EMS and Its Disconnect from Effective Modern Leadership

The photo shows the side of an ambulance with a blue Star of Life.
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What Leaders Need to Understand about Leadership in Modern Times

Many people look at the emergency medical services (EMS) as an entity of public safety, but when it comes down to it, EMS is also a business. While to most EMS professionals—the medics and the EMTs—it’s about providing high-quality care to the sick and injured, there also is a very important aspect, especially when it comes to EMS leadership roles, which is the financial success of an organization. As more EMS agencies are being operated by major healthcare systems integrating 911 care and interfacility transport, mobile health programs, and the growth of private industry, financial wellbeing coupled with high quality patient care and employee satisfaction and well-being must be at the forefront of all EMS leaders. In order for an organization to be successful clinically, have satisfied and happy employees and generate revenue, the organization must operate effectively. We all know, or should know, that effective operation means we need effective leadership.

I’ve been a paramedic for 12 years. I’ve worked for small, local ambulance squads and large billion dollar healthcare systems. Over the years I have seen good organizations and bad organizations; I have seen good leaders and I have seen bad leaders. So I ask myself, as I am sure many do, what makes an organization a good one versus a bad one? In order to understand this, we must not think of EMS as EMS, but we must think of EMS as a modern day organization, such as Google, Amazon, or Walmart, and one thing organizations such as these have done, is they have adjusted their practices and business models to the current times.

For far too long and still to this very day, EMS organizations have operated under age old practices. There are too many EMS organizations. In fact, let’s just say “organizations” are still operating under the ideas of Max Weber that to be successful you need a well-defined hierarchy of authority, formal rules and procedures, clear labor divisions, impersonality, and merit-based careers and that has failed miserably in adjusting to modern times. These “classical” approaches to management just simply do not work in our current business atmosphere.

It has become a systemic failure, specifically in many EMS organizations, to adopt the ideas of those such as Frederick Taylor’s “Principles of Management” and the forward thinking ideas of those like Frank and Lillian Gilbreth. So what exactly do I mean? Taylor explained it well in 1911 when he said for an organization to be successful, an organization needs realistic performance goals for a specific job, carefully selected workers for the right job, proper training and incentives to do a great job, and work methods that ease the way for workers to do their jobs.1 In this article, I’m going to further break it down to explain what, how and why EMS organizations or any organization needs to do to be effective, garner satisfied employees, and ultimately increase their bottom line, and there is one common denominator in all of this, leadership.


Employee-Driven Hiring Processes

This is a topic that shouldn’t be new to those in business, but still, at least in my experience, is lacking among many EMS organizations. Hiring of supervisors, managers, and leaders should be driven by the employees with whom the managers or leaders will oversee. Many organizations have implemented peer interviews, however the way in which they have implemented them is flawed. Managers and senior leaders should not be involved in the process until the very end, not the beginning. So what would an effective and 21st century peer hiring process look like?

I am going to speak specifically to larger organizations where EMS is a smaller department of a major healthcare system, although these processes could work for smaller organizations as well if adjusted appropriately. After vetting the candidate to ensure they meet defined specific minimum requirements of a management position (which likely should be done by an organization’s human resources department), the first round of peer interviews should be completed by organization managers from different departments (non-EMS), who do not know and have no vested interest or working relationship with the candidates. This first interview should be geared to determine who would make an effective manager, should contain general management type questions, and not be specific to EMS.

Once the third-party panel identifies the top management candidates, the next round of

interviews consist of an EMS employee panel interview, absent of any management members. This is the time where EMS specific questions can be asked, and the panel of employees can determine if they feel the candidate would make, not only an effective manager (which the first round determined), but an effective EMS manager, for whom employees would respect and work well under. Then after the EMS employee panel selects the top two candidates, the department management and senior leadership will select from those two candidates who will get the position.

So why should the process look like this? Well it’s simple really. When management or leadership is involved in the initial selection of candidates prior to third party and peer interviews, there undoubtedly will be bias when a decision is being made. Perhaps the manager used to be partners with one of the candidates or is friendly outside of work with one of them. Or maybe, years ago, the leader and one of the candidates had a disagreement and the leader is unconsciously still holding a grudge. That candidate could be the best candidate of them all, but because of an issue or decision that was made in the past, isn’t moved on in the process. We all know the past is the past right? They may make the choice to move this candidate along in the process, despite this candidate not being one of the best choices. Implementing an effective employee driven hiring process for managers is one of the first steps in creating great leaders among an organization.

Progressive Discipline

Many leaders and organizations love to use progressive discipline. In 2020, I wrote an article about progressive discipline and why it simply is ineffective in improving employee behaviors.2 Simply put, progressive discipline does absolutely nothing to improve employee behavior and performance, yet EMS leaders today still cannot wrap their heads around this fact, and deploy aggressive progressive discipline practices thinking it improves employee performance.

Instead, it does the exact opposite. It creates a culture where employees fear being outspoken, fear making decisions, and “walk on eggshells” all because they don’t want to get “written up.” Additionally, leaders and managers would rather create a paper trail on employees they feel are underperforming, instead of finding the root cause for the poor performance and improving upon it effectively.

Let’s look at it as an example. A common progressive discipline aspect we see across many organizations, not only EMS, is attendance policies. When employees reach a threshold of “call-outs” they receive progressive discipline. Ask yourself, has a manager ever asked you why you have missed work so many times in the past year, or asked you, “is there anything I can do to help you not miss work?” You’ll be hard pressed to find a manager who has. Instead, you’ve reached your fifth call out, here is a write up, call out again and you’ll be suspended. Who cares if you’re sick, the policy is the policy. Oh well!

So how can we adjust this to modern times and apply it across all aspects of an organization? Leaders must work with employees to determine the cause of the policy violation. Has the employee missed work because they have a sick family member they are caring for? Are they burnt out? Stressed? Depressed? Can we provide resources to the employee such as state or federal leaves, employee assistance programs, or how about just some good old “if you need anything let me know.” How about leaders who tell their employees that if they are sick, take all the time you need, come back to work when you are well. Countless studies in management have shown that organizations and companies who actually have no attendance policies actually have less attendance issues and employee absences than those with strict attendance policies and progressive discipline to enforce them.

I won’t continue to dwell on progressive discipline. I have explored the topic in length before, but a simple solution to improving employee performance is to not use progressive discipline and instead understand why and how the policy or procedure was broken and how the employee and leader can work together to avoid violations in the future. An employee who feels valued and doesn’t have to worry about their next move constantly and whether or not it will result in a write up, will undoubtedly perform better, and isn’t that what it’s all about; high performing employees to increase the organization’s bottom line?

Failure To Implement Just Culture

A leader actually admits a policy or procedure is flawed and a violation of said policy or procedure was actually the organization’s fault and not the individuals – no way! A great leader, in EMS or any business organization, will look at the underlying process and procedure each time an employee makes a mistake and look to see if there is a way the process can be improved to avoid the mistake being made in the future. I can assure you that if an employee makes a mistake or violates a policy, they are not the first to do it, and will surely not be that last. While yes, there are employees who make poor choices and they should be held accountable, but only after their leader looks at the root cause to determine if there is a way to improve upon the process or procedure as a whole. This is something that should be occurring regularly, each and every time an employee makes a mistake. Not until this mindset becomes the organization’s culture will an organization truly be exceptional.

Subjective and Ineffective Evaluation

“Exceeds expectation.” “Performs above expectations.” We’ve all seen these terms on a yearly employee evaluation before. Can someone explain to me what exceeds means? How about what above means? How about, what are the expectations! All too often we see organizations have no clearly defined expectations of employees for which they are evaluated. The expectations may be different from one front line manager to another and in some cases even different from employee to employee. The evaluation process in so many organizations has become so subjective it’s not only sickening but highly ineffective.

Evaluation of employees, in order to be effective, needs to be three things. One: measurable with data to support it. Two: Based on clearly defined and documented expectations, and, Three: performed by a manager or supervisor who directly works with the employees they are evaluating. By employing these three aspects, it allows employees to know exactly what they need to do, how they need to do it, and what they need to improve upon.

As mentioned above, and I cannot stress enough, is the fact that an effective evaluation needs to be performed by a supervisor who has a direct working relationship with their employees. When I worked for my local ambulance squad, there were four people on a shift. A captain in charge of the shift and three providers. The captain would ride the ambulance with each of the providers on a daily basis. This gave the captain direct observation and knowledge of how each employee performed and allowed the captain to perform an effective evaluation of each employee based on a direct working relationship.

Now, working for a major health system, my supervisor oversees anywhere from twenty to fifty providers per day and is responsible for the evaluation of nearly fifty employees. When was the last time I actually worked side by side on the truck with my supervisor; not once in my seven year tenure with the organization. The same way I could not effectively evaluate my supervisor, it is virtually impossible for him to evaluate me. How does he know how I interact with patients, fellow employees, hospital staff, families, etc.? Well, he doesn’t, yet every year he evaluates my customer service skills and interactions on my yearly evaluation.

This dovetails into the management span of control. There is absolutely no way a single manager can effectively manage more than 10-12 employees, yet on a daily basis we see organizations, especially healthcare based or private EMS organizations, where front line managers are responsible for the supervision of twenty, thirty, forty, sometimes even more employees. It is ineffective and doesn’t work. Period. EMS organizations need to adjust their span of control to be effective. You do not see fire department captains overseeing a shift of fifty firefighters, the same way you do not see a police sergeant overseeing a squad of forty police officers. For example, fire departments have a department chief who oversees two or three deputy chiefs, who oversee three or four battalion chiefs, who oversee two or three captains who oversee three or four fighters per shift. Police departments have one chief, who oversees two or three captains, who oversee two or three lieutenants, who oversee four or five sergeants, who each oversee six to ten officers on a shift. Why has this span of management control been lost when it comes to EMS?

I’ve worked for several major healthcare corporations EMS departments. Every single one of them had a vice president, who oversaw a director, who oversaw three or four operations managers, who oversaw two or three supervisors, and the supervisors in turn then oversaw forty to fifty paramedics. Why do we allow this to happen in EMS? A fortune 500 CEO doesn’t have 200 direct reports. They have two or three, who in turn have two or three, and so on. This is the only way of effective management.  

So how do we make it work? Well there are several ways. For one, we need a realistic span of management control in EMS. If your organization has fifty employees working on a given day, then there should be at least four supervisors on duty, each responsible for ten to twelve employees at most as their direct reports. Does this cost money, sure, but it also leads to employees being held more accountable, which in turns leads to a better performing employee, which then, as you can expect, leads to a better performing organization, and a better performing organization will ultimately have a better bottom line. Secondly, the supervisor could effectively evaluate employees who they work with every single day and by evaluating employees this way, you get a much more true and accurate evaluation of the employee.

Leaders Who Hear, Not Listen

My mother taught me when I was a young kid that there is a difference between hearing and listening. I’m sure that an organization’s leaders were taught the same thing. Yet, way too often do we have leaders who hear what their employees have to say, but simply aren’t listening. We have all heard it before: “You have a great idea, we’re looking into it.” It’s a term that is common among EMS organizations and corporate organizations alike. Only to find that six months or a year later, the idea went in one ear and right out the other of management and an autonomous decision was made by the person in charge.

How would you feel as an employee if you brought an idea to your manager or supervisor and instead of telling you they will look into it, they direct you to put together research, present it to senior leaders, and your idea becomes a reality. You would feel great, I’m sure. You would feel valued, your organization would benefit, other employees would be happier, and your manager or leader would be doing exactly what they should be doing, empowering employees and providing the resources needed to use each individual’s strengths to better your organization altogether; everybody wins. The employees are happy, the employee who brought the idea to the table is satisfied and feels appreciated, and the leader has done their job by making the organization better for all involved.

Effective Shared Governance

That leads me to my next point, effective shared governance. Shared governance is exactly what it sounds like, decision making shared among all of an organization’s constituents. This could be employees, managers, senior leaders, outside entities, whomever. However, for it to be effective, an organization has to go all in and accept that the decisions made collectively by a shared governance model, may not align with what the leadership wants, but should be implemented regardless (so long as it does not create a budgetary or operational bedlam.)

I’ll give you an example. At an organization I previously worked for, a shared governance team was put together to develop a new time off and vacation policy for the organization. For several months, the team, which consisted of ten employees, met to brainstorm and come up with ideas for a new time off policy. A policy was created, edited and presented to management. The team was thanked by the senior leadership, told “great job” and waited. Three months later, when I checked my work emails, I saw the email with the title “New Vacation/Time Off Policy.” I was ecstatic. I opened the e-mail and find a policy that was nothing of what the shared governance team had presented, was changed, and was what management wanted. Myself, as well as the other nine employees who spent hours of our free time working on this policy, were deflated like a balloon stabbed with a chef’s knife. It was that moment when myself and several other said screw it! Why should we continue to participate in shared governance when one or two people were going to make the decisions they felt were best for the organization without any input from staff.

Shared governance works. It has been proven. But it only works if the organization’s leaders are willing to accept the solutions and ideas presented by the shared governance committees. Also, in order to make it work, you need input from all aspects of the organization. Employees who are outspoken, employees who fly under the radar, new employees and senior employees alike, they all must be involved and participate in order for it to work. Shared governance teams and committees hand selected by management or teams that do not allow for the involvement of anyone willing and wanting to participate defeat the purpose of shared governance.

Shared governance teams must also be adaptable and ever changing. New members rotated onto the teams to bring new thoughts and ideas is necessary. If an organization is not willing to allow all employees who want to be involved to be involved, keep the same stagnant members on a team for years on end, and are not willing to accept the ideas fostered by a shared governance committee, then an organization shouldn’t implement shared governance. And what does an organization without shared governance in the 21st century look like, well it looks like a dictatorship, which is exactly the type of organization that people do not want to work for and that underperform due to unhappy and discontent employees.

Great Leaders Surround Themselves With People Who are Smarter and Should Never be the Smartest Person in the Room

Yup, the title of this section says it all. Great leaders should never be the smartest person in the room and should surround themselves with other people who are smarter than them. But isn’t that contradicting to the person who is supposed to be in charge? Nope, it’s not. Being smart and having an alphabet soup next to your name never has and never will make someone a great leader. A great leader is born a great leader and has innate talents to be just that. What makes someone a great leader, it’s simple really. A great leader needs to do two things: listen to those who are better versed in an area of their specific organization and empower those around them to use their strengths to create a better organization. That’s it, that’s what makes someone great.

Yet all too often, when someone gets into a position of power and leadership, these basic mentalities of leadership go right out of the door. Whether the leader worked their way up through the organization or was hired from outside, once most people get into a leadership position, it suddenly becomes my way or the highway!

When a concern or strategic issue arises and the leader calls his management team together to look for various solutions, the leader’s job should be to use his resources, people – whether managers, supervisors, or regular ole employees – to harness and search for ideas, collectively decide what would be best for the organization, and then provide the necessary tools and resources to bring to fruition the idea and solution. That is what makes a person a great leader, that’s it. Nothing else. Not until someone can understand this simple concept can they become truly a great leader.


In order for an organization, whether EMS or not, to be successful, they need successful leadership. Successful leaders are willing to empower their employees, connect one-on-one with employees, swallow their pride, and know that they aren’t always right. Great leaders work together with their employees, see themselves on the same level, not as “in charge” but instead as a guide to successful for all. When a leader can accept this, and know that just because they are “in charge” doesn’t mean they are always right, the leader will find themselves leading a successful and high performing organization full of effective managers and supervisors and full of what matters more than anything in business, happy and satisfied employees.

Leaders must also realize that post pandemic, in 2021, the days of limited job opportunities is over. Employees are no longer forced to stay at an organization they are unhappy with because there are no jobs available. If an employee finds themselves unhappy or underappreciated, they can easily find another job and when that occurs, an organization will find themselves with staffing shortages, paying overtime to cover shifts, and with a poor perception among potential job applicants. It’s at this point that the organization may look to the leader to determine why employee retention is low, and when that happens, the oligarchic leader themselves may find himself looking for a new job.


1. Taylor, Frederick Winslow, et al. The Principles of Scientific Management. Cambridge Text Education, 2021.

2. Imperatrice, Louis Nrp. “Progressive Discipline: Why the Process Is Flawed and How to Improve Employee Performance.” JEMS, 8 Jan. 2021, www.jems.com/administration-and-leadership/why-progressive-discipline-is-flawed.

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