Updated June 2015
As one of the largest and oldest fire departments in the country, Philadelphia Fire has a long history of providing both fire protection and EMS, having put its first ALS ambulance on the streets in 1974. Today, the department’s 2,200 firefighters and medics handle 289,000 911 responses annually for the city’s 1.5 million residents.
As fire paramedic service chief at the department’s fire academy, Mike Touchstone runs the EMS training unit, where he oversees curriculum development, EMT certification of cadets, the recertification of approximately 950 firefighter-EMTs and 230 single-role paramedics, and CPR certification for all uniformed staff.
Touchstone got his start in EMS in 1980. Driving home one night, he and a friend came upon a serious car accident in which a young woman had been ejected from her vehicle. They called for help, and a police officer driving a Chevy Suburban showed up to drive her to the hospital. At the time, ambulance response for medical emergencies in his suburban Philadelphia neighborhood was very limited. “It bothered me,” Touchstone says. “I lived there. My parents lived there. I knew some guys who had died when they wrecked their motorcycles. So I became an EMT.”
Touchstone began volunteering for Narberth Ambulance in Ardmore, Pa. He later became a paramedic and went to work for a newly launched hospital-based ambulance service. In 1989, he was hired by the Philly Fire Department as part of the department’s first group of eight single-role paramedics. He was made acting chief of fire paramedic service in 2006 and chief in 2007.
Touchstone has served as an adjunct instructor at the National Fire Academy, where he taught EMS management courses. He is also the National EMS Management Association’s (NEMSMA’s) president-elect. His two-year term as president will begin in January 2015.
Touchstone spoke with Best Practices about EMS leadership issues, including the need for a professional standard, curriculum and credentialing for EMS officers.
What was it like to be a single-role paramedic in a large urban fire department that had never used this staffing model before?
It was a real challenge, but I had a lot of field experience, so that helped. And I was confident about what I was doing, so I wasn’t dependent on others to get the work done. I think I earned their respect by being good at what I did.
The other thing I brought to the table was that I was a cook. One of the best ways of incorporating yourself into firehouse life is by taking control of the kitchen! I made all kinds of stuff: lasagna, chicken parm, coq au vin, fish. Another thing was pitching in. When it was time to do housework every morning at 9 a.m., I tried to be the first guy with a broom in my hand. You have to earn the respect of the people you work with. Be humble, listen and watch.
Have attitudes toward EMS changed among firefighters, many of whom might have gotten into the job primarily to fight fires?
Philadelphia is an old, traditional fire department. It was an early adopter of ALS, but there are still some guys who feel they are there to be firemen. I think it’s a minority at this point, though.
Most of the people paying attention understand that EMS is an important component of public safety. I don’t think there is anyone left on the job who didn’t have to be an EMT as a condition of employment. So, yes, attitudes have changed.
There’s been much discussion about how community paramedicine and mobile integrated healthcare can transform EMS. Is the fire service prepared to compete in this new world? How about Philadelphia?
Any fire department that has paramedics has an opportunity to participate in this. Moving forward, it’s going to be an important component of any EMS system.
The original concept of EMTs and paramedics was intervening in life-threatening emergencies to reduce morbidity and mortality. Over time, it’s evolved in a way that wasn’t originally conceived. Today, paramedics and EMTs are responding to requests for services that aren’t life-threatening; we respond to chronic medical problems. Particularly for the underinsured or the uninsured, EMS is an entry into healthcare, which is very inefficient. So it’s inevitable that EMS is going to have to change, not only because of the way CMS is going to pay for things, but because the community has a different kind of need. Over time we’re going to have to figure out ways of providing care holistically: How do we interact with public health, hospitals, the public? Community paramedicine was originally conceived as a way to get medical care delivered to underserved, rural populations. But that same concept should work for underserved, urban populations.
In Philly, we’re looking to do a pilot. I see us eventually doing community paramedicine in partnership with hospitals, payers and a broad consortium of stakeholders. But in the difficult economic times we’ve been through, it’s hard to get resources to expand into new areas of service. Older urban municipalities are going to struggle a little bit because money is tight and resources are limited.
I think the term mobile integrated healthcare may confuse the issue, though. I refer to it as community paramedicine. Names are important; we have to define a term for what we do. The term should be paramedic. Mobile integrated healthcare is a thing; community paramedic is a person. We still don’t have clarity for a name—we still get called ambulance driver, emergency responder, emergency worker or EMT. I was even called a stretcher-bearer once. To me, anybody in an ambulance should be a paramedic.
NEMSMA has been growing rapidly in its national agenda and clout in the industry. What issues are at the forefront for the organization?
Developing credentialing for EMS managers and leaders. In 2000, NHTSA put out EMS Education Agenda for the Future: A System Approach, which outlined core content, scope of practice and education standards for EMTs and paramedics. In 2008, NEMSMA published EMS Management and Leadership Development in America: An Agenda for the Future. Then in 2010, we held a meeting with broad stakeholder representation to discuss the future of EMS leadership and management. There was a consensus outcome that we would work using three levels of EMS management: frontline supervisor, mid-level manager or EMS officer and the highest level, executive EMS officer. We’ve been working on competencies for each level, which should be released in a white paper soon. We’re also exploring the process and method for EMS officer credentialing.
What’s lacking in terms of leadership development in EMS?
The gap we identified is that EMS lacks a common standard based on consensus about the competencies needed to be successful as an EMS officer. In the fire service, you have standards for fire officer professional qualifications that are dictated by a consensus standard, NFPA 1021. We don’t have anything analogous to that in EMS, though there are some courses you can take.
Officer development has been a component of the fire service for a long time. Some places require education for promotion, such as an associate’s degree to make a certain rank, a bachelor’s to make a higher rank, even a master’s degree. They acknowledge the value of formal education, whether it’s in emergency management, fire science, leadership dynamics or organizational dynamics.
What seems to happen in EMS is that people get promoted because they are good guys or skilled paramedics, but often they are put in a position they are not prepared for. There are a lot of components that EMS officers need to spend time practicing and learning. Communication skills. Performance evaluation skills. Listening—that’s a really hard-to-develop skill. Documentation. Performance improvement planning. How to delegate. Personal improvement planning and career planning.
Organizations have mission statements, vision statements and a strategic plan. It’s really important for a leader to take time to reflect on their own personal values and the organization’s values. If your personal values and the organization’s values are not similar, they are going to be in conflict. Part of being a good leader is being true to your own values.
Why is listening an important skill for EMS leaders?
Communication is a two-way process, and our primary mode of communication is spoken language. In order to truly understand what somebody is trying to tell you, you have to actively listen. What we often do when we’re listening to somebody is we begin to listen to our interior voice, creating our response to what they said. The hard work of listening is learning to shut off that interior voice and attend to the person who is speaking.
It starts when you become a paramedic. You have to listen to what the patient says and what the patient’s family says to help you in your diagnosis. The same is true with human resource problems or when you are trying to help somebody improve. We can’t make anybody do anything; we can only provide the support and tools to help them choose to succeed for themselves, which is hard work.
Is there more to delegating than just telling someone what to do?
Most people think that assigning something to a subordinate is delegating. But doing it well is more involved than that—you have to choose the right person and make sure that they have the opportunity to say no. You have to provide them with authority, sufficient resources to accomplish the task and checkpoints so you can monitor performance, and it all has to be done collaboratively. There also has to be accountability, defined communication and contingency plans if something is not going well. And there has to be a clear reward.
Leaders also need to prepare people for future roles and responsibilities, and teach them how to delegate. It’s a component of succession planning.
How do you define the difference between a manager and a leader?
It’s pretty clear in the literature. You need both skills, but a leader is a person who is looking outside of an organization, defining the vision and bringing people together to be committed to a group effort. The leader sets the parameters for what the future is and defines it using a collaborative process. A manager looks inside the organization to provide the tools and resources that members of the organization need to get the job done.
During the recession, animosity between the fire service and private ambulance services re-emerged in many areas. Is that issue still relevant?
In a troubled economy, everybody is trying to figure out ways to survive. EMS is made up of so many disparate components, you can’t define it as one thing. Many times, those different components are in conflict.
A concept worth exploring and talking about is known as the wicked problem. It grew out of public policy issues that were too complex to easily solve. EMS is a poster child for wickedness. With tame problems, you can use standard problem-solving methodologies; with wicked problems, you can’t.
This reflects the complexity of EMS. Stakeholders have different definitions of what the problem even is. The fire service has one way of describing what the problem is. Same for interfacility, or a hospital-based 911 service, or a municipal third service. The public defines it differently, too. To solve a wicked problem, you have to use different methods. Collaborative planning and problem-solving seems to have been successful in some areas of public policy and can apply to EMS.
You’re in the midst of a postgraduate education. Where are you going?
I’m going to Naval Postgraduate School, Center for Homeland Defense and Security, working on a master of arts in homeland defense and security. Initially I thought I was going to pursue a master of education. I am an educator, and homeland security is not my area of expertise. But the more I thought about it, the more I thought it would be good to get a different perspective on homeland security and public safety.
They don’t have many EMS people in the program, so I also thought we needed to have our perspective included in the homeland security enterprise. Like EMS, homeland security is a very young discipline, and it’s not really clear if it’s a separate discipline in and of itself. EMS hasn’t been at the table in how the homeland security money got spent; it mostly went to police and fire. But anytime there’s a homeland security situation, EMS is right on the front line. So we need to be at the table.
