Episode 25: Implementing a Just Culture with Matthew Streger


First of all, let us take a second to extend our sincere gratitude for Matthew Streger coming on the show and sharing this concept with us!

Listen here, or download on iTunes, Podcast Addicts, or Podcast Republic.

stregerMatthew Streger is a paramedic and attorney with more than thirty years of EMS experience. Matthew is a Partner at the law firm of Keavney & Streger in New Jersey. He has worked in EMS systems in New Jersey, New York, South Carolina and Ohio. He has served as the Executive Director of Mobile Health Services (EMS) at Robert Wood Johnson University Hospital in New Jersey and the Deputy Commissioner of EMS in Cleveland. He currently sits on the Panel of Commissioners for CAAS and the Editorial Advisory Board of EMS World Magazine. Matthew is a past Chair of the Health Law Section of the New Jersey State Bar Association, and a current member of the Legislative Committee.

What is Just Culture?

Just culture is a system that attempts to not punish individuals, but attempts to figure out how human factors influence medical errors. Instead of looking for ways to punish individuals, just culture attempts to improve systems as a whole.

EMS Systems Strengths and Weaknesses

  • What we’re good at:
    • Identifying errors
    • Creating checklists
    • Root cause analysis
    • Crew resource management
  • What we’re not good at:
    • Addressing system and culture problems that lead to errors
    • The investigative process
    • Handling discipline
    • Taking errors and turning them into an opportunity for learning and growth

There are approximately 250,000 deaths related to medical errors every year in this country. For all of the problems that have been identified in this field, there are still some major elephants in the room that are not being addressed:

  • Crew fatigue
  • Lack of equipment standardization
  • Lack of checklist utilization
  • Lack of video/audio accountability

Paradigms of Just Culture

  • Category One:
    • Reasonable conduct
    • Mistakes that are made despite attempting to follow policy; this is tied to understandable human errors.
    • Example:
      • Forgetting your stretcher at a hospital due to trying to clear for a high acuity call like a pediatric cardiac arrest.
    • Category one behavior needs to be addressed in an educational manner; while evaluating the situation, there needs to be system wide analysis to see if the organization needs to change a certain policy or procedure that contributed to the error; i.e. pediatric field guides with predetermined drug dosages that limit split second calculations.
  • Category Two:
    • At-risk behavior that takes a calculated risk.
    • Example:
      • Driving over policy limits responding to an officer down. There is still a chance that you will make it to the call safely, however, there is a chance that you could cause a collision.
    • Category two behavior still needs to be addressed with training and remediation.
  • Category Three:
    • Dangerous or reckless conduct; subverting a known safety system.
    • Example:
      • Coming to work hungover or intoxicated and operating a vehicle or performing normal procedures. While there may be no harm that results from this, it does not justify the reckless behavior.
    • Organizations need to respond to category three behavior strongly; an organization that allows category three behavior to go unchecked is asking for trouble, and will attract dangerous behavior.

Repetitive category one and two behavior can eventually lead to a category three response; inability to change behavior shows an unwillingness to follow the rules that are in place. A common pitfall that managers make is the inability to provide documentation of initial education or remediation efforts. EMS managers must stray away from the thought that consequences should influence the type of action that is taken against an error. Patients still die from understandable errors, and gross misbehavior does not always result in bad outcomes. As supervisors, do not be afraid to provide the “why” when asked. Giving reasons for policy enforcement helps providers understand the gravity of why they are being spoken to, and often curbs risky behavior.

The Investigative Process

Good clinicians do not always make good supervisors or managers. The majority of the time, departments take high performance clinicians, give them a set of bars on their collar, and expect them to transition without incident. However, that is not the case! The difference in a mindsets between clinicians and managers is simple. Clinicians assume there is a problem that needs to be fixed and dig until they find a problem. However, good managers presume that there is a reasonable cause for a mistake until proven otherwise. This concept is the basis for our country’s legal system: innocent until proven guilty. We are all guilty of this within EMS (and healthcare in general!) management.

To streamline the investigative process, keep one supervisor or manager in charge. This ensures continuity throughout the investigation and makes sure that there are no significant pieces that get overlooked. Another major thing that gets overlooked is the recognition of conflicts of interest. For supervisors and managers that have come up from within the ranks, often times, relationships have developed between them and their subordinates that can skew the investigative process. This can either be a positive or negative bias; i.e. investigating an old partner.

While handing out discipline, it is important to make sure that it is line with previous precedent and remains in line with the organization’s core values. There needs to be a “presidential pardon” option of sorts if the judgment that has been handed out is too harsh, or not harsh enough.

For those of you that would like to know more about how to implement a just culture within your organization, please visit:


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