Administration and Leadership, Columns

The Reasons Why EMS Systems Go Astray

Issue 3 and Volume 40.

In my January article, “Normal Deviance: How slipping performance becomes the new norm,” I introduced the concept of “normalization of deviance.” 

When practitioners, managers, or leaders drift away from the expected behavior documented in policy and there’s no negative consequence, the deviations can become acceptable—what was once considered unacceptable becomes “how we do things.” It happens because we, as leaders and mangers, allow it to happen. The further from the rules, regulations and procedures systems allow their employees to stray without taking corrective action, the greater the risk for a dramatic failure.

Why Does Practice Drift?

In the article “The Normalization of Deviance in Healthcare Delivery,” published in Business Horizons in 2009, author John Banja discusses seven factors that account for the normalization of deviance:

  1. Believing that rules are stupid and inefficient. EMS practitioners who deviate from the rules, “often interpret rule compliance as irrational or a drag on productivity.” They believe the individuals who construct the rules are out of touch with reality and don’t know what it’s like in the field. EMS practitioners see it appropriate to then develop workarounds and shortcuts in order to “get the job done.”
  2. Knowledge is imperfect or uneven. Some may not actually know there’s a rule or they may have been taught an already normalized deviation. In some instances, they may not be comfortable asking for help or admitting they don’t know the proper protocols.
  3. The work itself, along with new technology, can disrupt work behaviors and rule compliance. As the work we do evolves and the pace of technological change accelerates, practitioners have to adjust and learn new processes and behaviors. If practitioners are already stressed and under pressure, these new factors that increase stress can be disruptive. Think about the transitions in CPR—from four staircase ventilations, five compressions and one ventilation; to a compression-ventilation ratio of 15:2; to high-performance CPR. How much disruption has that caused and how well do crews follow that policy?
  4. Breaking rules for “the good of the patient.” It can be easy for practitioners to justify breaking the rules because it was “best for the patient.” But it’s hard to defend protocol violations in court. In effect, the practitioner is saying they know more than the physicians and committees who created the protocols.
  5. “The rules don’t apply to me; you can trust me.” This is very much like the situation described above. This sort of excuse can strain friendships and can be bad for the patient.
  6. Practitioners are afraid to speak up. There are a couple of unfortunate aspects that deter speaking up about wrongdoing. Firstly, practitioners don’t want to be labeled a “rat.” Secondly, they may believe speaking up is ineffective because it won’t bring about any change.
  7. Leadership is ignorant of, withholding or diluting findings of system problems. This situation is very problematic. Leaders are supposed to know what’s going on in their organizations; ignorance is no excuse. If leaders are withholding information to protect funding, or to make the organization look better, there exists significant risk and liability within that system.


What Can We Do About It?

First, we must ensure our agencies have up-to-date policies, procedures, rules and regulations.

Second, we have to make it clear to our practitioners that we expect their behavior to be in compliance with organizational performance standards documented in standard operating guidelines, codes of conduct, clinical standards and other policies. The consequences of failing to meet standards must be clearly articulated in the system’s discipline policy and communicated to personnel.

Third, we have to regularly evaluate our practitioners’ performance. We can use chart review and performance improvement activities as part of the evaluation process, however, the best method is direct observation of behavior by a supervisor. Peer evaluation is valuable but difficult. While it’s uncomfortable to be honest with a peer when they’re performing poorly, the process is valuable if you can implement it correctly.

Fourth, the consequences of violating the policies, rules and regulations must be applied consistently between practitioners. We must recognize that maintaining acceptable performance standards and improving performance is a collaborative, team activity. Discipline is about changing behavior, not about punishment.


Normalization of deviance is a process that takes time. It occurs because we allow it to. It’s hard work to keep an organization on track, but it takes even more effort to bring back a system that’s gone astray. We owe it to ourselves, our practitioners and, most importantly, our patients to recognize and correct performance deviance outside of our expected standards.