Somewhere on the left coast, the regional vice president of a large EMS agency calls his operations manager into his office. With the door deliberately left open, across the hall from the person he's talking about, he loudly berates his subordinate.
"One of your supervisors stopped by while you were out yesterday," he says, ˙and asked me what he should do about a personnel issue of some kind. "I'm the vice president of this organization, fergoshsakes! I have better things to do than deal with that s#!@. Can't you find supervisors who can do their own thinking?"
The vice president should have known better. He's a smart guy, and he was an EMT himself once. But he was one of those EMTs who stays in the field just long enough to realize they don't like taking care of sick peopleƒthen presumes that qualifies them to lead people who do.
An executive at another service 1,000 miles to the east has just eliminated his ops director. He's meeting with the former director's subordinates and telling them he'll be their new boss. He says not to worry, he has years of entrepreneurial experience in manufacturing, and he knows what he's doing. Of course, service is nothing like manufacturing, and EMS is nothing like serving lattes. He's just informed his people he's a ditz.
At a conference on the right coast, four big-city fire chiefs take a coffee break. Each of them is convinced their young recruits, all paramedics as a condition of hiring, are "impossible." They're selfish, they're fussy, they're demanding, and they hate working in ambulances. "It's like you have to justify everything you tell them," one says, and the others nod in agreement.
Search the Internet for "turnover in EMS" and you'll immediately glimpse an industry in turmoil. Someone at a famous university is researching an industry-wide personnel crisis. The EMS offices of state after state are wondering how their agencies are going to continue staffing their ambulances. A major eastern city has concocted an unlivable staffing schedule for its EMS crews, and the city's director is explaining to a TV reporter why his paramedics are leaving in droves. The truth is, he has no idea why. His comments sound detached, like he's discussing martians.
High turnover among today's EMTs and paramedics makes perfect sense. The leaders described in the preceding anecdotes are not bad people, but they're not EMS leaders. Some are blatantly wasting the public's training dollars, hiring folks who are smart enough to survive paramedic school, but who have no desire to be caregivers. A paramedic is not just an entry-level firefighter, and discovering that you don't like to run calls does not qualify you to lead people who do.
Leading EMS people is not just an assignment; it's a responsibility and a discipline. It requires talent, education and desireƒespecially today. Why? We're stretched pretty thin. In a time of overtaxed and under-supported social services for the poor, crumbling VA benefits and a failing economy, we've become the public's go-to people.
If that's not challenging enough, EMS people are tough to lead. They're professional interrogators who get lied to for a living and who have disciplined themselves to investigate things. They deserve to be paid for what they do, but they don't do what they do for the money. In fact, you couldn't pay them enough to do some of the things they do every day. So, they simply don't follow weak or uncommitted leaders.
Environments that produce great EMS providers don't occur without the right peopleƒproviders or leaders. And talented providers predictably seek environments that support and enable them to do their jobs. Let's examine these people and the environments they seek.
Essential Traits of EMS People
Let's discuss providers first. Think about the traits you look for when you select an EMT or paramedic. Your list will probably resemble the left-hand column of Table 1 (see p. 74). As you may have learned the hard way, every item in that list comes with a dark side (listed on the right). What enables the most valuable people (including you, actually) to keep their gifts in balance isa good, strong, two-fisted grip on their egos. See if you recognize the gifts in the chart, along with their dark sides.
Nobody's perfect. Every good EMT has a unique blend of these positive traits and their drawbacks. So do their leaders, and that's what makes leading an EMS workforce so challenging. It takes considerable talent to lead these folks -- at least as much as it does to do the jobs they do. Even then, EMS subordinates eventually decide whom they'll follow and whom they'll never respect.
Similarly, the most successful EMS leaders seem to possess at least a dozen traits that EMTs and paramedics universally recognize and respectƒcharacteristics that are essential on a daily basis. Consider the following list:
That's a truckload of expectations, but there's one more, and it's important enough to mention all by itself. An EMS leader needs to be naturally nice. When you're expected to go out in the middle of the night and be nice to cranky, stinky, nasty people who are having the worst moments of their lives, you need to know what nice feels like. If your leaders treat you like crap and your customers treat you like crap, you're probably going to feel like crapƒand dish out some of your own.
Providers shouldn't have to be perfect and neither should their leaders. But the reasons EMS leaders fail are simple and predictable. Here they are, in no particular order: 1) They're not very smart, 2) They're unethical, 3) They don't like or respect people, 4) They're not nice, and 5) They lack humility.
Benjamin Franklin reportedly said, ˙a man wrapped up in himself makes a very small package.Ó People who cannot control their egos make poor caregiversƒand poor leaders for caregivers.
That said, there are also some people you can't leadƒthose who are naturally dishonest, those who don't respect or like people, and those who are determined to be unhappy. Those are all matters of the heart, and you can't fix them. No matter how good of a teacher you are, you can't teach the heart -- only the brain.
Attracting & Retaining the Best
The back of any current EMS journal is sure to contain dozens of ads soliciting applications from paramedics. Those ads will attract some applicants, but probably very few experienced keepers. The reason? Good paramedics know that agencies who repeatedly advertise for paramedics have turnover problems. They're not fooled by schmooze, and they're immune to ads that vaguely advertise "competitive" wages and benefits. Good paramedics tend to find good systems all by themselves, and they don't come cheap. Why should they?
On the other hand, nobody attracts good paramedics like other good paramedics (or recognizes them once they've applied). And good paramedics don't recruit good people into bad working environments.
Creating & Sustaining the Right Environment
Presuming you've done a good job of selecting people who can be good field caregivers and that you have the potential and the background to lead them, how do you create and maintain an environment where they will want to come to work every day? Fortunately, that's no more mysterious than identifying the right people: In a hundred ways, youserve your subordinates, enabling and empowering them to fulfill the mission of serving others. That's servant leadership. If your job isn't taking care of customers, then it's taking care of people who do.
Taking Care of Your People
Battalion Chief Jeff Forster, of the Rocky Mountain Fire Protection District in Boulder County, Colo., has said for years that you need to know what kinds of things people will fight for, and respect those things. He calls them the Four S's: sleep, schedule, spouse and safety.
But, if you consider Maslow's Hierarchy of Needs, you're reminded that EMS people will probably fight over a lot more than just four things -- and it turns out, they all begin with "S." Let's discuss them.
Safety: All people need to feel safe, not only in the performance of their work but as valued and appreciated individuals. They deserve safe equipment, safe uniforms, safe procedures, safe workloads and safe surroundings. People need to be praised in public and criticized in private -- always. Their leaders should faithfully refrain from demeaning comments, gossip or sexual come-ons, even in jest (even just once), and should aggressively protect the good names of their subordinates.
Further, an agency needs to develop and sustain a language of safety, such that the word is heard sincerely and in every aspect of an operation. When a crew departs on a call, or even leaves work for the drive home, it should be a leader's standard practice to offer comments like, "Drive safely," "Come back safe" and the like. Eventually, it needs to become part of the way people think and talk every day.
Self-esteem: These aren't bricklayers we're talking about. They're caregivers, and their job is to answer the needs of people in crisis whose expectations can be inflexible, unrealistic and often conveyed in demanding and uncivilized terms. They need to be reminded often and sincerely that they're valuable, their ideas matter and their work is appreciated. That requires talent, imagination, persistence and hard work from a leader.
An organization should find numerous ways to thank people for what they do, from tracking and posting customer comments, to hiding Starbucks cards in the equipment, to bonuses, to frequent positive comments in front of peers, to gifts and lunches on the boss. But the message should always be "Thank you, you're valuable, you make a difference, you're appreciated, you matter so much to us." And the message must be real and heartfelt.
Schedule: EMS is important. It's an essential public service, and it's a serious business. But those who make it happen are people, and people's lives are bigger than EMS. Their schedules matter to them. As hard as it can be for a leader to manage overtime, fill shifts and maintain staff, people have weddings, anniversaries, funerals, kids' soccer games and any number of life events outside of EMS that simply matter more to them than staffing ambulances. Not only that, but EMS routinely beats people up, and sometimes they simply need to get away from it. Think that's nonsense? Well, there's a problem, or you wouldn't be reading this article. None of us can afford to forfeit the solid, balanced performers upon whom the very survival of our systems depend; and if we fail to support their balance, there's a predictable consequence: They leave.
Significant others: We all have families, or at least somebody we love more than anyone in the world. They matter to us. In fact, they should matter more than our life's work. When an EMT is 23 years old and their grandma dies, that's a major life event, and this important work of ours becomes irrelevant. When a dispatcher's spouse has a baby, that's a big deal. And when a paramedic's dad learns he has cancer, that paramedic needs to go home, with pay, and see their dad.
Anytime we fail to acknowledge these realities, we communicate to whole workforces that we're clueless about what's important to people. Likewise, birthdays are important, and they need to be acknowledged by an organization's chief officer. And the same is true of hiring dates. When it's somebody's anniversary with your agency, do what Platte Valley Ambulance Service's Chief, Carl Craigle, does in Brighton, Colo. Send the family a card. Tell them what their loved one means to your organization and the community, and thank them for sharing.
Sleep: Many years ago, EMS borrowed the idea of 24-hour shifts from the fire service. EMS agencies finally seem to be abandoning these shifts, especially busy agencies, because they beat the hell out of people. But plenty of us still employ them, andwe need to stop.
Aside from providing people with more days off every month (people do need to get away from this work, as mentioned above), nothing else about 24-hour shifts is good for us, our families or the public. Until we adopt shifts that make sense, we need to respect the fact that 24-hour workers need sleep. They need to sleep on shift, and they need to sleep between shifts. That means somewhere there needs to be procedures and facilities that will accommodate sleep.
Crew members who believe they're impaired by lack of sleep must have the authority to take themselves out of service. And when they get off duty, if in their judgment they aren't safe to drive home, they need transportation home (for themselves and their vehicles).
Space: It's a simple law of life that people occupy space, enough space to exist and to move. EMTs need access to comfortable station environments -- that's all. The cab of an ambulance does not offer sufficient space for an EMT working a 12-hour shift, especially a slow one, even if it does save money, or minimize chute times.
Spiritual beliefs: Most cultures hold that there's a spiritual side of life which remains unseen, but which is no less real than what we see, hear and feel around us. Questions, comments and opinions about an EMT's spiritual beliefs are protected territory in every aspect of labor law, and are not the concern of an organization's leadership or rank and file. It's tough for an EMT to arrange for regular time off to attend religious services. Perhaps because of that, many of us don't routinely attend. But there's a difference between religious life and spiritual life, and many seasoned EMS providers lead rich spiritual lives. That's their right, and it deserves the respect of the people and organizations around them.
Sexual identity: Human life is complex and multi-dimensional. Like spiritual beliefs, people's sexual lives are a part of their personal identity that makes them who they are. They deserve the respect of peers, leaders and organizations, and warrant the protection of all three.
Sustenance (food, fluids & rest): Given fuel, a diesel motor can run for weeks without ceasing. But people are not machines. When a crew gets tied up for hours on a call, like a fire standby, its leadership needs to be aware of that so someone can bring them food and drinks.
People need food, fluid and rest, period. That priority is more important than response times, turnaround times and any of the other measurable parameters we use to quantify our systems' performance, only it's not so measurable. What makes it happen is the hour-by-hour vigilance and commitment of smart, concerned supervisors. When agencies ignore the human needs of their crews, run them on back-to-back calls and fail to add resources, rising turnover makes perfect sense.
Organizational "Physical Findings"
In the process of patient assessment, some things are numerically quantifiable (like heart rate and temperature). In an organization, some analogous things include turnover (of course), customer feedback, collisions, injuries, illnesses/absenteeism, tardiness, lost and damaged equipment and so on. In either a patient or an organization, those are vital signs.
In medicine, unless the patient is doing very well or very poorly, these measurable things provide only a sketch of the patient's status. A complete assessment involves innumerable other physical findings, which are observable but not measurable. Reading their relevance presupposes intelligence and experience on the part of an examiner. And the same is true in organizations. Following is a list of those findings we should consider important.
Laughter in the hallways: Crews don't fool around when they're angry or when they don't feel safe. Frequent laughter is a good thing, and a boss shouldn't feel embarrassed by itƒeven if the mayor happens to be on the premises. In this business, humor is a healthy finding, because it's a sign that people are having fun.
Clean wheels: People don't keep their wheels clean when they're running too many calls, when they're frustrated or when they lack organizational pride. Clean wheels are one way a system tells its leaders that people are probably doing OK. (They also tell the public their EMS crews are professionals.)
Shined leather: Like clean wheels, shiny boots are a manifestation of health in an EMS organization. These are both sensitive indicators of morale, because they're one of the first things that go away when an organization is stressed.
Clean bathrooms: You can assign anybody to clean a bathroom. But when they get done, is it merely acceptable, or does it sparkle? This is a job nobody likes to do. It should probably be done by leaders along with everybody elseƒnot just the newest employees in an organization.
No gossip in the dayroom: As an industry, we gossip too much. Gossip can end careers and destroy lives. It's a sensitive indicator of the health of an organization. What do your people talk about between calls? Are they a bunch of slanderous back-stabbers, or do they respect one another too much for that? Either way, gossip begins with and belongs to leadership, which either fosters gossip (by participating in it) or absolutely abstains from it, and can be counted on to interrupt a malicious conversation immediately.
Hugs: This may seem a strange thing to consider as an organizational feature, but EMS providers' lives intersect more closely than most co-workers in other industries. It's not a bad thing if people in your organization don't hug a lot, but it's a good thing to see happening. It occurs when people love one another.
Showing up early: People who relieve one another early protect each other from late calls. When they do it routinely and voluntarily, you know you're seeing respect. It's good for them and it cuts overtime costsƒso, it deserves a leader's attention. And to the degree that it minimizes costs, it probably warrants some kind of financial rewards.
Doing stuff: What do peopledo for your organization in their downtime? Do they participate in studies? Conduct projects? Or coordinate aspects of the operation, like supply or maintenance? If they do those things, it means they're willing to invest their energy and ideas in something. Cranky people in unhealthy organizations usually aren't.
Wearing agency colors/logos on days off: Likewise, this doesn't happen when people are angry or distrustful, or when they don't feel proud of their agency. The degree to which it does happen is an indicator of organizational health, and that would be evident to a prospective employee.
Confiding in leaders: People don't confide in leaders they don't trust or respect. Nor do they seek personal advice about things like education or career plans. This is a valuable finding when you do see it, and it should make a leader feel personally honored.
Organizations are all about people, and EMS organizations are all about people born with very special gifts. Their leaders need to have a sense for themƒunderstand what makes them tick, and appreciate what makes them different. Leading them isn't a job for just anybody. But it's a manageable task for someone who thoroughly understands EMS and honestly cares aboutƒand honestly likesƒthe people who do it.