Balancing work-performance expectations in EMS agencies

Most EMS workplace conflicts are rooted in a mismatch between manager and employee understanding of responsibility, authority and accountability


A few years ago, I was leading a staff development workshop for an EMS agency. We were coming up on a discussion of some of the key responsibilities of a paramedic chief or first-line supervisor: responsibility, authority and accountability.

As my presentation started, one of the students asked, "What’s the difference between those words? Don’t they mean the same thing?"

As frequently happens when I’m teaching or facilitating training, my mind suddenly conjured up a story to make a difficult concept more easily understood by my audience.

What is your organization's authorization process for new paramedics? (Photo by Robert Avsec)
What is your organization's authorization process for new paramedics? (Photo by Robert Avsec)

My story was about how I first obtained my driver’s license in the state of New Jersey.

Responsibility
My mom taught me how to drive. She taught me everything there was to know about operating and taking care of a car. She started out letting me drive in parking lots and on the back roads where there wasn’t much traffic. She focused on making sure that I knew the traffic rules, driver courtesy and what happens when you don’t do preventive maintenance on your car.

She taught me everything I needed to successfully obtain my driver’s license and become a safe and courteous driver who understood my responsibilities as a driver. But none of that instruction allowed me to start driving the family car on my own.

Authority
To drive the family car, I had to pass the New Jersey Department of Motor Vehicles written and practical tests. Only by demonstrating competency by passing those tests did the State of New Jersey give me the authority to legally operate a motor vehicle.

By successfully obtaining my license, I entered into an agreement with the state. I could legally operate a motor vehicle so long as I obeyed the state’s rules on operating a motor vehicle.

Accountability
Along with that driver's license came accountability. By obtaining my driver’s license, I also understood and accepted that there would be consequences if I failed to follow the rules. Violations of those rules, such as exceeding the speed limit or being involved in a motor vehicle crash, would earn me points. Earn enough points and the state would revoke my license — my authority — to legally operate a motor vehicle.

Balancing expectations between chiefs and personnel
Analyze most any workplace conflict between a manager and an employee and the result will likely be a case of mismatched expectations for the situation on the part of one or both of the parties involved. The paramedic chief can more effectively manage such risk from conflict within their organization by ensuring that they, and their entire staff, have a clear understanding of responsibility, authority and accountability.

Here is how the paramedic chief can apply these concepts to their leadership and management of the staff of their EMS organizations.

EMS workplace responsibility
EMS providers can better meet expectations when they know those expectations in advance. Create and maintain accurate job descriptions and performance criteria for all positions. Use those documents as the foundation for all training that personnel receive for the positions they fill. Don’t assume that because a person earns their EMT or paramedic certification that they know what the job entails in your organization.

If the organization does not have job descriptions or they need updating, the paramedic chief should survey their incumbent staff for each job in the organization to identify the job tasks that an individual is expected to take responsibility for completing. Use the results of the survey process to develop job descriptions that match reality.

Authority to provide EMS
Create and maintain an objective process for each position in your organization that requires the employee or member to demonstrate that they have the knowledge, skills and abilities to meet their job description identified job responsibilities. The Chesterfield County (Va.) Fire and EMS Department addresses the issue of authority with the following process for all its personnel who become newly certified paramedics.

1. Schedule shifts with a paramedic preceptor
A new paramedic is scheduled to ride as the third person on one of the department’s ambulances for 10 24-hour rotations. One of the other crew members is an experienced paramedic who’s been selected by the department’s ALS Training Coordinator and authorized by the department’s Operational Medical Director to serve as a paramedic preceptor for the new paramedic.

During those 10 rotations, the new paramedic works with their assigned preceptor for the first three tours and the last two tours. During those first three tours of duty, the new paramedic functions as the attendant-in-charge for all patient care and completes all the required patient care documentation.

2. Patient care review and skills practice
Following each patient response where care was rendered, the preceptor reviews the call with the new paramedic for teachable moments and improvement opportunities. Written evaluations of those call reviews, along with a copy of the patient care report, are placed in the paramedic’s three-ring binder preceptor manual.

During the tour, the preceptor and paramedic review protocols and practice patient care skills, for example, airway management and patient assessment, using an ALS training manikin. Written documentation for the completion of this hands-on skills practice are also placed in the preceptor manual.

For the five tours inbetween, the new paramedic is assigned to a different ambulance crew where a different preceptor continues to supervise the new paramedic's work as the attendant in charge. This helps round-out the new paramedic’s experience and get evaluations from another set of eyes.

3. Staff review and approval
When the new paramedic has completed their 10 rotations, they forward their preceptor manual to the ALS Training Coordinator for joint review by the coordinator and the department’s EMS Director. Their review can result in a positive recommendation to the Operational Medical Director; a recommendation for assignment of the paramedic to additional time with a preceptor; or a recommendation that the OMD not authorize the paramedic to deliver patient care as a paramedic for the department. For a recommendation on non-authorization, the employee — who was already a firefighter/EMT as required for employment — continues to fill that role for the department.

4. Operational Medical Director review and approval
The OMD reviews the recommendation and the contents of the preceptor manual to make their final decision regarding authorization. If approved by the OMD, the new paramedic is authorized to provide ALS patient care under the OMD’s medical license.

This process is followed for all newly certified paramedics. If an experienced paramedic is hired as an entry-level firefighter, there is a modified process that only entails the paramedic to complete five 24-hour tours with a preceptor.

Your department's authorization process should not be limited to patient care responsibilities. The most critical job function in any EMS organization is safe response to the scene and equally safe transportation of the patient and crew to a medical facility.

What is your organization's authorization process for new paramedics?

Accountability for assessment and care
Create and maintain a system of counseling, coaching and disciplining so that from the moment the employee or member assumes the position that they understand the potential consequences of not fully carrying out their authorized job responsibilities.

It’s probably a fair assumption that too many EMS organizations do not have a fair and consistent system of progressive discipline. Too often disciplinary actions are determined on a case-by-case basis; such actions tend to be very subjective and tainted by a supervisor’s personality or their prejudices regarding the employee who committed the infraction.

In 2013, Assistant Chief Shawn Robinson looked at the lack of consistent administration of existing discipline procedures and policy, and the resulting negative effect on morale and leadership confidence that these cause on the Greentown (Ohio) Fire Department [1].

"Recommendations included utilizing a committee made up of members of the department to update the discipline policy to meet the current needs of the department; distributing the discipline policy and all policies to all members in writing; having training on the policies at least annually and whenever a policy is updated; training the officers that are tasked with administering discipline to ensure fair and consistent administration; and to establish a documentation system that ensures discipline is administered in a consistent manner."

Robinson’s review of current literature on the subject of progressive discipline policy found consensus on the key elements that could be part of an organization’s progressive discipline policy [2]:

  • Appropriate standards of conduct
  • Written job descriptions outlining expectations, duties and performance standards
  • Steps in the disciplinary process
  • Notice that the steps of the disciplinary process may be skipped based on the severity of the infraction
  • The length of time that a disciplinary action remains a part of the member’s employment record

Share how responsibility, authority and accountability work in your EMS organization in the comments.

Author's note: Robinson’s work, an applied research paper that he completed as a requirement in the National Fire Academy’s Executive Fire Officer Program, is a solid piece of scholarship that is worthy of a full read by any Paramedic Chief.

Identifying and Correcting Deficiencies in the Discipline Policy and System of the Greentown Fire Department

References

1. Robinson, S. Identifying and Correcting Deficiencies in the Discipline Policy and System of the Greentown Fire Department. Applied Research Project completed as requirement for Executive Fire Officer Program. National Fire Academy. Emmitsburg, MD. P. 2. [Available On-line] http://www.ohiofirechiefs.com/aws/OFCA/asset_manager/get_file/79811

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