Paramedicine, like agility, is a team sport

Big thanks to guest blogger Caidyrn Roder who has shared his unique perspective alongside his paramedic co-speaker (and uncle!) Nick Roder, at AgileAus – not once, but twice.

Ambulance Victoria employs over 5,000 paramedics to provide emergency health care across the state. These paramedics are all trained to work outside of the hospital environment, which means that they have no defined workplace, limited managerial oversight and they are often remote from support.

And yet their performance is nothing short of remarkable. In 2023 – 2024, they attended over one million incidents. And 97% of patients surveyed reported that their experience was positive, and that they felt safe and cared for¹.

So when I learned about this, I got curious. How do they collaborate? How do they deal with the complexity? And what can we borrow from them to improve how we work in organisations?

In my opinion, the answer for many organisations is that they unintentionally work against their people.

I believe that we can learn from paramedicine, adapting the techniques that they use to create high-performing teams. Once we accept that people are our delivery system, we can work with them them by doing the following 4 things:

1. Design processes for humans
2. Create a just culture
3. Foster civil interaction
4. Flatten the authority gradient

Design processes for humans

Paramedics deal with cases that range from interhospital patient transfers to accidents to search and rescue. They have complex protocols and procedures which they have to perform under pressure. They work with people that they may have never met before. And all of this in challenging environments like accident scenes, remote areas or residences with access issues.

In response, paramedics have developed a range of tools that provide a systematic approach, constructed in a way that recognises that they will be deployed in a range of contexts while keeping the needs of patients and paramedics at the centre. In other words, they design processes for the humans who are involved.

Consider your organisation for a moment. I’d wager that you also have to deal with complexity. Do you have processes that don’t serve the people who use them? Or aren’t documented? Or are documented but not followed? The insight that I think we should take from paramedicine is that processes that are not designed for humans, will not be used by humans.

The good news is that there are simple steps that you can take to design processes for the humans in your organisation.

• Listen to your people – Talk to your teams. Talk to your people leaders. Talk to your executives. Listen carefully to understand the current context, what’s working well and where there are opportunities to improve.
• Involve the people who do the work – The people who understand the work and the environment are the best ones to (re)design the processes. So make sure that you involve them. Better yet, empower and support them to continuously improve the processes themselves.
• Prioritise simplicity – When you’re designing process changes, challenge yourself to make them as simple as possible. Could you have fewer steps? Do you really need to involve all of those people in a decision? When faced with a choice, prioritise creating a simple process that covers 80% of cases over a complex one that covers 100%.
• Continuously improve – I hate to be the one to tell you this, but you won’t get your processes right the first time (or even second, third or fourth). So build in continuous improvement from the start by creating an environment that encourages your people to continuously try new ways of collaborating.

Create a just culture

Continuous improvement is not just important for paramedics, it’s non-negotiable. For them, raising concerns can lead to valuable changes in practice that improve outcomes for patients and paramedics. This is only possible in an organisation that both makes it safe for employees to speak up, and is prepared to listen.

In other words, continuous improvement is about much more than just processes and tools. You can’t simply tell teams to do retrospectives or to implement tools like lean A3s and leave it at that. To unlock the true power of continuous improvement you need to create a culture where people are comfortable talking about and learning from their mistakes. A culture where people are empowered to change the way they work and to challenge existing practices.

Paramedics call this a just culture. A just culture means that people are able to raise concerns, mistakes or challenges within the organisation in an environment that treats employees with due respect. A just culture recognises that human error is inevitable and that complex systems designed by humans will fail². There is shared accountability between the organisation (the system) and the individual when things go wrong.

In a just culture, you don’t blame or punish individuals when their actions or decisions are commensurate with their experience or training. Instead seek to understand the broader context for their actions so that you can identify improvements. This is not the same as a no-blame culture. People are still held accountable for their actions, and negligence and willful misconduct are not tolerated.

There are 3 simple things that you can do to foster a Just Culture in your organisation³.

1. Support the people involved – When something goes wrong, your first priority should be to support the people involved. Making a mistake is rarely a positive experience, however a supported employee is more likely to resolve their experience productively and learn and grow as a result. They are also more likely to talk about mistakes in the future.
2. Manage your biases – Give people the benefit of the doubt by assuming that they set out to do their best and achieve a good outcome. When someone makes a mistake, put yourself in their shoes to ensure that you are empathetic to them. Try asking yourself this question: Could another person with similar knowledge and experience make the same decision in the same situation?
3. Consider the system – Rather than focusing solely on individuals and their actions, you need to recognise that they are working within a broader context. Remember, a Just Culture recognises that there is shared accountability between the organisation (the system) and the individual when things go wrong. So ask: What aspects of the system contributed to the actions they took, and the decisions they made? Why did it make sense to them at the time?

Foster civil interaction

There is a growing body of evidence in both medicine and business that rudeness and incivility undermine team effectiveness. In their 2015 study, Riskin et al concluded that “not only does rudeness harm the diagnostic and procedural performance of [medical] practitioners, it also seems to adversely affect the very collaborative processes that might otherwise allow for teams to compensate for these effects”⁴. In other words, incivility affects both an individual’s cognitive abilities as well as their ability and willingness to collaborate with and help others.

Incivility includes overt behaviours like mocking, teasing or insulting. Or yelling, slamming doors, or talking about people behind their backs. It can also be more subtle behaviours like responding to emails in a meeting, not smiling or acknowledging others when you pass them in the hall or not listening when someone is speaking to you.

Importantly, perceptions of incivility can vary from person to person. What one person finds rude, might be totally acceptable to another person.

Incivility is a common cause of stress in the workplace. For example, given that paramedics often work in traumatic circumstances you might expect their main cause of stress to be the work itself. However, they often report that how people behave has a larger impact on their stress levels.

Rudeness can also lead to reduced creativity, lower productivity, increased absenteeism, lower quality of work and in the worst case, employee churn and damaged customer relationships.

Interestingly, the impact is not just on the person on the receiving end of the behaviour. People observing uncivil behaviour are also impacted. So, if a team lead is rude to a team member in a meeting, the whole team’s performance may suffer as a result.

The implications for organisations are profound. Fostering civil interaction not only supports staff wellbeing, but it can also improve team effectiveness. So what can you do to foster civil interaction in your organisation?

• Model good behaviour – Be conscious of how you interact with your colleagues and hold yourself to a high standard. Avoid mocking, teasing or insulting people. Even if you think that it is “good natured” it’s possible, even likely, that others don’t see it that way.
• Ask for feedback – Feedback is a good way of monitoring how you’re doing. It helps you improve by giving you other perspectives, and it builds psychological safety and encourages a growth mindset in those around you.
• Establish team or company norms – Norms are an agreed set of behaviours that are acceptable in your context. They help you be clear about what behaviour is expected and what won’t be tolerated.
• Take bad behaviour seriously – Organisations who don’t address rude behaviour often pay the price. When leaders ignore bad behaviour, they are giving their implicit approval of the behaviour. Staff stop reporting incidents because they feel that nothing will be done. The behaviour continues unabated, stress levels increase and often the simplest solution for staff is to quit.
• Include civility in recruitment and employee training practices. Look out for indications of rude behaviour in interviews. Get multiple perspectives by involving team members in the interview process. Make people aware of the concepts and the impact in training

Manage your authority gradient

Authority gradient is a concept borrowed from the aviation industry and adopted by medicine and paramedicine. It refers to the established, or perceived, command and decision-making power hierarchy in a team or organisation⁵. It is the status difference (real or perceived) between 2 or more people in a team.

At one end of the spectrum, an extremely steep authority gradient is where an individual holds all of the power. An example is a team lead who has a controlling or prescriptive management style – “it’s my way or the highway”. Team members are expected to do what they’re told and not ask questions or express opinions. This results in fewer perspectives and ideas, reduced communication and collaboration, lower team engagement and an environment where feedback is not given freely.

At the other end, an extremely shallow authority gradient is where everyone’s opinion is valued equally on all topics. There is no difference between experienced senior team members and more junior ones. Everyone’s voice is heard and feedback is given freely, but decision-making may be slow and/or poor and responsibilities may be unclear.

Studies show that getting authority gradient wrong can have disastrous results. I’ve seen the impact on teams and organisations myself. I once worked with a team developing a proof of concept for a new digital product with the primary purpose of learning what users wanted. The cross-functional team was talented and experienced, but they were hamstrung by a leader who had an authoritarian leadership style and a fixed view of how things should be done. The team did not feel safe to suggest a better approach, so they followed the leaders directions slavishly. The result was a lot of wasted money and effort and very little learning.

Authority gradient is also particularly important for work on complex problems (i.e. most of the work we do in organisations), because this entails a high degree of uncertainty and risk. In organisations we often have to make decisions based on incomplete information, under conditions of high uncertainty and risk, where there is no obvious right or wrong answer, where people hold conflicting opinions and decisions and actions are only proven right or wrong by the results they achieve.

Interestingly, the concept of managing an authority gradient challenges traditional views on leadership. All paramedics can be both leaders and followers, adjusting dynamically depending on the situation. For example, it’s not uncommon for the first crew on an accident scene to retain the leadership role, even when a more senior paramedic arrives. They may even enlist that more senior person as a ‘follower’, leveraging their skillset to get the best outcomes for their patient.

Being a follower does not mean passively following orders. In high-performing teams, followers anticipate the next step, offer different perspectives and solutions and demonstrate initiative.

There is no single “correct” authority gradient for a team or organisation. It changes based on circumstance. The most effective teams are conscious of their authority gradient and have protocols in place to adapt it dynamically. So while there is no one-size-fits-all approach, there are some heuristics that you can use to determine what is appropriate for the circumstance.

• Shallow authority gradient – Well-suited to dealing with complex problems. Creates a space where team members feel safe to contribute ideas, ask questions, challenge each other and debate solutions. A shallow gradient also helps to create a learning environment because people are more likely to give feedback and share learnings when things go wrong.
• Steep gradient – Appropriate in times of crisis, when fast decisions made by an experienced leader are more important than getting a range of perspectives. Be careful not to maintain a steep gradient for extended periods of time as this often makes teams less productive and reduces learning, morale and engagement.

Conclusion

Paramedics consistently achieve remarkable results in high-pressure, complex environments because they understand that people are their delivery system. Organisations seeking to emulate this level of performance can draw profound lessons from the field of paramedicine. By designing processes for humans, organisations can empower their workforce to operate efficiently even in complex scenarios. Furthermore, cultivating a just culture that not only tolerates but actively encourages learning from mistakes is paramount. This creates an environment where individuals feel safe to speak up, share insights from failures, and continuously improve, rather than hiding errors due to fear of blame. Promoting civil interaction within teams is also crucial, as incivility erodes trust, impairs cognitive function, and undermines collaboration. Finally, consciously managing the authority gradient – adapting it dynamically to the demands of the situation – allows for optimal decision-making and leverages the diverse expertise within a team.

Ultimately, investing in these human-centric principles will not only improve internal processes; it will unlock the full potential of your people.

Stay tuned for more information on AgileAus26 – we cannot wait to gather with curious minds and rethink the way we work and live!