Can Paramedic Services be Learning Organisations?

Change has always been a challenge in paramedic services. Traditional management paradigms have tended to follow more Newtonian management approaches which are underpinned by a traditional scientific approach which sees change as an event. Kurt Lewin’s Three Phase approach, for example has been widely applied to manage change and is an example of seeing change as a specific and isolated event to be managed.

 However, in the modern world, change occurs constantly. One of the challenges for paramedic services is adapting to working conditions which change both over time and location. Environments and communities are unique and have multiple variables which may impact on the provision of health services, including those provided by paramedics. There is inherent risk in operating a service with a static model which is required to operate in an environment of constant change.

 A few approaches can be used to look at ways in which service delivery models can adapt to ever changing requirements. Learning Organisations are a model of organisation which is based on the constant sharing of information to allow organisations to adapt to the environment in which they are operating. Garvin (2008) suggests that firstly you need to understand the building blocks of a Learning Organisation which he outlines as:

1)      A supportive learning environment

2)      Concrete learning processes

3)      Leadership that reinforces learning

A supportive learning environment is fundamentally a change in culture to value the collection, creation and dissemination of information. It is through learning about the context in which the organisation operates that information can be collected to allow the organisation to adapt. Garvin suggests four key elements which support this culture of learning.

Psychological safety: People need to be able to express themselves without fear of being sanctioned if they disagree with peers or authority figures and must be able to be comfortable asking questions and expression opinions

Appreciation of differences: When people are aware of opposing ideas or world views, fresh thinking can result. 

Openness to new ideas: Learning involves crafting novel approaches as well as responding to and correcting issues. People need to be able to take risks to find innovative solutions.

Time for reflection: Reflection is a critical tool for analysis and learning. When work effort is solely judged by production output or time spent, it lacks thoughtful review which can lead to new lessons being learnt.

For example, a number of hospitals and health systems have improved patient safety by firstly introducing “blameless reporting”. As a result, errors and omissions become available for analysis and innovation solutions to patient safety issues have been developed which translate into real impacts on patient outcomes.

Garvin also argues that concrete learning processes are critical. Knowledge needs to be collected systematically to ensure the quality of the data and experience collected. Likewise it needs to be systematically disseminated to maximise the benefit to the organisation. Systematic reviews and reflection are excellent strategies for creating knowledge and analysing it to determined what lessons can be learned.  

 An example of these are the After Action Reviews (AARs) developed by the US Army.  These reviews rely on a clear set of guidelines and objectives which allow events to be deconstructed and lessons learnt. AARs can operate both formally resulting in a report or be done informally, often known as “Hotwashes”. The results of AARs are then centrally collected and knowledge managed through the Centre for Army Lessons Learnt allowing organisation wide access to the review outcomes.

Finally organisational leadership needs to support learning. This is more than leaders setting policy but involves leaders listening to followers and questioning them to show that they value the information which they collect and manage. People in authority needs to accept the cultural principals in the first building block and demonstrate them, including accepting new ideas and supporting creativity.

There are a range of advantages in health organisations adopting a Learning Organisation approach. Firstly a collective approach to learning  provides sustainability as individual members of health organisations come and go. Secondly, learning supports innovation and increases the capacity of an organisation to respond to uncertainty, which is a common challenge in health services (Davies & Nutley 2000).

One may argue that an incremental change paradigm may face significant resistance in traditional service delivery models of paramedic services. However, there have been a number of studies outlining the efficacy of Learning Organisation approaches in both the military and in hospital systems. Learning Organisations do not inherently contraindicate hierarchical leadership models as the military experience has shown but in fact empowers lower ranked personnel and shifts the role of officers into becoming stewards of the learning system (DiBella 2010).

 Paramedic Services face not only incremental increases in workload combined with geographically disparate workload patterns influenced by factors such as local demographics, local prevalence of chronic disease, availability of health services and a wide range of other variables. The use of a Learning Organisations approach would not only allow paramedics at a local level to respond to incremental changes in their context of practice but also adapt their clinical practice to more effectively reflect skills and knowledge they require.

 Combined with related concepts such as Complex Adaptive Systems, a concept borrowed from Environmental Science which allows systems to evolve based on responses to individual stimuli, Learning Organisations can be part of an adaptive to organisational change which does not rely on single episodes of cardinal change but rather an ongoing process of evolution at both the micro and macro levels. One of the key benefits of micro-adaptability in organisations is organisational sustainability in changing service delivery environments (Molnar & Mulville 2003).

For paramedic services, it is accepted that workload variability and growth is a part of the operational environment in which these services exist (Lowithan Et Al 2011). Service delivery will need to be constantly adjusted to meet changing demands and the use of sustainable learning organisation approaches will not only encourage innovation in service delivery but will have a positive impact on organisational sustainability in an scenario where there is both increasing demand and unpredictable workload

More importantly, at the micro, or community level, local providers may have the capacity to adjust local service delivery to maximise impact of paramedic services on health service delivery and health outcomes. Such an approach would support concepts such as demand-driven service design and the emerging area of Community Paramedicine.

Do rural people call ambulances in serious health emergencies?

My first big foray into research was the HETI sponsored project into rural ambulance utilisation. We know anecdotally that rural hospitals have high self-presentation rates and many rural paramedics have stories of the farmer who appeared in the ED ambulance bay with a major multi trauma having bounced down miles of country road in a ute with no treatment whatsoever. This posed a number of interesting questions. The principal question was “how often does this happen?” This is an interesting because previously noone had looked at an ambulance service’s “market share” of sick people. We measure well what ambulance services do but rarely compare it to the pool of potential patients.

To find out we looked at a year’s worth of ED data from an Area Health Service with both urban and rural areas. Rurality was defined by the Australian Standard Geographical Classification. From this data we separated patients who arrived by ambulance from those who arrived by other means. We principally stratified by acuity based on the Australasian Triage Scale but also analysed against age, gender, aboriginality, and a range of other factors.  A retrospective analysis of 354,746 ED cases found that the proportion of ambulance use for both high acuity patients (as defined by a triage score of 1 or 2 in the Australiasian Triage Scale) and across the general patient population to be lower in more remote locations than in metropolitan locations. This analysis found that six in every ten rural patients with serious health emergencies arrived by a mode of transport other than ambulance.


Jason Bendall and I found that rurality was a predictor of ambulance usage in almost all category of patient. There was no significant difference in age or gender although it was noted that children under three were significantly more likely to be transported by a means other than ambulance even in life threatening situations. While one of the limitations was that we could not separate interhospital transfers from primary ambulance transports, we did find they constituted only a small percentage of hopsital patient arrivals.

Other studies have found similar discrepancies between rural and urban areas. In a study by Brismar, Dahlgren and Larsson (1984) urban usage was almost double rural usage in analysis of two regions in Sweden. This study also outlines the differences in the character of rural and urban workload. Also from Scandinavia, Beillon, Suserud, Karlberg and Herlitz (2009) found that not only was use lower but acuity was often higher in rural patients. Unfortunately most work around ambulance demand is focused around inappropriate use rather than utilisation analysis.

Several other questions arose from the study including why rural people make decisions to transport other than by ambulance, whether ambulances actually good for you (ie will the presence of an ambulance change your clinical outcome versus self transport),  and whatt steps can be taken to increase ambulance use in rural populations experiencing health emergencies. I will look at these in future blog posts.

You can read the full report here.

Making it about the professional

I am just back from the Paramedics Australasia conference in Hobart and the Rural Health and Research Congress in Wagga. At both conferences, one for paramedics and one for rural health professionals, community paramedicine featured high on the agenda for the first time. Community paramedicine is a new and evolving subset of practice, really having not existed before the mid-2000s. Given “Paramedicine” itself is thought to only be less than 16 years old as an academic body of knowledge, there’s a lot of room for growth.

One of the key issues being discussed is how does a paramedic working in the community paramedicine model is whether the profession is centred around the paramedic or the ambulance. In rural practice where there is increasing emphasis on multi-disciplinary and situated practice, the ambulance is less aand less a part of the paramedic’s professional identity. Having said that it will always be a key component of the rural paramedic’s arsenal of tools and the continued role of rural paramedics role in emergency response.

A number of papers have been done which outline the unique position of rural paramedics and the diversity of their role. These papers all discuss the unique community-based nature of rural paramedicine and discuss the context of practice. (Mullholland, Stirling, &Walker 2010, Blacker, Pearson & Walker 2010, O’Meara, et al 2006)

A model I have developed to help conceptualise a paramedic-centric view of the profession is shown below:

Emergency response will always remain at the core of paramedic practice. However, as paramedics in rural communities are not always engaged in emergency response taskings this creates capacity to expand the role to incorporate other health activities with the unused capacity. Primary health care is one of the logical extensions of paramedic practice given the impact of primary health care on acute heath emergencies. Health promotion is an equally related area which assists in building community engagement as well as improving health outcomes and equity.

Some services, especially in Canada are reconceptualising themsleves as “paramedic services” (for example Country of Renfrew or Frontenac, or Ottawa Paramedic Services). This concept potentially moves the focus from the vehicle to the professional.

Having said that, ambulances will always have role in paramedic practice and the movement of discourse away from the vehicle by no means reduce the importance of ambulances or transport to hospital from emergenc response to health emergencies. While a large focus of paramedicine is moving highly trained professionals to patients, the value of rapidly moving patients to appropriate facilities is equally as important.