EMS Insider, Expert Advice

Seeking Stability


The director of a medium-sized service in the Northeast told me a few weeks ago that “I just want some control. It feels like I’m constantly crashing into the rocks instead of being the rock for my team.”


Reasons for chaos


We are living and leading in a chaotic world. In EMS, the pressure takes a heavy toll on the organization and its leaders. Four common sources of pressure include financial issues, mismatched caregiver expectations, increasing performance requirements and governance issues.


From a financial perspective, I’ve never met an EMS director who feels they have too much money. Revenue compression from payers, loss of subsidies, the confusion about Obamacare, and increasing federal scrutiny, audits and investigations all contribute to the current financial chaos.


Caregiver expectations that are unrealistic or not well aligned with the organization’s mission, vision and values are also problematic. So many EMS workers expect their needs to be met in the time it takes to complete a Google search. In contrast, many leaders have to deal with external factors that move as fast as cold peanut butter. When expectations are deeply mismatched, relationship issues between caregivers and leadership become more difficult, with both sides questioning the intent and integrity of the other side.


Performance requirements have changed. EMS is being held to a higher clinical standard than in the past. Outcomes are being measured and benchmarked. It’s not just about timely responses, door-to-needle times and general process measures. Systems and their leaders are being held accountable to document achievement in the areas of quality, internal and external customer satisfaction, financial performance and growth.


Governance issues are also becoming more complex. When the city council or an external board has conflicting agendas (think about recent Congressional politics) it can make the EMS leader’s professional life miserable. If the governing authority’s perspective isn’t balanced, it can spell trouble for the leader. Making a difficult decision in such an emotionally charged environment requires special attention to the process of making the decision in a disciplined manner and then implementing the decision with positive action.


Each of these factors can cause an EMS leader to feel out of control. In trying to discern how to be “the rock” for your team, it’s helpful to remember that you chose to navigate the class 5 rapids of EMS leadership rather than sailing the sea of tranquility in some safe, non-demanding, non-fulfilling civilian position.


Becoming the rock


Here are seven suggestions to help steer your EMS boat so the team avoids crashing into the boulders in your path


1. Face forward: Plan well and execute better. Don’t dwell on the past. Know that there are rocks out there and create a step-by-step plan with timelines. Often EMS leaders get stuck playing “poor me.” Instead, engage your team so that they are truly invested in the plan and its success.


2. Over-communicate: It’s been said that EMS leaders have to listen loudly. To do that, we have to go where those with opinions are and ask for them. It’s also helpful to communicate using multiple media. For example, communicating verbally at caregiver meetings, in writing via email and social media posts and, most important, interacting with caregivers in settings other than at the office or while they are on-duty.


3. Develop clear expectations: When they were growing up, my children understood that a midnight curfew did not mean 12:15 a.m. The same is true with your supervisors. They need to know what you expect, when you expect it completed and how you will know if it’s done correctly before they embark on a task.


4. Transparent processes: Leadership, including human communications, clinical improvement, operations and deployment, technology and information systems, human resources and financial processes can be problematic if not transparent. When caregivers don’t understand why a process exists, why it’s important, or why it may not appear to be consistently applied, then that process becomes opaque.


5. Cross-validate data: Having clarity on the facts is important. Whenever possible, cross-validate what you’ve been told using multiple sources. Look deeper for system issues rather than assuming that the problem is simple. There could be a system issue that created the problem. For example, when B shift complains about A shift not getting the unit in for preventive maintenance, be sure the metrics confirm individual perceptions. In this case, a quick review of the shift report may show that several other units were down and there were multiple out-of-town trips, so a reasonable decision was made to defer planned maintenance to the following shift.


6. Small corrections work best: When a problem is caught early, it enables a minor course correction rather than having to make a large scale or sudden turn. Being aware that a correction is needed is the first step. Leaders must be constantly looking downstream. Sudden turns make it more difficult to keep the boat afloat.


7. Accountability: Despite best efforts, there are times when EMS systems hit the rocks. When the same processes are used, the same outcomes can be expected. Leaders don’t like to hold people accountable and when we don’t do so, the system and its internal and external customers suffer. Remediation is appropriate for errors commensurate with a team member’s experience and training. However, for those who are unwilling or continually unable to perform, there must be consequences.




We live in chaotic times in EMS. One of the paradoxes of being the rock is that our leadership must be agile. We have to anticipate and act on those things we can control. To assess your organization’s agility, take the survey and compare your results at www.fitchassoc.com/agility


In a follow-up conversation up with the previously-mentioned director seeking “control,” he recognized that being the rock for his team didn’t mean that he would never get banged up. He indicated that using the seven strategies above “lets me lead from a position of stability and gives me a ballast when things get out of control. In that way I can be a rock instead of letting the team crash on the rocks.”