When Louisville, Ky., merged its city and county governments, it became the 16th largest city in the nation and Louisville Metro EMS was created.
After spending the first four years building the operational infrastructure of Louisville Metro, its command staff began to refocus on the medicine. I became the quality assurance (QA) officer and we began evaluating new employees by having them come into the medical director’s office for an oral scenario.
One day, a 17-year paramedic brought in an EMT he had been training for weeks. During the scenario, it became obvious the EMT didn’t know what was supposed to be in his kit. When we asked the paramedic preceptor for an explanation, he replied that he assumed someone else had shown the EMT. We also experienced other challenges, including with providers who came in as lateral hires or who may have been on long-term leave. They had difficulties with such things as rhythm or EKG interpretation or management of complex ACLS scenarios, even though they had been through the traditional required ride-time with a preceptor. Soon after, we created a new preceptor program, beginning with identifying the problems with the old one.
As with most EMS services, we were using an age-old system of making our most senior EMTs and paramedics into preceptors and assuming they would turn out good employees without much guidance. The program lacked accountability, responsibility, structure and a means to measure what the trainee had learned. We needed to teach our best EMTs and paramedics to train others, set up a clearly outlined structure and apply a healthy dose of accountability and responsibility. The structure seemed the easiest problem to tackle, so we started there.
We pulled together a group of our command staff and asked them what they wanted a new employee to learn. The answers varied depending on the command staff member’s perspective (e.g., those involved in QA, training or medical direction focused on the clinical competency and critical thinking, while operational staff leaned toward standard operating procedures (SOPs) and daily field tasks).
We took these responses and built a daily curriculum that contained all of their answers. This grew into what we now call the “Field Orientation Binder,” which contains the following items:
1. Level of activity (i.e., observation, directed patient contact and guided patient contact);
2. Daily and weekly evaluation forms;
3. Educational aids (i.e., a patient evaluation and management check sheet), and
4. Daily curriculum, including protocols, field tasks and SOPs to be covered.
Each day is a review of the previous day with additional material. The daily curriculum, protocols and SOPs have signature lines for the trainee and preceptor to sign off on what was accomplished. In addition, daily evaluation sheets, which remain in the binder, are reviewed by the preceptor and trainee. These are also reviewed by the operations officer on a weekly basis to ensure progress is being made and establish accountability for the trainee and preceptor.
The Field Orientation Binder also has the following four clinical levels:
1. ALS for new employees;
2. BLS for new employees;
3. ALS upgrade for current EMTs being promoted to paramedic, and
4. Return-to-duty for those employees who have been off work for an extended period of time.
Once we established the basic elements and standards of the new program, we created its structure.
Four Building Blocks
Perhaps even more important than accountability were the larger issues of responsibility and leadership. Because we couldn’t find a suitable program as an example, we turned our known problems and our vision into a training program that included the following four parts:
2. Adult education;
3. Responsibility, and
4. Critical thinking skill development.
Leadership: For some, leadership is a natural ability. But for most, it has to be developed. When we asked our pilot group to identify the traits that make a great leader, they listed trust, confidence, responsibility, technical proficiency, effective communication and a willingness to get in the trenches and do the job.
Next we gave them our 10 steps to talented leadership:
1. Solve problems;
2. Be proactive;
3. Make decisions and take responsibility for the consequences;
4. Share your vision;
5. Look for people who are struggling and find a way to help them;
6. Compliment talented work;
7. Be willing and enthusiastic;
8. Ask for help when you need it;
9. Offer honest, useful, detailed feedback and be honest, and
10. Remember it isn’t about you.
The following leadership styles were identified and defined:
• Authoritarian task-oriented leaders do what they’re told and don’t ask questions. This style of leadership is appropriate for critical task situations only.
• Team leader-oriented leaders encourage goals and lead by example. This style is appropriate for all other learning situations.
Adult education: Adults are internally motivated to learn and will resist the “because I said so” tactic taken by most old school preceptors. The focus of adult learning must be on the application of knowledge and skills. The following learning styles were defined and associated with the teaching styles most appropriate for each.
• Visual learners like graphs, diagrams and illustrations;
• Auditory learners are careful listeners who like verbal step-by-step instruction, and
• Kinesthetic learners (most EMS providers by nature) like hands on, scenario/lab based learning.
We stressed with the following parts of trainee education and taught them how to address and manage problems using the SOAP method (subjective, objective, assessment and plan):
1. Listen to trainees express their feelings, opinions, experiences and knowledge;
2. Be engaging and avoid barriers to effective communication;
3. Acknowledge efforts and successes;
4. Start with positive feedback and never put the trainee down, make personal attacks or display harsh attitudes;
5. Establish reasonable and clearly identified goals;
6. Define your expectations and theirs;
7. Recognize problems early and deal with them directly;
8. Provide one-minute lessons, and
9. Constantly evaluate.
Testing Process: At two to four weeks, an e-mail sent to the QA department indicates whether the trainee is ready to meet with our initial interview committee. This committee, which includes someone from QA, education, operation and the preceptor, reviews the binder to ensure the trainee is making progress, talks with the preceptor and the trainee (both together and individually) and gives the trainee an oral scenario to manage. Once the scenario has been completed, the committee formally evaluates and discusses the case-management conducted during the course of the scenario. We discuss the management as a group.
The group identifies a basic scenario category, a brief summary of the case and the trainee’s strengths and weaknesses. If they hit a critical failure point, they’re removed from field orientation and return to the education division for remedial training. If the trainee does well, they can be conditionally released from a three-person crew for two to four weeks and meet with our medical director.
If the trainee fails to pass the interview with our medical director after three attempts, one of three things can happen:
• Their employment is terminated;
• EMTs attempting to upgrade to paramedic status are offered their previous position as an EMT, or
• New employees seeking a paramedic position are offered an open position as an EMT if one exists.
It used to take us months to get new employees functioning up to our standards. Now we turn out highly competent new employees in six to 12 weeks. Since the start of the program, we’ve seen exceptional work by many of our providers, including an increase in thinking outside the box. Louisville Metro EMS is using this program to combat complacency by focusing on the medicine, increase leadership by field providers and encourage critical thinking. We’ve raised the bar by asking our providers to be “clinicians not technicians”. Our goal for the future is to push our paramedics and EMTs to new heights with protocols that stretch their critical thinking skills.