The 3 Ps: Applying Policy, Procedure and Process to EMS
Paramedic chiefs can use the three Ps to communicate the organization's expectations regarding operational preparedness to EMS providers
Many years ago, I heard noted public safety risk management professional, Gordon Graham, speak on the topic of reducing organizational risk in public safety agencies. One of Graham’s basic tenets is, “Predictable is preventable.” In listening to Graham speak, something else caught my attention as a fire officer and manager back in my organization: the correlation between delivering good customer service and reducing organizational risk.
We’re all aware of the inherent safety risks that come with the provision of EMS, the operational risk. But are you equally aware of these other types of organizational risk? 
- Legal – the risk arising from litigation that names an organization as the plaintiff.
- Financial – the monetary risk (e.g., loss of revenue, budgetary support, employee theft) arising from the organization’s failure to meet its fiduciary responsibilities.
- Governance – those risks arising from lack of effective policies and procedures or the failure of management to enforce same.
- Compliance – risk arising from failure to comply with applicable state, federal or local laws or regulations, or failure to comply with applicable professional standards that may entail fines or loss of certification for the organization or individual members.
Delivering good customer service
I attended another lecture in Washington, D.C., on EMS legal issues, where the speaker, noted medical malpractice attorney Richard Lazar, said, “Patients don’t sue doctors that they like.” He went on to explain that a doctor’s degree of competency does not carry the same weight with a patient and their family as the doctor’s bedside manner. Patients and loved ones prioritize the physician’s compassion and caring, and most importantly, value being informed and educated about the care plan.
While listening to Graham’s lecture on the elements of delivering good customer service, I realized that he was essentially saying the same thing (only differently). Every day, EMS providers are faced with situations, large and small, that require appropriate action. Whether it’s a paramedic delivering patient care, an office manager filling Medicare claims or a supervisor dealing with a personnel issue, improper response can have unwanted consequences for the paramedic chief and the organization.
Paramedic chiefs can increase the likelihood of proper care and response by following Graham’s 5 Pillars of Good Customer Service: 
- Hire and retain good people;
- Have good policies, procedures and processes;
- Provide good training;
- Provide good supervision; and
- Demand good discipline.
EMS organizational knowledge drain
One of the personnel challenges faced by many paramedic chiefs is turnover: older employees retiring, incumbent employees moving into new positions, along with separations, both voluntary and non-voluntary. Not only does this turnover require the paramedic chief to recruit and hire new employees, it also creates a drain on the organization’s knowledge base.
Every time that a paramedic chief loses an employee or member, they’re losing a person who (hopefully) knows and understands how to do their job properly; the organization’s values and culture; and how proper individual behavior is important for the organization to succeed.
Getting those new employees up-to-speed – and keeping them there
While all five of Graham’s pillars of good customer service can have a degree of influence on reducing organizational knowledge drain, I believe that having good policies, procedures and processes (the three Ps) can help the paramedic chief take a giant step in capturing organizational knowledge by creating the organization’s owner’s manual.
So now when those new members come on board, they and their supervisors have the body of knowledge needed for them to learn how to do the job in your organization. This also serves to develop consistency in the onboarding process because the new employee’s orientation and learning is not predicated on how their supervisor (or senior employee that they’re partnered with) thinks the job should be done.
This is equally true when employees move into management positions or non-patient care roles (e.g., quality assurance, recruiting or logistics). It’s also important for those administrative jobs that the paramedic chief must fill from time to time; these new hires may come from outside the organization, making it more imperative that they get access to the organization’s knowledge base.
Policies, Procedures and Processes
Frequently, we use these terms – policy, procedure, process – interchangeably, but they are not synonymous at all. However, if paramedic chiefs understand how they fit together, they will find they can serve as powerful tools to help transfer organizational knowledge to new employees or those taking on new roles.
Policy – A policy defines an outcome. What should happen? For example, “All crews are responsible for ensuring their assigned ambulance is in compliance with State EMS Regulation 3.5.5 regarding the vehicle, patient care equipment, and on-board consumable supplies and readiness to provide patient care during their tour of duty.” Policies should be broad in scope and usually should not require significant change on a regular basis: a well written policy should serve the organization for years on end. 
Procedure – Standard operating procedures should provide the answer to the question, “How do we comply with the applicable policy?” SOPs provide the tool for the paramedic chief to ensure consistency in how things are done to comply with the policy.
All approved SOPs should be documented in a format that is easy to follow and which reduces the chance of errors being made. The goal of a good SOP is to reduce the possibility of human error and to provide guidelines for employees to follow. 
A well-written SOP is also an excellent teaching tool to help new employees or members learn and understand required behaviors or skills so their actions are always in compliance with the applicable policy.
A procedure is a detailed listing of those items that must be checked along with parameters for what is acceptable (e.g., the vehicle fuel level should be 3/4 of a tank or greater, biomedical equipment is operational, consumable supplies are at or above minimum inventory requirements).
Process – Processes take an element of a SOP and provide a succinct description of the steps involved in following the SOP, and in turn complying with policy. An individual SOP can have several applicable processes. Process flowcharts provide a great picture of how the task or function is performed successfully. Most of us do better when we can see the big picture.
For example, if an EMS provider finds the emergency warning lights do not function while checking the ambulance, the process should show what actions are necessary to correct the deficiency (e.g., take the unit out of service, contact the on-duty supervisor and maintenance supervisor). 
When do we need a defined process? Good question; and one that is frequently asked in any business. According to Dr. Edward Deming, the father of the total quality movement, an organization or group needs a defined process when these three criteria are present: 
- A task or function must be repeated on a frequent basis;
- A task or function must be done by a number of different people; and
- A task or function must have a consistent outcome.
Together, policies, procedures and process can account for an effective internal control system that can enhance an EMS organization’s ability to ensure:
- Compliance with regulatory requirements and standards is achieved;
- Operational needs are met;
- Risks are properly managed; and
- Continuous improvement takes place across the organization.
SOPs and their associated processes must frequently be reviewed and updated as necessary because changes in conditions – new technology, new equipment, finances and more – can influence on how the task or function must be completed in the future.
1. Serio G. Re-evaluating Risk. Fire Chief, June 2008.
2. Graham G. Virginia Fire Chiefs Association Conference. Keynote Address. Virginia Beach,VA. Feb. 24, 2001.
3. Philley B. Definition of policies and procedures. Available at: www.ehow.com/facts_5005965_definition-policies-procedures.html
4. Campanella A. Why do we need standard operating procedures? Available at: www.ehow.com/facts_6784701_do-need-standard-operating-procedures_.html
5. Agiledge. Why are processes important? Available at: www.agiledge.com/process/why-are-processes-important
6. Air University. Handbook for Basic Process Improvement. Available at: http://www.au.af.mil/au/awc/awcgate/navy/bpi_manual/handbook.htm#What is a process