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LEADERSHIP BEST PRACTICES | By Sean Caffrey, MBA, CEMSO, NRP ACCOUNTABILITY CAN BE a loaded word. According to the dictionary, account- able means a person, organization or institution required or expected to justify actions or decisions. Accountable can also be described as being responsible and transparent. Ideally, accountability also includes a willingness to admit to and learn from mistakes. Unfortu- nately, however, our culture has mostly turned accountability into a description of punishment. In many contexts, when someone "needs to be held accountable," it's code for someone who needs to be fred as the result of a bad outcome. The challenge EMS leaders face is how to orient their organizations to use accountability as a tool for improve- ment, while avoiding the pitfalls of an organizational culture based on blame and punishment. Accountability Building Blocks The exercise of personal responsi- bility by individual practitioners and their leaders is the foundation of professionalism, trust and credibility that is needed to allow for organiza- tional accountability. Therefore all practitioners must recognize their duty to be skilled in prehospital care and to learn and follow clinical care and operational rules. This commitment demonstrates professionalism. Managers must recognize that they are accountable to those they lead to ensure the systems they develop and the rules they create are logical, well communicated and practical for team members to implement. Furthermore, all members of an organization must be open to examining their actions, admitting their mistakes and working to contin- uously improve systems. To the extent possible, organizations should screen for these characteristics when hiring new members and promoting individ- uals to leadership positions. Building a governance structure of transparency is a cornerstone of organizational accountability. Transpar- ency, however, can be diffcult in public safety organizations. EMS services in particular have a broad responsi- bility to keep the public safe and have signifcant authority to violate traffc laws, enter people's personal spaces and provide invasive medical proce- dures, often at some risk of injury. It is critical, however, that EMS systems do not view themselves as detached or above the public they serve. Account- ability, including regular and accurate reporting to the public, should be built into oversight structures. EMS organizations should report to external authorities outside of public safety that are representative of the community, which may include an independent board of directors, elected offcials or a parent organization. A Just Culture With individual responsibility and organizational transparency in place, the true value of accountability within an organization becomes the ability to recognize and learn from mistakes. To accomplish this, however, requires a recognition by leadership that mistakes, sometimes with bad outcomes, will happen in all organi- zations. These mistakes will have a variety of causes. In many cases, errors will be attributable to the systems and procedures put in place by manage- ment. If managers punish individ- uals for bad outcomes as a matter of course, they will destroy trust within the organization, discourage team members from reporting mistakes and create a blame-shifting culture that will inhibit organizational learning, improvement and excellence. Creating a Just Culture environ- ment is perhaps the best approach currently available to understand errors, treat team members fairly and improve organizational performance. The concept has received much atten- tion in EMS and been widely utilized in a variety of high-consequence indus- tries such as aviation and healthcare. The newly released Strategy for a National EMS Culture of Safety document recognized the concept as the frst of six core elements of a national EMS safety strategy. The National Association of EMTs further endorsed Just Culture in a position statement in 2012. At its most basic, Just Culture is about accountability and fairness. It recognizes that the reporting of errors offers a better opportunity to improve systems. It further recognizes that errors occur and those errors may fall into the categories of simple human error, at-risk behaviors or unjustif- able and reckless behavior. Errors are addressed differently based on their origin and regardless of their outcome. The system only strives to blame or punish when reckless behavior or unjustifable risk taking is the origin of the problem. Inherent in accountability is the leader's responsibility for setting expectations and managing systems. As mentioned above, team members have a duty to follow procedural rules. Building Accountability in EMS What does it mean, and how can we achieve it? "Just Culture recognizes that the reporting of errors offers a better opportunity to improve systems." 24 APRIL 2014 | EMSWORLD.com EMS_24-25_LeaderBP0414.indd 24 3/13/14 2:34 PM