How EMS Can Achieve in the Face of Adversity - Administration and Leadership - @

How EMS Can Achieve in the Face of Adversity

Navigating the current EMS economic environment



Larry Boxman, EMT-P | From the February 2013 Issue | Wednesday, November 21, 2012

“We should be able to see that things are hopeless and yet be determined to make them otherwise.” —F. Scott Fitzgerald

You can’t open a newspaper or listen to radio or television news today without hearing about some organization that’s downsizing, restructuring or closing its doors. Over the past decade, organizations operated within a system of up and down cycles, facing periods of ambiguity and change with a fair amount of confidence. Although the situation might have been unsettling, some elements remained familiar, patterns were recognizable and the direction the market, and budgets, could take was somewhat predictable.

Then, seemingly overnight, in the fall of 2008, credit markets ceased to function normally, major banks disappeared, housing values plummeted, financial systems failed and commodity prices lurched wildly.

Life as we knew it had been drastically altered. Instability is now chronic, uncertainty seems permanent, the pace of change is accelerating, disruption is common, and we can no longer predict events or their affect on our budgets and operations. This turbulence is forcing managers in the public, private, volunteer and hospital sectors to change the way they operate.

As leaders of EMS organizations, we are also discovering that our leadership playbooks are consistently out of date, and that our strategic models and business planning processes are being challenged in new ways. For example, the American Recovery and Reinvestment Act of 2009, has raised more questions than answers, and the unknown impact of Accountable Care Organizations (ACOs) puts us in a state of bewilderment.

So how can we thrive in this era of uncertainty? How do we lead through chronic chaos, ferocious instability and rapid change? What does it take to protect our organizations from unforeseen disruptions? How do we build confidence and achieve success in the face of adversity?

There’s no single blueprint or magical answer to these questions. There is, however, a framework of skills we can draw on, ideas we can adopt and concepts we can adapt to best fit our organization’s culture.

The Brutal Facts of our Current ’Reality’
First, let’s accept reality as it really is, rather than the way it was or the way we would like it to be. Uncertainty now seems to be a routine part of our operations, chaotic times are normal, change is accelerating and instability will likely characterize the rest of our lives. There is really no “new normal.” There is only a continuous series of “not normal” times.

These are the brutal facts of our current reality and by understanding and accepting these facts we can avoid the past holding our future hostage. There must be an emotional connection to acknowledge that our world has changed and we are not imprisoned by the insecurity of constant uncertainty. We can’t cave in to the notion that success owes more to circumstance than to action, execution and discipline.

EMS managers must reject the perception that what happens to us matters more than what we do about it. We can’t predict what’s going to happen, and we must respond and adapt successfully to whatever unforeseen events might occur.

Whether we prevail or fail depends more on what we do than on what the world does to us. Thriving in uncertainty, leading in chaos, dealing with a world full of disruptive forces we can’t predict or control requires a new type of expertise.

Filter & Focus
We now live in a world of excess access to information delivered via our computers over the Internet. We can find whatever we want, whenever we want it, as soon as we want it. This can be helpful if we’re trying to track response times, patient refusals or claims processing times. If we’re not careful, however, this instant and constant access can overwhelm us. Too much information can be just as damaging as too little information. Thriving in this environment of information overload requires the skill of filter and focus. We must learn to sort through the information so easily accessible to us and identify the information that is most critical.

As EMS leaders, we monitor hundreds of factors. We track call volumes, lost unit hours, inventory control, loss control, response times, labor costs, vehicle maintenance costs, worker compensation claims, employee turnover, collections by source, utilization, etc. The list goes on.

In a world plagued with instability, confusion and constant data flow, the key is for EMS managers to separate the “nice to know” information from the “need to know.” The result will be different for every organization.

In my organization for example, we identified five key performance indicators (KPIs) that we felt were the most vital. We display these KPIs daily on a 50-inch monitor in our communication center. It shows our emergency response times, non-emergency times, wheelchair response times, overtime and utilization. We apply ourselves with laser-like precision in these areas because we found that success in these individual categories gives us the best opportunity for overall success.

A common misconception about success is that it comes to those who aspire to be well rounded and balanced in every area. But in times of instability and seemingly constant change, success comes most readily when we deliberately focus on a few carefully selected areas of our operations. We’ve found that this focus has actually increased our capacity and that it fuels our resilience.

The Power of Paradox
To thrive in turbulence and instability, EMS leaders must learn to be comfortable with paradox, having the ability to embrace two opposing ideas at the same time.

We shouldn’t afflict ourselves with the destructive nature of “or,” which pushes us to believe that things must be either A “or” B. Instead, we should embrace the genius of “and,” the ability to accept both extremes in a number of dimensions at the same time.

Take the paradox of control and non-control. On one hand, we understand that we face continuous uncertainty beyond our control and the fact that we can’t accurately predict significant aspects of our operations. On the other hand, we reject the idea that forces outside of our control determine our performance. We accept full responsibility for our own fate because we understand there are things we can’t control while furiously attacking the things we can control.

Another example of paradox is consistency and change. Our EMS organizations can’t succeed without consistency. Equally true, however, is that our agencies can’t succeed without productive evolution.

We must adhere to organizational values and principles while also remembering to take a step back to examine changes in the industry. It takes paradoxical vigilance to know what to change and when while still maintaining consistency.

Experimental Validation
In the face of uncertainty, chaos and rapid change, relying on analysis alone to fuel organizational changes can cause significant damage. By using experimental validation to test the changes we think we need to make based on our analysis, however, gives us a much better chance of figuring out what works and what doesn’t.

Experimental validation is trying small experiments, like pilot programs, before initiating large-scale change. The method should be low cost and low risk and allow us an opportunity to more accurately project successful outcomes before committing to a major investment.

Experimental validation allows you to try to create and innovative ideas without wasting resources. It gives you confidence that full implementation will likely succeed and deliver the results you expect based on confirmation of actual experience.

Consider this example of experimental validation from the automotive insurance industry. As described in Jim Collins’ book “Great By Choice,” in 1988, California passed a law mandating a 20% price reduction and refunds to customers. This single event plunged the country’s largest auto insurance market into chaos. Needing to cut costs and also wanting to improve customer service, Progressive Insurance Company tested an idea called “immediate response claim service.” Their goal was to respond 24 hours a day, seven days a week, 365 days a year to their customers’ homes or even to the accident scene, issuing checks within 24 hours of an accident. The experiment proved highly successful in cutting costs and improving customer service, and Progressive implemented the model company-wide, transforming the organization into one of the most successful insurance companies in the world.

By marrying creativity with experimental validation, we give ourselves the freedom to try a variety of ideas, some to succeed and others to fail, but we only invest significantly in the ideas that deliver us the results we want to achieve.

Prepare for what We Can’t Predict
In times of unpredictability, full of threat and risk, we can’t afford to leave ourselves exposed to unforeseen events. We must assume that conditions will turn against us at the worst possible moment. We must stay highly attuned to changes in our environment, while also preparing and developing contingency plans, building buffers and maintaining large margins of safety.

One way of preparing for disruptions and instability in a high-performance ambulance system is to have management and supervisory personnel trained as EMTs and paramedics so that they can respond during periods of high demand and major incidents.

Having flexible part-time employees available to report to work when regular employees are absent is a way to avoid overtime and contain labor costs. Knowing that economies of scale have a powerful effect on containing the cost of readiness, many ambulance providers market their services to healthcare facilities, thereby creating an additional revenue stream while maintaining the ability to respond to major incidents and natural disasters.

Southwest Airlines uses only 737s to simplify preventive maintenance and to minimize the number and types of parts they need to keep in stock. The airline also doesn’t give seat assignments, which decreases their boarding times and results in an increased number of on-time arrivals. Crises and difficult times are special-case scenarios of accelerated instability and uncertainty. Remember, it’s what we do before the storm that determines how well we’ll do when the storm actually comes. If we fail to plan and prepare for instability, disruption and chaos, we will suffer even more when the next Superstorm Sandy, 9/11 or unforeseen event occurs and disrupts your service.

These don’t always have to be large scale. For example, one ambulance service that had been in business since the early 1960s recently folded because they didn’t have contingencies in place when one of their vehicles struck and killed a pedestrian. This is an example of an unforeseeable event that can happen to any EMS provider. The ambulance service failed to provide adequate driver training and maintain proper insurance and appropriate financial reserves.

Since it’s impossible to predict specific catastrophic occurrences, we must systematically build buffers and shock absorbers for dealing with unexpected events.

Resilient People
Despite living in an environment of chaos and uncertainty, it isn’t the environment that determines why some agencies thrive in chaos and why others don’t. So what is this determining factor? The people involved.

People can have the discipline to confront the brutal facts of reality; people have the ability to apply filters and focus, to embrace the power of paradox, to experiment creatively and to prepare for what they can’t predict.

As Collins highlighted “Great By Choice,” companies that made the transition from average to above average first began by getting the right people on the bus, the wrong people off the bus and the right people in the right seats.

You might ask what the right people are like. As Collins says, “The signature of truly successful people is not the absence of difficulty, but the ability to come back from difficult times even stronger than before.” Meaning, successful people are resilient. And as Friedrich Nietzsche famously wrote, “What does not kill me, makes me stronger.” So the people who can help us thrive in chaos, to lead us through turbulence and instability need to have the characteristic of resiliency.

Resilient people shine when clobbered by setbacks and misfortune, turning bad circumstances into good results. Resilient people use difficulty as a catalyst to deepen purpose, recommit to values and respond with discipline and creativity.

Populating our EMS organizations with the right people is essential for navigating through chronic instability, permanent uncertainty, never-ending disruption and persistent chaos. These people make the right choice when they are afraid, exhausted or tempted. They don’t abandon their values or give up. They don’t accept average performance because that’s what most everyone else accepts. They also don’t capitulate to the pressure of the moment. When slammed by the brutal facts of reality, the right people, resilient people, don’t quit.

Achievement in the face of adversity requires the fanatical resolve to never give up, but it also requires the willingness to accept the brutal facts of reality. Developing the ability to filter out the noise, focus on the few things that matter most and embracing the power of paradox are crucial skills if you want to successfully navigate through adversity.

Experimental validation and preparing for what we can’t predict puts us in a position to not just survive, but thrive. Confidence is earned by our achievements in adverse conditions. Success and failure depends upon what we do and not what the world does to us.

Almost no one predicted the 2008 economic crisis. The next disruption will inevitably come, followed by the next one and the next one after that. We can’t know with certainty what they’ll be or when they’ll come, but we can know with certainty that they will come.

Life offers no guarantees, but it does offer strategies for managing the odds, instability, chaos, uncertainty and rapid change.

A great EMS organization doesn’t just react to events, but shapes them. As management consultant Peter Drucker taught, “The best way to predict the future is to create it.”

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Related Topics: Administration and Leadership, Leadership and Professionalism, uncertainty, planning, leadership, instability, EMS managers, EMS management, economic climate, change management, budget, Jems Features

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Larry Boxman, EMT-P

Larry Boxman, EMT-P, is the vice president of operations for Metro West Ambulance located in Hillsboro, Oregon. He is a Six Sigma Black Belt, a site reviewer for the Commission on Accreditation of Ambulance Services and a volunteer paramedic for the Mist-Birkenfeld (Ore.) Rural Fire Protection District. He welcomes your comments at


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