We were desperate.
For years, our department_s position on how to acclimate a new paramedic was to test their sanity by partnering them with a seasoned veteranƒwho was often burnt as toast. Depending on the lot they drew for a partner, the employee was subject to a sink-or-swim approach. Lessons were often learned by trial and error, with no set objectives or goals for the new paramedic_s success during the formative years of their career. An evaluation was completed by that randomly selected partner, but it wasn_t given much credibility or regard. We were adding personnel with little more than a license and a pulse.
In addition to the lack of consistent field training, it took a new employee more than a year to become a fully independent paramedic, amplifying the staffing problems the department already faced. We had heavy turnover of firefighter/paramedics due to staffing problems, frustration with inconsistent operations, the high call volume of an urban system and an overall shortage of paramedics in the Midwest/South.
Thus, the nonexistent field supervision of the 12th largest EMS system in the„U.S. fostered dysfunction and was beginning to be rattled by multimillion-dollar lawsuits. Like I said, we were desperate. Our field training program needed an overhaul.
A Familiar Pattern
In the mid 1990s, the„Memphis (Tenn.) Fire Department (MFD)ƒlike many other fire-based„EMS systemsƒwas faced with a federal Fair Labor Standards Act that led to the creation of the dual-role system. As a result, MFD today has 33 ALS ambulances married to 33 pieces of ALS-staffed fire apparatus that provide rapid response to 9-1-1 calls. Firefighter/paramedics rotate during their 24-hour toursƒ12 hours on the ALS ambulance and 12 hours on the ALS fire company.
At first, not all MFD managers were in favor of the change to a dual-role system. This conflict led to a breakdown within the system that resulted in all„EMS supervision and rank structure being abolished, and total supervision of firefighter/paramedics being given to a fire officer without a solid prehospital care background. Soon after, a training program was put into place that required a new employee to spend 20 weeks at the„MFD„Training„Academy to study firefighting, the department_s standard operating procedures (SOPs) and„EMS protocols. After release from the academy, a new firefighter/paramedic would spend six months on an ALS ambulance, essentially relearning how to be a paramedic.
After the initial tour of duty with the ˙seasonedÓ„EMS veteran, probationary time was combined with an additional six-month period served on an ALS engine company. This time was primarily focused on reviewing firefighting skills learned at the academy. However, because 80% of the fire service_s call volume is a response to„EMS needs, the tradeoff was unbalancedƒwith the new paramedic relying on the company officer for experience in fire suppression and the officer counting on the paramedic to manage 80% of the calls. The recruit was still responsible for patient care but was to do so without any support or supervision from an experienced paramedic at their side. Acclimation to the business of daily„EMS operations was lost.
A New Era
Two administrations and 10 years later, EMS in„Memphis is finally getting some attention. After taking office three and a half years ago, MFD Chief Richard B. Arwood immediately called for a comprehensive study of the city_s„EMS system. The group_s findings revealed that many aspects had led to the decline of service, including such system deficits as inefficient field supervision and inadequate training and quality improvement (QI) measures. Chief Arwood and the Memphis City Council made a commitment to turn the service around, and Deputy Fire Chief Gary Ludwig, a 29-year veteran in EMS, accepted the challenge to lead EMS in„Memphis to a new beginning.
The proactive approach to service delivery, coupled with a management philosophy that human resources are the department_s most valuable asset, has led to a new era for our prehospital delivery. A series of meetings led to the development of strategic goals and related solutions within the„EMS improvement plan. Those goals were developed by the end userƒthe employeesƒand facilitated by Chief Ludwig. The result was a list of service improvements that included EMS supervision, training, QI and the development of a mentoring program for our most valuable assetƒthe new employee.
The real challenge was to develop an effective mentoring program that would equip new employees with the tools needed to function independently and properly. ˙The goal of the program is to create a learning environment that helps the recruit succeed, not fail,Ó Ludwig says. ˙I feel some recruit programs around the country are designed to bring out weaknesses [and] instill lack of confidence, and, subsequently, the recruit either drops out or fails when the rubber hits the road on a call.Ó
The program also required a process for proper information relay, retention and evaluationƒwhich depended on establishing qualified field training officers (FTOs). And time was a factor. We needed to place a competent paramedic in the field in a timely manner, and the old method was inefficient and unacceptable.
˙When I came to Memphis, I felt the current process of placing a paramedic with another paramedic [and company officer] for one year as a second crew person was not effective because it did not create a conducive one-on-one learning environment,Ó says Ludwig. ˙After all, how can one paramedic teach another paramedic when one is driving the ambulance and the other is trying to render care in the back of the ambulance or riding on a fire apparatus with no EMS supervision?Ó he asks.
Program Takes Shape
Our goal is to retain quality paramedics and offer the city_s residents and visitors the best prehospital care available. With this goal in mind, the new approach to field training is proving a success in many ways.„EMS education now focuses on enhancing the existing and new paramedics_ capabilities, rather than repetitive drilling of skills learned in paramedic school. Also, skills are evaluated early in the recruitment process, and the employee is terminated if they don_t perform at acceptable standards. As a result, we could start with 40 applicants, but only 20 may make the cut after the academy_s academic program and„EMS mentoring process.
Development and implementation of the new FTO program was assigned to Lt. Pamela Kiestler, and her vision of a comprehensive program is paying off. Key components include proper selection and training of paramedics to serve as FTOs, a task list manual for orienting new hires to our„EMS system, and, in the affective domain, matching the new employee with a compatible FTO to accentuate both paramedics_ attributes. These components have combined to achieve one of our important„EMS strategic goals for system improvement.
Train the trainers: The purpose of the mentoring program is to teach new employees how to operate independently within the MFD EMS system. To do so, the recruit must be mentored by an active crew member who_s qualified and trained to serve as an FTO. ˙Field training officers [who] were chosen to be mentors were our best clinicians and best employees with [positive] attitudes toward the job. We wanted the first exposure that our recruits had to the department to be a positive one,Ó Ludwig says.
Beyond being model clinicians and employees, FTOs must understand the entire scope of the training programƒits goals, procedures and measures. They must be intimately familiar with the training manual and also possess good interpersonal skills in order to motivate and coach new recruits.
Each FTO is carefully selected by an interview and clinical evaluation process, which involves evaluation of the potential FTO_s training records and results of their EMS QI reviews, with attention paid to documentation and clinical application of skills. Interviews with the prospective FTO_s superiors and partners are also conducted to assess personality traits. To date, 45 firefighter/paramedics have been chosen and trained as FTOs.
By the book: One key to the success of any department is a set of standardized, up-to-date policies and procedures. It had been several years since the department_s policy manuals had been updated, with policy changes coming out in memo form. Therefore, no single document was appropriate for training recruits, and a manual had to be created from the ground up.
Lt. Kiestler performed an exhaustive document search, photocopying 20 years of EMS related memos, cross-referencing them with the existing„EMS policy manual. She then sorted the documents into topics and by date, removing any policy or memo no longer applicable either because of revision or a change in the legal or resource climate. The remaining topics were broken down into individual tasks.
Focus groups were also held with current firefighter/paramedics of varying levels of seniority and experience, whereby all job responsibilities and tasks, both written and unwritten, were listed. The tasks from the focus groups were then integrated with the tasks taken from the document search. After the integration, the topics were prioritized to determine at what point in the training they would be introduced to the recruits. For instance, one sure way to run afoul with the authorities is by mishandling narcotics, so this topic was defined as Day One material.
The result of this effort was controlled language related to functioning as a firefighter/paramedic within MFD. The training each recruit undergoes is now scripted by the manual, whether the recruit is assigned to an FTO on Unit 1, 3 or 5, or whether on A, B or C shift. Each recruit learns the same material on Day 1, Day 2 and so on.
This scripted training also attempts to control for quality and content when the recruit is detailed to a different FTO; there_s no confusion about what material has been covered to date and what remains.
Each recruit and FTO receive their own copy of the appropriate manual, titled ˙Recruit Training ManualÓ and ˙FTO Manual,Ó respectively. Both parties are encouraged to make notes and write down questions for later exploration. Each day, the recruit and mentor must complete daily tasks as outlined in the task list manual, with a minimum of three hours of active instruction (see p. 57). The recruit also has other reading and studying assignments that must be accomplished. By developing and complying with this manual, our department ensures each recruit is taught all the information they_ll need to become a fully functioning, independently operating paramedic within our department.
Mentor match: After the classroom portion (which is now completed in less than half the time previously experienced due to a streamlined, enhanced EMS educational track at the MFD Training Academy), recruits are paired with an FTO to complete the EMS component of their training. Successful field training relies on matching a recruit with an appropriate mentor in terms of attitude and other elements in the affective domain, so the pairing is a conscious decision. The recruit must be able to trust their FTO in order to accept their guidance and instruction.
For 30 24-hour shifts, a recruit mirrors their FTO. For example, if the FTO is on the ambulance, the recruit will ride third-party with an ALS transport crew of one EMT-IV and one EMT-paramedic. If the FTO is on the ALS engine, the recruit will ride fifth-person, along with the driver, lieutenant, firefighter/EMT and firefighter/paramedic.
If staffing requires the FTO to be detailed to another ALS resource, the recruit is detailed with them for consistency in mentoring. However, if an FTO is sick or otherwise not able to work a scheduled shift, the recruit is detailed to their designated alternate, who has also been through the FTO selection process. The recruit may also be detailed to the alternate if the primary FTO is scheduled to ride on an ALS fire company that can_t safely accommodate a fifth person (e.g., the rig has no seatbelt).
During the mentoring process, recruits wear red recruit work T-shirts so they can be easily identified and helped on the scene by other members of the department. After the mentoring program is completed, the recruit is assigned regular department work clothing. The change from red to blue has become a right of passage.
For accountability, safety and proper communications, each recruit is also assigned a portable radio. The radio accompanies the recruit from station to station as they rotate through the FTO process. Thus, recruits can fully participate while on the ALS ambulance and the ALS fire company during their training and actually take part in active„EMS and fire-ground operations with their FTO.
The FTO also evaluates the new recruits by using the behaviorally anchored rating scale (BARS) system. BARS is a performance appraisal method that combines elements of the traditional rating scale and critical incidents methods. Job behaviors are derived from critical incidents, both effective and ineffective behavior, and are described more objectively in writing by the FTO. With BARS, various performance levels are shown along a scale and described in terms of an employee_s specific job behavior in both positive and negative aspects (see right).
At or near the completion of the 30-shift evaluation, recruits report to the training academy for an oral examination to test their comprehension of the ˙Recruit Training Manual,Ó BLS and ALS SOPs, and other materials. The recruit is evaluated by the departmental„EMS chiefs and medical director. To limit interruption of field operations during the oral examination process, the recruits are placed off-duty but compensated for their time. If a recruit_s performance is deemed sufficient to operate independently, they_ll be assigned to an ALS fire company and then begin training on that equipment and apparatus.
Reflecting on the achievements of the mentoring program in the past year, Ludwig says, ˙I am extremely proud of how well the Memphis EMS training staff embraced this paradigm shift, took ownership of the program and then executed it with perfection.Ó Lt. Kiestler says the program has addressed prior staffing needs. ˙We have hired three classes under this system, two of which have completed the mentoring process and are now in the field, giving much-needed relief to those already out in the streets,Ó she says. The first two added 47 paramedics to the field, and she expects the 19 members of the third class to complete the process in January.
˙Paramedics hired and trained under this system are more consistently and thoroughly trained than any previous class of paramedics. We believe this will help increase morale, increase protocol compliance, decrease lawsuits, decrease burnout and decrease turnover,Ó Lt. Kiestler adds. ˙The department also plans to adapt the program to create an FTO program strictly for fire suppression, as well as an FTO program for EMTs. We are consistently trying to raise the bar of performance and believe that such programs across the board will help to achieve this goal.Ó
And the mentoring program_s success doesn_t end in„Memphis: EMS systems in„Texas,„Maryland,„Arkansas,„North Carolina,„Mississippi and„Massachusetts have adapted the Memphis EMS Mentoring Program into their services.
Albert Einstein once said that the purest form of insanity is doing the same things over and over and expecting different results. Our service was guilty of subscribing to this principle that easily catches managers and systems off guard. But we need to ask ourselves, What type of product are we delivering to the public? Does our system_s approach to its most valuable asset need an overhaul? Remember, your service is only as good as the people you put on the streets.
If your system would like to learn more about the Memphis Fire EMS Mentoring Program, contact Lt. Pamela Kiestler at 901/826-5377. JEMSJ. Harold Logan, BPS, EMT-P, is a 23-year veteran of fire-based EMS and serves as a lieutenant firefighter/paramedic for the Memphis Fire Department in an EMS administration capacity, specializing in„EMS consequence management. He_s an EMS instructor coordinator and fire instructor for the Memphis Fire Department„„and the state of„Tennessee and holds a bachelor_s degree in health and safety. For more than a decade, he has also served as a rescue/medical specialist and a medical coordinator for FEMA_s Tennessee Task Force One Urban Search and Rescue Team. Contact him at„[email protected].