How to implement patient-centered EMS leadership

Follow this five-question framework to set the direction for your agency's future, watch the system, and support vital processes


When I’m teaching classes for EMS and fire service leaders, I’ll often start by asking a few questions.

Question: While you’re here in this room, are people calling 911 back in your community?
Answer: Yes.

Q: Are call-takers answering calls, following protocols, dispatching the proper resources and providing pre-arrival/post-dispatch instructions?
A: Yes.

Q: Are your clinical professionals responding, doing assessments, and providing treatment and transportation if needed?
A: Yes.

Q: Is preventive maintenance being done on your vehicles, are people being scheduled for open shifts, and are bills being prepared and sent out?
A: Yes.

Q: So are you telling me that all of the vital functions of your system are going on right now without your participation?
A: Yes.

Q: So what good are you? What value do you provide?
A: [Uncomfortable silence with people looking around, shifting in their chairs.]

What value do you or can you provide as a leader if all the vital functions of your organization run just fine without you?

It’s a scary question, and if you’re willing to ponder it, you’re likely to come up with concepts that will improve your effectiveness. Following are some of the ideas that have emerged from my thinking and learning about leadership and quality management during the past few decades.

EMS leadership basics

I think EMS leadership can be boiled down to this: Your job is to set the direction for the future, watch the system, support the vital processes to keep them running smoothly and make improvements. I’ve found this simple yet powerful five-question framework really helps me stay centered:
 

  1. Why are we here, and why do we exist? This is your purpose. It is not for your wallet cards or wall posters. To be effective, this answer must live in the conversations and daily actions of folks on your team. One example—“To reduce or relieve suffering and improve health”—is pretty easy for the people on a team to align with.
  2. Where are we going? This is your vision, a crystal-clear image of a state that does not yet exist that you and your team are working toward making a reality. Vision statements that say things like “____ is the premier EMS system on or off the earth” don’t give folks anything tangible to work toward. The ESO vision statement, “We believe in the power of data to improve community health and safety,” while incredibly challenging, is clear and specific. It gives people something to work toward.
  3. What guides your day-to-day decisions and actions? These are your values, the things that matter most. The STAR CARE Guidelines written by Thom Dick more than two decades ago serve as one of the best examples of strong values. Safe, Team-Based, Attentive to Human Needs, Respectful, Customer Accountable, Appropriate, Reasonable and Ethical.
  4. How are we doing? These are your organization's key performance indicators.
  5. What are you doing to make things better? These are your improvement projects.

It's more important to be a leader/facilitator than a boss

Leadership author Peter Block said, “Most of our organizations and communities are parent-child, boss-subordinate, mayor-citizen conversations—we think that matters. We think the boss-subordinate relationship matters, but I don’t think that it does.”

My bias is that once a person buys into the vision that they are the boss and are smarter, more powerful and more important than the other people on their team, they are destined to lose their way.

Leadership guru Peter Drucker said, “Most of what we call management consists of making it difficult for people to get their work done.” As you think about your role as a leader, it’s helpful to make a commitment to yourself that you’ll focus on making work easier for folks rather than harder. It helps if you see yourself as a leader/facilitator rather than a boss.

Go for commitment, not buy-in

Have you ever used the phrase “buy-in”? As in, “We’re going to have a meeting this afternoon to get buy-in from the C shift for the new summer uniform.”

I attended a small workshop several years ago led by Peter Senge, Ph.D., an MIT professor and the author of The Fifth Discipline. One of the people in our circle said something about how frustrating it was to get employees to buy into the system changes we were discussing. Senge stopped the group and invited us to explore what “buy-in” really means. He said that buy-in is a description of a level of employee involvement in a change effort. He described four levels:

  1. Terrorist: Someone who is actively working to sabotage what you’re trying to accomplish. For example, I once rode with a crew in Queens as part of a consulting job. During the check-out, the paramedic opened the side compartment and cried, “I hate these new stair chairs!” He proceeded to take the stair chair out and lay it on the street. He then got in the ambulance and backed the rear duals over it. He picked up the mangled stair chair and crammed it back in the side compartment. Calling his supervisor on the portable radio, he said, “Our stair chair seems to be broken. Can you bring us another? I’d like it to be one of the old models, as these new ones don’t work well.”
  2. Buy-in: What you get from folks at this level is non-terrorism. You get no active support—only people who stand back and watch.
  3. Enrolled: This literally means putting your name on the roll: signing up. People who are enrolled will take active steps to make the change a success.
  4. Committed: These folks are in the Get out of my way, we are going to make this work mode when it comes to implementing change. Cultural anthropologist Margaret Mead said, “Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it’s the only thing that ever has.” Change is nearly impossible without a few committed people leading the charge. In my experience, people will not commit to my ideas; they are much more likely to commit to ideas that they had a hand in crafting.

Be empathetic and honest with ems personnel

If I’m not actually caring for patients, taking blood pressures, holding hands and giving D-50, my job is to take care of the people, processes and partnerships that do. Relationships, which are your ability to listen, learn from, support and influence other people, is key to leading a system that takes good care of the ill and injured. Of all the relationship competencies, there are two that I believe are essential to effectiveness: empathy and the ability to have difficult conversations.

A few years ago, an EMS operation decided to close four 24-hour shifts because of fatigue and change them to 12-hour shifts. The employee meeting about the change had pre-riot energy when the leadership team walked in the room. This is the kind of situation where empathy and the ability to hold difficult conversations separate eagles from road-kill pigeons.

The boss opened the meeting with this statement: “I can sense some anger and frustration in the room. There’s no doubt this change will mess up many of your lives. Some of you have long commutes, childcare arrangements, school schedules and second jobs, all of which will be disrupted by this change. It sucks.”

The violent energy in the room drained instantly. The leader had recognized their emotions and said most of the things that had been boiling in their minds since they learned of the change. This allowed them to have a frank, civil conversation about the rationale behind the change, protecting employee safety, and how they could work together to make it less painful.

Empathy is the ability to recognize that someone else is experiencing an emotion like anger, fear, joy, disgust or happiness. In leadership situations, the practice of empathy involves recognizing that someone is feeling an emotion, getting a sense of what that emotion is, acknowledging that you’ve recognized what they are feeling and, if it’s an emotion of suffering, offering a bit of compassion.

There are some traps in the world of empathy. For instance, some leaders believe that if they acknowledge the emotion, they are agreeing with it. Yet understanding that someone is frustrated because they can’t get the shift they want is not the same as agreeing to change their shift. Others make the mistake of pronouncing the other person’s emotion as if it were fact by saying something like, “You’re frustrated.” It’s much more effective to share your emotional observation as a question: “You seem frustrated?” This allows the person you’re talking with to clarify how they feel using their own language.

It's all clinical

One of the realities of EMS is that it is the delegated practice of medicine. My medical director for most of my front-line paramedic career was Norm Dinerman, M.D. He used to talk about blowing up a large poster of his license to practice medicine and hanging it on the wall of our Denver Paramedic Division day room. He said, “I’d put a sign under it that says, ‘This rides with you today and every day. Please take good care of it.’” He spent many years in school, lots of money and mind-boggling study time to earn the right to practice medicine, and he allowed all of us to practice on his license.

That perspective has been a central part of my approach to EMS leadership. The way I see it is that our responsibility is to as closely as possible replicate our medical director’s practice of medicine for every patient we care for. To do this effectively requires that the leaders in an EMS system, if they are not the medical director, have a solid relationship with their top doctor. If your medical director is currently practicing medicine, one secret to really understand his or her approach to the practice of medicine is to shadow him or her for a shift.

It’s all clinical. My friend Thom Dick wrote an article for JEMS magazine several years ago titled, “Who Saves the Most Lives?” Just under the title was a photo of the lead mechanic for Hartson’s Medical Service in San Diego, where Thom worked. The article went on to describe how, regardless of how well trained and equipped the paramedic, if their response vehicle fails, the patient suffers.

All aspects of an EMS organization are necessary to support clinical care, including recruitment, HR, fleet maintenance, supply management, training, billing and more. If there is something in your organization that could disappear and not affect clinical care, it might be time to ditch it.

Another thing Thom said to me while sitting on a rock behind his house: “EMS people get lied to for a living. They can smell B.S. a mile away. You can’t lie to them ever.” Over the years I’ve found that people appreciate it when you tell them the un-sugar-coated, non-politically sensitive, non-corporate-speak truth. It’s amazing what people can do together if they trust each other.

This article, originally published November 25, 2013, has been updated

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