Our team embarked on a mission for better front-line staff engagement, especially with operational issues that impact the job they do. Leadership based on strong core values and inclusivity when implementing several very significant changes to the front-line operations that directly affects the paramedics staff.
The operational projects that were simultaneously undertook included implementation of an electronic asset management and inventory control system, design and implementation of paperless mobile documents management, new and safer uniforms, and new paramedic response bags.
The truly challenging and game changing project was the paramedic response bag project since this was done in a manner that was not typical of most purchasing projects within municipalities.
We set out with a hypothesis that we could improve patient safety, paramedic satisfaction and efficiency of use in rendering life saving procedures. Have a look at the old setup:
This was obviously a project that had high impact on front-line paramedic work, a relatively high cost, and potential for significant impact in two important areas: Patient safety and Paramedic safety. This was a prime opportunity to engage the paramedics to find innovative ways to make the service safer while affecting the equipment that they use on every single call they attend.
The project was planned with a detailed timeline and specific bench marks. The idea was to eliminate the typical barriers and present the paramedics with a question. What if we took the manufacturers off-the-shelf products out of the picture and you could design the most ideal set of paramedic bags? Can they be safer for patients? Can we eliminate drug errors? Can we make the call flow smoother and quicker? Can we make them more ergonomically safe?
These questions led me to research the field of Human Factors and Ergonomics. Coincidentally, I was at a paramedic chiefs conference and there was a guest speaker, a visiting professor from Israel, Dr. Yuval Bitan, who is a former paramedic and working with University Health Network – Human Era at University of Toronto. He was speaking about engaging paramedics in Human Factors in health care research. As soon as he finished speaking I caught up to him walking out of the room and ask if he would be interested in assisting with our paramedic bag project. After explaining our approach, it was evident that was exactly what he had just been speaking about.
We shared our program outline with him and asked for input on how he would see his expertise best fitting with our goals. We reached determination on how it would work and UHN provided a quote and we contracted the professor through UHN to work on the project. The intent of his participation was to meet our goals, but also for us to publish our project as Human Factors and Ergonomics research.
Dr. Bitan was brought to Northumberland Paramedics to work directly with the paramedics who formed our bag project committee. He provided the paramedics with an educational workshop on Human Factors and Ergonomics and then we set them out to design the bags. Dr. Bitan and myself facilitated the design process by presenting scenarios, problems, and reinforcing the educational materials.
The design process included drawings and mock-ups by modifying an existing variety of bags followed by a final specification list. We then invited product vendors through public notice to an open house to display their products. The vendors were provided with the specifications the paramedics had designed.
In addition, the paramedics on the bag committee evaluated the vendors’ products with a set of criteria they had designed with the human factors and ergonomic aspects that they felt were most important in their specification. It was determined that none of the “off the shelf” product vendors had a product that met most specifications that the paramedics had determined. We then drafted a request for proposals for the bags based on the specifications and had custom production vendors respond.
We then selected a successful respondent to our RFP that also specified participation and cooperation in both the design process and research. We worked through several designs and modification until we reached a product state that would be suitable for field trial. We adjusted the design based on feedback from front-line staff that were not involved in the design process and who used the bags in real-life situations. Finally, we went into production.
We broke our project and research down into two phases. The first phase was a narrative publication and presentation of the end-user design process (Bitan, 2015). The second phase was a quantitative and qualitative analysis of the final product (Bitan, 2016). Are there less medication errors? Does a call run smoother and quicker? Are the new bags easier and safer to use ergonomically? Do the paramedics like them better? The qualitative analysis occurred by way of surveys at 3 and 6 months post implementation.
The quantitative analysis was done in a controlled environment with simulated patient care calls done on a high-fidelity manikin. The simulations were controlled by removing the decision-making process and having paramedics begin and end various isolated treatments from the bags based on specific interventions. The scenarios were video recorded from three angles with simultaneous synchronization and then used for analysis. We are in the process of writing the final manuscript for the quantitative analysis combined with a descriptive summary of the qualitative aspects.
In developing the action plan to not only implement a change in front-line equipment but also a change in how front-line staff viewed equipment. The real challenge with this project was to educate all the front-line staff why such a significant change in their equipment was important.
The role out of the new bags was phased in over several months. They were introduced to the theories that the committee was working with to make design decisions in a fall education session. This information was delivered to the staff by the paramedics on the bag committee themselves.
next part included equipment lists and photos in an online e-learning format and then the third aspect was a physical introduction and hangs on scenario practice in a spring education session. Each station in this service has two ambulances per operational unit. One was stocked with the new bag setup and the other stocked with the old. For four weeks, the paramedics had the option to use either ambulance with pending deadline to transition to the new bags in their spare vehicles.
The team dynamics of the bag committee were excellent. During the learning process with Dr. Bitan the team began to understand new concepts and gelled in learning that they were becoming experts among their peers in the Human Factors concepts. A culture shift and cohesiveness developed with the bag committee as a team (Lussier, 2013).
The team was diversified and made up of a cross section of stations, paramedic levels, size, sex and a supervisor. The team split tasks and section of bags to design and came together with their ideas and suggestions. The team work of the bag committee worked quite well however it did not fully reach the level of a self-managed team. The paramedics still looked for guidance and approval throughout the process.
In a leadership perspective, this project approach created a situation that allowed for a relational power base and the ability to empower others (Lussier, 2013). Providing the bag committee with the knowledge and skills to make transformative change and then empowering them to educate the other paramedics presented a situation optimized for larger buy-in of the project. I would like to believe that the manner that this project and equipment change was designed and implemented was based on a stewardship and servant type leadership (Lussier, 2013).
The end user of the equipment are the front-line paramedics. They were provided knowledge through education, empowered to seek input from their peers, provided knowledge to their peers and developed the product that they would use daily. The intention was to serve the needs of the staff as directly as possible. The authority to make the decisions around the change was decentralized, team work was emphasized and everyone’s input was treated as equal with the end reward being the responsibility of the employees (Lussier, 2013). I believe this was implemented quite effectively as well.
Finally, and most importantly, the reason that we approached the entire project and change in this manner is the organizational culture that we adopted internally. Our service underwent what we called a cultural transformation through collaboration. We developed our mission, vision and values as well as a set of guiding principles in collaboration with our front-line staff. We all promised to live by and make decisions based on these values and guiding principles which included caring for the health and safety of our staff, ensuring patient safety, having an inclusive and empowering leadership style, and being innovative in how we implement change. Since we had moved over several years from a low performing culture to a high performing culture, (Lussier, 2013), and we embraced our values in this project we could overcome much resistance to change. In addition, we had developed a strong people oriented organization and had an emphasis on excellence. Both aspects of strong leadership of culture that was successfully implemented in this project.
Overall the change of paramedic response bags was well implemented with many positive leadership factors embraced throughout.
Lussier, R. N., & Achua, C. F. (2013). Leadership: theory, application & skill development (5th ed). Mason, OH: South-Western Cengage Learning.
Brophy, J. R. (2010). Leadership essentials for emergency medical services. Sudbury, Mass: Jones and Bartlett Publishers.
Bitan, Y., Ramey, S., Philp, G., & Uukkivi, T. (2015). Working with paramedics on implementing human factors improvements to their response bags. Proceedings of the International Symposium on Human Factors and Ergonomics in HealthCare, 4(1), 179–181. https://doi.org/10.1177/2327857915041016
Bitan, Y., Ramey, S., Philp, G., & Milgram, P. (2016). Evaluation of Ergonomically Redesigned Paramedic Bags – A Usability Study. Proceedings of the International Symposium on Human Factors and Ergonomics in Health Care, 5(1), 61–64. https://doi.org/10.1177/2327857916051013