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We’re changing the way we look at driving incidents, and it’s an important step change for St John Ambulance. Last year, we received a number of Freedom to Speak Up concerns about the way investigations into driving incidents were being handled.
In taking an in-depth review of each case, we discovered some organisational areas of improvement around our processes, our approach to investigating and how we see driving incidents in St John.
Earlier this year, we launched the Driving Investigation Procedure to provide a structured approach to incidents and to change the way they’re seen across the charity. This included launching several CPD sessions on what it was that we got wrong and how we plan to improve with the help of our people.
So, what changed?
We’ve moved away from driving investigations being a punitive measure, towards an ethos of learning and improvement. A real step change within driving standards to shift from a blame culture towards a just culture based on five core principles to ensure transparency, accountability and fairness. With that, there is now an understanding that incidents are generally a product of our culture and are rarely brought about by the people directly involved.
An organisations culture is a powerful force. It’s made up of the basic values, norms and beliefs that characterise ‘the way we do things around here’ and it persists through institutional change, restructures and departure of key personnel.
Fundamentally, organisational culture underpins the assumptions that our people make as they go about their day-to-day activities and it’s generally the day-to-day stuff that goes wrong. I regularly speak to leaders in the emergency sector who recognise and acknowledge this is the case for driving, but often do very little to tackle it. Driving standards are a complex beast and knowing where to start can be tricky.
Human error is inevitable, as leaders we have to accept that! Our policies, processes, training and other interfaces need to be continually monitored, adapted and improved in order to accommodate those errors. Incidents can therefore be seen as healthy; they help us learn and grow stronger which is why people shouldn’t be punished for simple mistakes or errors. We do, however, also have to be realistic. Sometimes people do knowingly violate processes or policies and in those instances, people should be held accountable for their actions.
How do we change a culture?
In the CPD sessions, I wrote to support the implementation of the new procedure, I used emotive case studies from occasions where we had got it wrong in the past, how it was raised and most importantly, openly acknowledged that the culture needed to change. The sessions were delivered to groups of around 30-45 people who were invited to share their experiences or ask questions at the end of the session and in fact, more time was allocated to facilitating conversation. Most people were content listening, while others felt they needed to be heard and we made sure those people were heard.
To help get the balance of a just culture right, we use a modified version of the Defence Aviation DA FAiR 2 model at the outcome of an investigation to assess the intent behind someone’s actions. The flow chart (below) is readily available for our people to read, and is used to analyse the facts and to provide a starting point for what action, if any, should be taken. It is purposefully designed to always fail in the favour of the person being investigated – that is to say if we cannot conclusively answer ‘yes’, the question has to default to ‘no’. We then apply two tests.
The first is the ‘situational test’ (also known as the Bolam test), where we ask whether a similarly trained, competent and motivated person would have behaved in the same way under the same circumstances. If the answer to this is yes, then we have to acknowledge that their actions were likely reasonable for the situation they were in at that time. This doesn’t mean they get away with dangerous behaviour or intentional breaches of our policies though, it just helps us with decision making and whether it would be sensible to reduce the level of accountability.
The second is the ‘routine test’, which seeks to ascertain if that type of incident happens often or has happened before to either the individual or the organisation. If the answer is yes, then it is likely that we haven’t done enough to manage the situation to prevent recurrence unless there is an obvious behavioural issue that seeks to go against measures in place.
Every end point on the flowchart has a clear and concise definition with a table of suggested interventions. Some recommend no disciplinary action but educational and other supportive measures to help the person improve whilst others require educational pieces to run alongside the disciplinary process. In any case, we’re looking to create an anonymised library of incident reports for our people to be able to read in their own time.
Initially, I was really nervous about how this procedure would land, and whether it would meet resistance or objection. While it initially raised some eyebrows and there are some who are still sceptical about the changes, the procedure was implemented successfully and has been well received by our people. Our approach is widely regarded as a positive step forward with colleagues from across the sector who are using it to review their own processes and policies.
Changing a culture isn’t an overnight evolution. The changes we made were a result of the freedom to speak up mechanism, months of review, procedure design, adopting approaches from other industries, testing processes, consultation and feedback before implementation – that all takes time.
Now though, we have to put our money where our mouth is. We’re training new people to assist in this space, ensuring we stick to the procedure, quality assure the process and publish learnings as we go. We’re building trust and ensuring our people are empowered to adopt a reporting culture whilst we demonstrate adopting a learning culture. All this alongside holding the organisation and individuals to account against transparent processes, where appropriate.
Since launching, we’ve seen an increase in incident reporting, along with feedback on positive experiences, indicating people are more comfortable about reporting minor incidents. We’re now identifying trends which are being fed into the training we deliver and regularly publish articles and newsletters on our internal networks to highlight common themes and what drivers can do to prevent recurrence.
We will continue to monitor our processes and will be using investigation data to supplement the validity cycle of our policies and procedures. I’m incredibly proud of the impact this is having and strongly believe in the change we’re making.
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