When the most awkward of subjects arose, it was always more comfortable to talk about the Vikings.

     "In those days, my peers and I could talk about just about anything related to EMS," recalls David McGowan, now program development manager for HealthEast Medical Transportation in Minneapolis/St. Paul. "But when it came to driving safety, we'd all kind of cough and change the subject--talk about the football game or something. It really wasn't on our radar screens."

     Even then, just five years ago, the safe operation of EMS vehicles could be the proverbial elephant in the room: large, imposing, indisputably dangerous, but too uncomfortable or esoteric to discuss. It wasn't that HealthEast hadn't considered the issue--the organization had a program in place--it's just that the average EMSer knew little about the subject, less about how to address it, and largely accepted that vehicle accidents were an inherent risk of his chosen career.

     Five years can make a big difference. HealthEast now has an advanced vehicle-safety program that has produced demonstrably better driving habits among its 90-plus providers. But like many organizations, it took a landmark event to get there.

     HealthEast's involved an ambulance en route, Code 3, to a vehicle crash. It was broadsided in an intersection with such force that the car that hit it split in half. The multiple resulting casualties included the driver of the ambulance, who endured major trauma to his leg and foot.

     "That incident, along with another one we had, really was an epiphany for us," says McGowan. "We had an outside consultant come in and audit our safety practices, and they made several recommendations that really changed the direction of our program. But often, it's not until you have some kind of sentinel event that you start looking at those things. It takes something big to happen."

     On this count, HealthEast was actually very fortunate. "Something big" often involves someone dying.

What We Know
     In many ways, we're a lot better off today than those providers who were struggling with the vehicle-safety issue even half a decade ago. We have a better idea of what works, and better tools to help us. We surely don't have the problem licked, but we know now that it entails a good bit more than "Watch those intersections--here are your keys."

     But what are the components of an effective, comprehensive vehicle-safety program? What must you do to have one?

Policy Pitfall: Unreasonable Expectations
     Consider a policy like this: When running hot through an intersection, an ambulance driver must make eyeball-to-eyeball contact with the driver of every other vehicle from whom he's seeking right of way. Sounds reasonable, right?

     "That's a policy that will be difficult in practice and harm you at every level if you have an accident," says veteran EMS attorney Orlando Blanco. "At the supervisory level, the first thing they're going to ask you is if you made eyeball-to-eyeball contact with every other driver. Well, one had sunglasses on. Another was looking away. A third was a little old lady you could barely see over the steering wheel. You can't make eyeball-to-eyeball contact with those people! The point is, some policies are not very thoughtfully articulated and communicated, and so you get unreasonable expectations."

     These can also doom you in court: For an accident to have happened under such a policy, either a) you made the requisite eyeball contact and proceeded anyway, without ensuring the intersection was clear, or b) you disregarded your own policy.

     Either way, you lose.

Detailed Policies & Guidelines
     Simply put, people need, above all, to know what's expected of them. That starts with the law and, to the extent they exist in emergency-vehicle operation, established professional standards.

     "A good place to begin is by doing the research, checking out existing standards from both regulatory and standard-setting organizations," says Rick Patrick, senior partner with International Consulting and Training Specialists (ICATS), which provides risk management and safety consulting services for emergency organizations among others. "Look to national groups like the NAEMT, the American Ambulance Association, the IAFF, the IAFC. That's where you want to build from."

     States will have their own laws, of course, so be sure to know yours. The IAFC also offers general guidance with its Guide to Model Policies and Procedures for Emergency Vehicle Safety, downloadable from its website, www.iafc.org.

     At the organizational level, relevant laws and standards will inform the creation of internal policies and guidelines to govern vehicle operations. These need to be clear, precise and doable--and that's harder than it might seem.

     "Many times, our policies are not thoughtfully and articulately communicated," says Orlando Blanco, a Michigan-based attorney whose firm, Blanco Wilczynski, specializes in defending EMS clients. "This can lead to miscommunications about what the standards are and what the law provides." (For some examples, see the Policy Pitfalls)

     Basically, "You need to take a practical, realistic approach," says Patrick. "It has to be something manageable."

Driver Screening
     That driving is a privilege, not a right, goes doubly true for emergency vehicles. Wise organizations will screen their drivers at hire and check their records annually.

     "All of our new employees get DMV checks," says Larry Wiersch, executive director of the Cetronia Ambulance Corps in Allentown, PA, and past chair of the American Ambulance Association's Mobile Medical Transportation Safety (MMTS) working group. "Then we do DMV checks every two years. Our policy requires that if they have any motor vehicle citations, whether in an ambulance or their personal vehicle, they have to notify us. Because if we find out about it from the DMV check, let's just say it's a less-than-pleasant outcome. We want to know if they're operating their own vehicle safely. If they're not, it's unlikely they will operate our ambulance safely."

     This is one of several key areas identified by emergency-services insurer McNeil and Company as vital to reducing EMS organizations' accident rates. McNeil, which offers the Ambulance Services Insurance Program (ASIP), conducted a five-year loss-control review of 1,000 U.S. organizations, looking for common themes and characteristics among their vehicle accidents. They found that those who were selective in choosing their drivers cut their accidents virtually in half.

     "We looked at how they were picking drivers," explains Bill Tricarico, the company's director of loss-control services. "Were they using motor-vehicle reports? Did they have a set criteria to compare against? We found that for folks who did it on an annual basis, it made a huge difference."

     Cetronia also conducts drug and alcohol tests at hire and whenever there's an incident in the field.

     "A supervisor will go out and pick up the entire crew and take them immediately for a screening," says Wiersch. "If they refuse, they're suspended. Everybody knows the entire crew will be going, and it's made our people significantly more accountable."

Policy Pitfall: Above the Law
     An emergency vehicle driver really doesn't have the right of way to go through an intersection against a red light. He's actually only asking permission, which other drivers don't have to grant.

     If you've heard that, know this: It's not true.

     "I hear that quite often, and it's completely, flat-out wrong," says Blanco. "There's not a single state that says you're asking for permission. All 50 have statutes that provide exemptions for emergency vehicles."

     Yet the notion lingers because it's perceived and taught as good risk management. In theory, it should make ambulance drivers extra cautious about proceeding through reds, thus reducing accidents. But it also serves to muddy the waters and leave providers unclear about what the law actually says and allows.

     Going above the law to set a standard can also come back to bite you in court. "In practically every intersectional accident case, the battle comes down to whether the ambulance came to a full and complete stop before entering the intersection," says Blanco. "But the law in most states says if you're an emergency vehicle, you have the right of way, and to maintain it, you have to slow and proceed with due regard. It doesn't say stop and proceed with due regard; it says slow. I could have five eyewitnesses saying the ambulance was traveling as slowly and carefully as possible. The plaintiff on the other side is going to argue, 'It doesn't matter. They're teaching policies, and their internal policies say they'll come to a full and complete stop. That's what they adhere to. They didn't do that in this case. They're liable.'"

Training
     McNeil's findings in this area were dramatic: Agencies that conducted no driver training averaged six accidents for every 10 vehicles over the five-year period studied. Those that trained employees on hire but not thereafter averaged 6.1. But when an agency trained all its people every three years, that rate dropped to 1.5. It did not improve further with increased frequency.

     "From that we can assume you really should be doing extensive driver training every three years," Tricarico says. "We found, in talking to a lot of folks who did it every year, that drivers became bored with it and really didn't pay attention. So the full-blown EVOC course every three years seems optimum, with a short refresher annually."

     EVOC (the Emergency Vehicle Operators Course) is one of the major options for emergency driver training; the other biggie is CEVO (Coaching the Emergency Vehicle Operator). Organizations will have to decide on their own what serves them best (in accordance with their state law, of course), but as de facto industry standards, EVOC and CEVO are good places to begin.

Monitoring
     Driver monitoring represents the area of greatest recent advance in EMS vehicle safety. The two biggest names here are Road Safety and DriveCam.

     Road Safety tracks the metrics of vehicle operation--things like speed, braking forces, turning forces, etc.--and not only alerts drivers who exceed preset safe-operation parameters, but also preserves the data for review by higher-ups. DriveCam adds a video component, again triggered by excessive forces, that captures instances of unsafe driving visually.

     How effective are such systems? Ask McGowan, whose organization implemented Road Safety last year. HealthEast started by training its drivers on the system and using it blindly--that is, tracking violations without matching them to specific drivers. Its average miles between counts, or violations, was a meager 0.03. "Basically," McGowan says, "we couldn't get out of the parking lot without getting a count."

     Today that rate is up to an impressive 22.8.

     Since implementation, "We've not seen any crashes that were chargeable to our crew," McGowan says. What's more, "Our costs on wearable items--brakes, tires, suspension systems--have decreased, and it appears we've reduced our maintenance costs. The results have been beyond what we expected."

     Officials at Emergency Health Services Nova Scotia, which oversees EMS in that Canadian province, turned to Road Safety after being called on the carpet by their insurer.

     "They came to us and said 'Your loss ratios are over 55%. You're at risk of being cut loose,'" recalls Tony Eden, EHS' director of ground ambulance services. "Now, in 5-6 years, our loss ratios are down to less than 20%, and in some years less than 15%. In insurance, we pay less per vehicle now than we did in 1995. Our insurer doesn't anticipate phone calls every weekend saying we've had a collision."

     There are several other important points to make about monitoring systems. First, the data is only as good as what you do with it. Amassing it and sitting on it robs you of the full benefit.

     "Many companies that have invested in this capability don't implement it fully because they don't go back and actually look at the data," says Blanco. "You have to have somebody who monitors it and can say 'Hey, Charlie had a lot of hard braking this month. Let's find out why."

     Relatedly, agencies must investigate and review not only their crashes, but their close calls as well.

     "Addressing near-misses is what it's all about," says Patrick. "If you can identify and remediate those, you've prevented a crash every time. There's a phenomenal economic benefit to proactively addressing near-misses."

     Second, with crashes and close calls alike, it's not enough to just razz drivers with tones and a talking-to. You have to follow up with an established program of (preferably) remediation and (if necessary) discipline.

     "We have a 'Do No Harm' Committee that reviews every single vehicle accident. They drill down into how it happened, why it happened and how it could have been prevented," says Wiersch. "Then they bring recommendations to our Safety Committee for dealing with the driver at fault. We start out pretty soft, but we hold both the driver and the shotgun person accountable. We'll create what we call a performance improvement plan that describes the specific issue a driver is having and spells out tangible improvement goals. Our job is to help folks improve."

     "When one of our guys isn't doing well, we don't use that data to shoot them," agrees Eden. "When you have a poor score, that means we have to spend more time with you. We have a full-time person who reviews scores and monitors performance, and if you're not doing well, he takes you for a long walk. It's about reinforcing those values of safety."

     Third, such systems can only realize their full benefit in the context of an overall organizational culture committed to safety.

     "We can come up with DriveCams and Road Safetys," notes McGowan. "We can come up with new ambulances and designs. We can come up with different kinds of training programs. But what we really have to do is change the mind-set of our staff and develop a true safety-conscious culture."

Building A Culture
     Ah, the old culture of safety. So easy to talk about, so hard to create.

     Yet it can be done. The first part is spelling out, at every opportunity and in no uncertain terms, that safety is the currency of the organization--the entire organization.

     "We talk about a culture of safety, with Road Safety being just one of the components," says Eden. "We want them to wear their seat belts and stop at red lights not because it's the law, but because they understand why it's important. There's no need to break land-speed records. Response times are about system status planning, and it's up to the communications center and our system status manager to have our resources appropriately placed."

     It has to start from the top and encompass everyone. The monitoring systems go in the supervisors' vehicles, too. If they have a crash, they fill the plastic cup alongside the rookie EMT.

     "It's a 'do as I do' approach--leading by example," says Patrick. "Management can have the greatest intent to have a safe culture, but if all the ranks don't promote it, it's never going to filter down. Each level has to be responsible for holding their people accountable."

     Buy-in is enhanced when the front-line personnel who have to abide by an organization's safety measures have a hand in shaping them.

     "We travel throughout the province on a regular basis, talking to paramedics," says Eden. "We want to hear what they think when we come up with the latest edition of an ambulance or a technological change. We show them the changes and upgrades, and we encourage feedback: If you don't like it, tell us. If you do like it, tell us. And we take that feedback back to our engineers and say 'The medics think this.'"

     "It makes all the difference in the world when their hands are on it," says Patrick. "That doesn't mean the employee dictates what the policies will be, but if nobody had their voice in it and they're expected to comply with it, that can turn them off real quick. They need to be involved in the review and refinement of policies, they must know why policies exist, and they need to see you doing what you're preaching."

     Finally, leaders have to make the hard calls, even when it's painful.

     "It's easy to fall into the trap of 'If I take you out of the loop, I'll have a problem filling that shift,'" notes Wiersch. "People can get bogged down in 'Oh, we're going to lose the truck,' or 'Oh, it's going to cost us overtime,' instead of 'Our standard is this.' And sometimes they're really nice people. 'Oh, I really like this person. He's never had any issues.' You have to take the personalities out of it. And sometimes you do lose a truck, and sometimes it does cost you overtime. But who knows what the cost might be if you didn't do something?"

Additional Tips
     Some additional tips for a comprehensive vehicle-safety program:

• Fleet standardization--EHS Nova Scotia buys from a single manufacturer and has a standard vehicle and inventory provincewide. A medic using a new truck will be familiar with its operational characteristics and the locations of things.
• Proactive maintenance--McNeil found that organizations that simply repaired problems as they occurred averaged 5.9 accidents per 10 vehicles over five years. Those that did only unscheduled maintenance averaged 3.1; those that stuck to an established internal maintenance schedule averaged 2.5; and those that followed the manufacturer's recommended maintenance schedule averaged 2.1.
• Tailor your program--"No one should just pick a standard program," says Tricarico. "Everybody has nuances within their organization, and it's up to leadership to take a standard program and to make it work for them."

Online Resources
CEVO: www.nsc.org/train/ddc/
DriveCam: www.drivecam.com
EVOC: www.nhtsa.gov
IAFC: www.iafc.org
International Consulting and Training Specialists: www.icats.net
McNeil and Company: www.mcneilandcompany.com/
Road Safety: www.roadsafety.com