential safety problems and speak up if needed.
  • Becoming resilient and maintaining that status is a driving factor.
    • The team has a fundamental understanding that there are unpredictable fundamental failures in pre-hospital care.
    • The team can rapidly assesses and respond to challenges.
    • Teams are proactive and seek to learn forward, solving problems while they are small or before they can be become bigger by being left unchecked.

In terms of my department directly, we had many lessons learned based on our internal conversations. One of our discussions showed that we were slacking hard compared to fire in terms of accountability. It was hard enough to know where my crew was at all times since I could not see them over the edge from where the CP was, let alone keep track of all the other players on the scene, as we were trying to hold accountability for our CDOT, LEO, State, and Federal air assists too. This prompted some quick training to our staff to reemphasize why ICS matters and how we were adopting ICS tags on each of our units again. 

Another prominent recognition we had was our delay in getting down to what may have been a rescue and not a recovery. This sparked discussion on increasing the frequency and quality of our rope rescue training and improving our depth in that area. We do not do it often enough, and we need to do it more. This is a long-term change and budget-driven, so plans were made to address this gap. 

In the short term, we made significant changes to how we approach the medical equipment that we take in the backcountry or over the edge. In the past, we had a medical backpack that crews would fill up with whatever they felt they might be needed on the call. There was no standardization, and unless you were there when the bag was packed, you had no idea what the crew took and often came back to a stripped ambulance. 

Embracing HRO principles, we put together a team of our most experienced backcountry providers to pick a new pack, develop its contents, and roll it out with training to our crew. We paired down gear and supplies based on current best practices, realistic capabilities to provide care in the backcountry, and what we were comfortable doing or not doing in a very resource-limited environment. We heavily addressed things like hyper and hypothermia management, limiting things like how much IV fluid we’d bring, and made some distinct decisions on airway management and medications we’d carry. 

All this came out from a direct HRO framework and let us find the problems we had. Let’s throw our experts at it and embrace it in a way that we can mitigate negative events and seek new ways to fix problems. Being upfront with things you did wrong is hard, and it’s a hard change to embrace, but it entirely changed how we approach our planning and debriefing of calls. Try it out; an HRO concept might just be what you are missing. 

High Reliability | PSNet. (n.d.). Retrieved September 24, 2021, from https://psnet.ahrq.gov/primer/high-reliability

Rochlin, G. I. (2010). Safe operation as a social construct. Http://Dx.Doi.Org/10.1080/001401399184884, 42(11), 1549–1560. https://doi.org/10.1080/001401399184884

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