EMS Insider

From the Minds of Many

During the development of Jonathan Washko’s important article on why EMS systems fail, I reached out to a diverse group of EMS leaders to ask them to candidly tell why they believe EMS systems fail. This included well-respected EMS managers, consultants, attorneys, EMS association leaders, educators, operations directors, medical directors and past and present federal officials.


What follows are key comments in specific categories, without their names presented, because it’s their message and not their name and position that’s most important. Some were edited for clarity.


Read these powerful comments carefully to see if your agency needs to address any of the areas of concern presented to stay fiscally and operational intact.




EMS is underfunded and poorly reimbursed. The lack of dedicated and stable funding sources will continue to kill EMS systems.


Many systems have a disproportionate burden of transporting unfunded patients who use 9-1-1 as their only medical access. In many metropolitan systems, close to 50% of all patients transported have virtually no funding.


The current federal reimbursements don’t meet the average cost of running a call. A 9-1-1 system must be funded to be staffed and ready to answer calls; not just funded for the calls that they answer that happen to have insurance or the ability to pay. Without this funding, systems are doomed to fail.


In EMS, physical infrastructure (e.g., ambulances, equipment) has a fixed cost and steadily increases. The only thing that can be fiscally-adjusted is employee costs and benefits. Jim Page called public utility models, “one of the worst threats to EMS ever.” The reason: They were essentially set up to keep EMS employees out of the civil service system and public sector—to keep costs down.


Many EMS services don’t get a subsidy and, in some cases, must pay the cities to operate. The only private companies that have done well are large companies like AMR and Paramedics Plus that spread their costs across multiple markets (wealthy and poor).


We need to “manage our business” and stop relying on handouts (donations, tax dollars, grants) and other nonsustaining funds.


We must begin to show that we make a difference in outcomes, can be fiscally responsible in running our healthcare business and develop with the next wave of public health.


A number of EMS public providers use deficit spending to cover budget shortfalls during the recession or support new programs/service areas. These agencies dip into reserves until they’re gone. Then, service must decrease in order to prevent spending more than is received. Solutions should be identified and implemented as soon as revenue doesn’t cover expenses; there shouldn’t be a “hope” that the economy/tax collections will increase.


While finances are critical, the process to achieve financial stability is the key point. If you look at successful communities like Seattle and King County, Wash., you’ll often find taxpayer-supported levies that allow total financial stability. However, it’s not all roses. While ALS transport in Seattle is “free,” BLS isn’t and is often provided by private agencies.


Home rule: In order to compensate for underfunding, systems need to regionalize and take advantage of economies of scale. When home rule comes into play, costs are multiplied by each agency and none of them can succeed.




Even the best aircraft carrier, with the best crew, will go in the wrong direction if the captain doesn’t know how to steer the ship in the right direction.


A top-down management style can hurt system development. (This doesn’t allow lower-level, bright officers to participate in the leadership process.)


There’s a lack of leadership training for new field supervisors. Most EMS supervisors come straight off ambulances.


A “non-EMS” manager in the hierarchy above the EMS leader is a big reason for system and morale decay. This sabotages the program through ego, limited EMS “attention,” fear instilled in innovators or those proposing change, or any of the other seven deadly sins.


Many fire departments have the EMS management structure, but not the EMS leadership they need to develop and prosper.


Supervisory positions must be about serving and supporting the crews running the calls. It can’t be all about the individual who got the position. He or she must work for the crews, and the crews must work for the community. It’s vital this not be reversed.


Transparency: EMS leaders must be transparent and honest from their financial standing to their protocols, policies and procedures, and hiring practices. They must openly acknowledge error and work toward solutions.


Ego protection: Whether chief, director, shift supervisor, trainer, field training officer, experienced paramedic, or just “not the new guy,” ego protection at any level ultimately results in system problems.


The public will forgive mistakes; they won’t forgive dishonesty.


EMS leaders must understand that a static management style doesn’t work in a rapidly changing medical environment. With constant changes in medicine, governmental processes, billing and technology, leaders must evolve their services.


EMS leaders must captivate, educate, and solicit buy-in from both internal and external stakeholders. Personnel want to work for good leaders. The public requires EMS for lifesaving capabilities and wants to be able to trust their leaders. When a system functions without these concepts, degradation begins to set in.


Lack of mentorship: This ultimately cripples the system when good seasoned leaders haven’t taught, or haven’t been able to teach, lessons learned to the next generation.


Leaders who are afraid to make a decision are worse than those that make bad decisions while trying to improve things. After a while, the employees begin to realize that issues aren’t dealt with and problems aren’t solved. They then either start making their own decisions regardless of the outcome or they don’t do their job properly—which affects everyone. There are multiple reasons why this happens, but when it does, the organization and public they serve suffers.


Leaders need to be consistent in their message about the mission of the organization. They shouldn’t allow external or internal forces to change the core of the organization in the delivery of quality patient care.


Some leaders don’t keep up with the industry and fail to make improvements and changes before they’re mandated to change. They aren’t role models or mentors to their employees.


Employees with no management experience get involved in running the EMS system.


Medical leadership


A key leadership component is the medical director! He or she can (often) arch over bureaucratic hurdles with a single bound. They can also speak “above” the noise and explain to politicians about EMS and why funding or enhancements are important.


The “Top Doc” must lead in the public debate. If they won’t, get another one. We’re talking survival here. They must be above and for lives saved, not shift-size in the firehouse.


Poor medical control can kill a system. A physician, who’s routinely absent, doesn’t want to change with the times or sticks with old ideas.


Politics, unions & poor public relations


Unions demanding to be paid for additional tasks can sink the ship.


Politics often chase good leaders from positions because the employees don’t like being held accountable for their actions. Whether it’s a group of employees represented by union representation or nonunion employees that bypass the chain of command and work with the elected officials instead of with the leaders, they don’t have the big picture of how to manage and operate the organization.


The employers/chiefs put “puppets” in place who pretend to be leaders but actually don’t make a single decision without consulting with the employees first. In the long run, these “leaders” are often exposed for their lack of leadership because their decisions don’t serve the organization or the community.


The more our EMS agency is accurately represented in the public eye, the more it works against the frustration of paramedics and EMTs who feel like no one has any idea who they really are and what they really do.


Failure to regularly engage the public and/or local elected officials can impact staffing and the overall budget of the department.


Lack of a true balanced review process during RFP processes drive controversy, lawsuits and often result in wasted time and resources when rebidding is required.


Your community should know who you are. If your community knows who you are, then your elected officials will too. If they both know who you are, then you’re in the best position to get the community and financial support you need to invest in providing the best EMS service you can.


Lack of a common message to political leadership on issues impacting EMS. (One voice, one mission, one vision.)


Failure to demonstrate value: If the community served, including the general public, elected officials, payers, hospitals and other stakeholders, doesn’t believe you bring them value, EMS becomes a commodity, and something to be bargained with based on price.


Quality of care, true evaluation & quality improvement


Not closing the quality assurance (QA) loop is a big problem. You can’t make the same mistakes over and over with no recourse. Many systems are also not using QA to drive education and personal change.


Lack of coordinated quality improvement (QI) and education programs: Both the fire service and other private providers should embrace a unified program for QI and provider education. Many of these care teams work together daily, but they don’t train together and build the important team relationships that can eventually benefit patient care.


Agencies that fail to make every day a training day for everyone up and down the chain, with the training focused on the core critical task specific to each given job.


EMS systems must build solid QA/QI initiatives that don’t localize blame when problems are systemic. All employees can benefit from learning from the minor mistakes of others. This should be done in an educational, non-punitive, setting. When employees feel as though their QA/QI systems are punitive and targeting, they lose valuable learning opportunities.


Many EMS systems have misinterpreted the “self-reporting” initiatives that were legislated across the country. Employees should feel comfortable and confident in self-reporting and agencies need to work toward fully legislated peer protection.


Some systems have created a volatile situation between continuous QI and personnel. The targeting of employees and the resulting “non-punitive” schedule change is seemingly supported by the administration. Consequently, you see the same minor mistakes repeated.


Agencies miss the opportunity to resolve a systemic problem and create a culture of fear and intimidation. Continuous QI shouldn’t serve to alienate the workforce.


Poor care results in frustration, resulting in poor morale, increased sick leave usage and attrition.


Employees make mistakes for three reasons: human error, at-risk decisions when they have several choices and pick the wrong one, and intention and willful intent to do something wrong. You should only discipline employees when they intentionally and knowingly do something wrong. In the other cases, you should look for system problems that need to be fixed, see if they need some other type of equipment, or if they need additional education.


Recruitment & retention of employees


Failing systems lack quality people due to poor recruitment, poor background checks, no probation period and no (or poorly developed/instituted) performance evaluations.


Provider retention issues have been on the burner for over 20 years. If a simple comparison to initial training costs were made to the costs associated with adding at least one additional unit, an agency could see benefits in decreasing the operations UHU and allowing a crew to have a few moments of rest in a busy urban system.


Painting the wrong picture for new recruits: No offense to the fine folks from “Emergency!,” but we don’t need Johnny and Roy as much as we need Dixie. There are plenty of kind, compassionate, caring young people who don’t even consider EMS because of the false impression we paint of some paramilitary, Kevlar-wearing group of knights in dull black armor.


Personnel turnover: People always coming and going. This can often be related to low pay and high call volume/ demands.


Many see no future in EMS as an employee. There isn’t much of a career ladder. Many see EMS as a dead end job. In addition, many barely make a decent living in EMS.


There aren’t many non-governmental systems that offer incentives or even reasonable benefits. Then to top it off, many of the supervisors don’t have the training or skills they need for their responsibilities in management. I have said many times that, “You couldn’t pay me enough to do this job: That’s why I volunteer!”



A.J. Heightman, MS, EMT-P, is the editor-in-chief of JEMS . Reach him at [email protected].