Updated February 2015
Like many leaders in EMS, Jay Fitch got his start in the profession as a high school student, volunteering as a firefighter-EMT in Fairfax County, Va. A few years later, he became one of the first paramedics certified in South Carolina and then spent five years as a paramedic and senior crew chief for Charleston County EMS in South Carolina.
Then, at age 24, having recently completed a master’s degree in public administration at Webster University in Webster Groves, Mo., Fitch got a job offer he couldn’t refuse. He was named EMS director for the city of St. Louis—a place that Jim Page, the publisher of JEMS, had just called one of the worst EMS systems in America. “At the time, there were very few people who were a paramedic and had a graduate degree,” Fitch says. “They deserved someone who was 40 or 50 years old with 25 years of experience, but it was a troubled EMS system and they couldn’t attract someone of that caliber. I was extremely fortunate to be selected for that position.”
Over the next four years, Fitch helped lead a turnaround in St. Louis, including improving response times and beginning to repair EMS’s reputation in the city.
Fitch eventually left St. Louis to become an operations executive for Kansas City’s EMS system, the Metropolitan Ambulance Services Trust, or MAST, which was created in 1979 when the city bought and consolidated five private ambulance providers. (MAST operated as a public utility model until it merged with the Kansas City Fire Department in 2010.) In 1984, he launched his consulting firm, Fitch & Associates.
Today, he’s a well-known EMS and public safety consultant and educator, working with small and large organizations throughout the world. He earned a Ph.D. in organizational psychology and was the lead author of the 1988 textbook Beyond the Street: A Handbook for EMS Leadership and Management. He was also the editor of two editions of Prehospital Care Administration, a collection of essays and case studies on leadership, ethics, finance and other topics. Fitch & Associates also pioneered the concept of learning programs that bring budding supervisors and managers together for several weeks of intense education.
With help from The RedFlash Group, Fitch founded the Pinnacle EMS Leadership Forum in 2006. Attracting more than 600 leaders from every type of service delivery model, Pinnacle has become the premier event for learning, education and networking.
As his firm celebrates its 30th anniversary, Fitch spoke with Best Practices about his experience as a consultant and educator.
Fitch is a strategic partner with the ICMA (International City/County Management Association) and you’ve authored several reports for them. What is local government’s view of EMS as it relates to healthcare reform?
Local officials are struggling with understanding the future of integrated healthcare and how it could impact local costs under accountable care organizations (ACOs) if they don’t become more outcome-oriented. The ACOs are going to become the funding entities, as opposed to the current funding model where you are reimbursed for transport. Cities will be negotiating with the ACOs, which are going to want to understand how the services provided improve care.
All of it is crystal ball, though—nobody knows how this is going to play out. Ultimately we would expect to see all providers having to deal with, and be accountable for, outcomes, and their reimbursement will be more outcome-oriented, rather than billing for transport under Medicare, Medicaid or private insurance. That means the metrics are going to be looked at in a very different way. Spending is going to be looked at closely. The delivery methods may change, too, through community paramedicine and other programs.
Are local governments engaged when it comes to how EMS can be a force in mobile integrated healthcare initiatives?
More and more communities are recognizing that they need to be engaged and are looking at how they approach the future, whether it’s mobile integrated healthcare or community paramedicine. We’re still in that anticipatory period where we’re exploring what other systems are doing, creating our own assessments, laying plans, developing ideas—working through what works and what doesn’t work, before the switch is flipped with regard to reimbursement.
Are there signs that a more outcome-based model for EMS reimbursement is imminent?
I don’t think it’s imminent, but it’s evolving under the Affordable Care Act. For example, as hospitals are being penalized for readmissions, they’re paying a lot more attention to opportunities for tightening relationships with field providers and approaching things in a way that makes good patient sense so the continuum of care is unbroken and the economic incentives will be more aligned with accomplishing those care goals.
What questions should our readers have for their leaders in local government in regard to reimbursement?
At the end of the day, it’s about helping educate local government officials about where the future of healthcare and healthcare reimbursement is moving, and that those changes require providers to work closely with their local hospitals and ACOs.
EMS has to communicate that we have value in helping save lives and reducing costs. We’ve always waved the flag, We save lives. We’re good guys. But now we also need to talk about how that impacts downstream healthcare costs. For example, if somebody manages a hip fracture in the field appropriately and that patient has a good outcome, it reduces downstream healthcare costs, as opposed to it not being managed and the patient having a longer hospital stay.
You’ve seen your share of battles over RFPs and turmoil in communities about who should run EMS. When a city decides to put its EMS service out to bid, is there a fundamental problem or disconnect in how communities construct a bid, properly balancing the needs of the provider as well as the community?
The disconnect is in policy decisions—knowing what they are asking for and if their expectations are realistic at a clinical, operational and financial level. Those expectations have to be translated into a specification that aligns the provider’s efforts with the community’s needs. Another issue we sometimes see is non-realistic time frames for conducting a procurement. Credible companies can’t produce RFPs in 30 or even 60 days.
The American Ambulance Association guide [“EMS Structured for Quality: Best Practices in Designing, Managing and Contracting for Emergency Ambulance Service”] is a very solid start for community leaders on how to conduct an RFP in a way that makes sense. Part of what we do as consultants is help guide this process for communities—it can be a complex and politically charged process.
A good outcome usually occurs when a city council or county government spends time up front to understand the implications of decisions, such as whether they want a sole franchise or multiple providers; whether they expect the system to be completely user-fee supported or partially subsidized; and who is going to own the core system infrastructure, such as communications systems and vehicles.
One of the reasons for a procurement is to make sure there’s competition for the market and to attract qualified bidders. We do that by having clear specifications so that everyone understands what’s expected of them, which then enables them to sharpen their pencils and present their best bids.
Recently AMR took over operations in Tulsa. This RFP allowed more leeway in terms of response times. Does this foretell a change in how communities will view response times in future contracts?
Yes, it does foretell a change. Response times are going to be more acuity-based in the future. We don’t need to have 8 minute, 59 second response times for all types of calls. When you have a fall off a tricycle and there’s no loss of consciousness and nobody bleeding, it’s questionable you’ll need lights and sirens.
What we’re seeing is Emergency Medical Dispatch (EMD) protocols being used more frequently, and more dispatch centers being accredited (through the International Academies of Emergency Dispatch) bringing high levels of reliability in being able to sort through what type of response is needed. There is also clinical evidence that supports that only certain types of calls require lights and siren response.
What surprises you about how EMS has evolved over the past 30 years?
The biggest surprise is we really haven’t evolved with a true career path. If you take a nurse, for example, they can start as a nursing assistant, become an LPN and R.N., get a master’s in nursing, become an advanced practice nurse and nurse practitioner. They can move across areas of healthcare—an ER nurse, for instance, doesn’t have to work as an ER nurse forever.
But for someone who comes into the EMS field as a 19- or 20-year-old EMT, their current paths are limited. You can become a paramedic and then go the administration route or go into training. To stay on the street is really tough when you’re 50 years old. There are not as many crossover opportunities into other areas of healthcare. Our educational approach isn’t designed to allow it.
So EMS providers get pigeonholed. They can’t grow, or there isn’t a smooth transition for them into other areas of healthcare. The fire service has a career track that’s pulling people from EMS into it; more fire chiefs, for instance, have experience as a paramedic.
As I look at EMS across the country, we’ve lost a lot of good and talented people because we haven’t planned for their career development.
How has Fitch & Associates evolved over 30 years?
We’ve prided ourselves on having a depth of talent that has allowed us to do many different things, from consulting to education to providing management and patient account services (billing and collections). We’ve also worked with a range of services, including the fire service and hospitals.
We’re also committed to helping people develop their career, through our education programs for entry-level supervisors (the Beyond the Street workshop) and the Ambulance Service Manager’s program, which we offer in collaboration with the AAA. Well over 1,000 people have gone through that program over the 20 years it’s been in place. We also conduct the Communication Center Manager’s Course for the International Academies of Emergency Dispatch. For more senior executives, we created the Pinnacle EMS Leadership Forum in 2006.
We’ve also done a lot of international work over the years, from working with the Hong Kong Fire Department to working in Australia and the United Kingdom. We had an office in London for close to 10 years. In 2006, when the U.K.’s National Health Service Ambulance Services Trust consolidated about 30 ambulance services, or trusts, into about 10 regionally based providers, that shrank our business base, so we eventually closed it. But our managing director was asked to head one of those trusts.
Earlier you mentioned Pinnacle, which now attracts nearly 600 leaders from all facets of EMS and even outside of it. What differentiates Pinnacle and what is your vision for its future?
We developed Pinnacle at a time when each area of EMS was focused on its own issues or problems. The fire folks had their meetings and the privates had their meetings. Big city agencies had their own meetings. The big trade shows catered to practitioners, with cavernous trade shows.
People weren’t talking to each other. We think leaders of different stripes can learn from each other. Putting Pinnacle in an intimate hotel, in a beautiful spot off the typical path of most conferences, gives our participants a chance to relax, meet each other casually, and even bring their families. The sessions and workshops, always forward-thinking, are designed to challenge even the most experienced executives. Our keynote presenter each year is an expert from another profession. We think that as EMS matures, we need to look outside our own walls. The result has been a true melting pot and a sense of collaboration, in terms of the types of leaders who come, as well as the service models they represent.
The vision for Pinnacle is not necessarily to grow larger, but to continue to attract the best minds in the business, whether it’s a fire chief, CEO, EMS chief, medical director, academic researcher or anyone with an open mind. When you get those types of people in a room to discuss the future, anything is possible.
Part of our goal with Pinnacle is for it to be focused on the future—and, more important, to be a melting pot of people from all types of services, as well as physicians, caregivers and administrators. What differentiates it is that the faculty comes intending to network and to share one on one. We really encourage participants to visit informally and cross-pollinate ideas. I don’t know that it’s our ambition to turn Pinnacle into a big conference—it’s not an EMS Today or EMS World Expo. We’ve worked very hard to keep it very personal.
What is the one common problem or mistake you see agencies making over and over?
Failing to make expectations clear or hold people accountable in a fair and just way. EMS is a decentralized operation; people aren’t in front of their supervisor every day. They are expected to have independent judgment and accomplish tasks independently.
In terms of management, leadership needs to understand caregivers’ expectations of management and make sure they communicate their expectations to caregivers clearly. We also need to be able to hold people accountable, and in my experience a lot of services don’t want to make those hard decisions in a fair and just way. At the same time, when we do something really, really well, we need to take time and celebrate that.
Have you had any mentors along the way?
Florence Hill. She started in St. Louis as a nurse’s aide and became deputy health commissioner. She was all of 40 at the time. She helped me understand the political process. St. Louis EMS was in the headlines for having employees fail EMT tests. She taught me how to work with a city council, how to present budgets, how to work with different parts of the community.
What’s the single best piece of advice you’ve ever received about being a leader?
It came from another important mentor of mine, Jim Page: To be present for your caregivers and to listen. If we don’t listen, we’re not going to hear. God gave us two ears and one mouth and there’s a reason for that. We need to listen more than we talk.
If you could recommend just one book to an emerging EMS leader, what would it be?
The Leadership Challenge by Jim Kouzes and Barry Posner. There are several key themes in the book that are useful to EMS leaders. One of them is a 360-degree review for leaders, in which leaders seek input from their subordinates as well as their peers.
Several agencies around the country claim to be (or are accepted as) “one of the best EMS agencies in the country.” What defines a great EMS agency in your mind and who are some who make the cut?
It’s hard for me not to offend somebody by responding to that. But I will say that what defines a great EMS agency is vision, “learning culture” and “just culture”: engaging people and holding people accountable. Organizations with those elements have high clinical standards and work toward that with evidence-based medicine and give great service. It’s a complete picture.
Looking back over 30 years of consulting, what do you consider your biggest accomplishment?
It was the city of Richmond in the late ’80s. They knew the ambulance contractor was struggling financially and they asked us to come in and do a systems review. We recognized that the contractor was going to be insolvent, so we negotiated the takeover of the system by the city. The city asked us to run it temporarily, to bring it to standard and put it out to bid in 18 months.
It was fascinating to watch that entity go through a metamorphosis from a struggling, beleaguered service to one that was meeting performance standards, had superb quality, was meeting the needs of the community and attracted multiple bidders.
Any special plans for your 30th anniversary?
We’re going to keep our head low and not let anybody know how old we are.
