Leading with Vision


It’s 9 a.m.–do you know how your EMS system is going to behave today? What about tomorrow, this week, this month?


EMS managers too often fnd themselves leading in a day-today, minute-to-minute crisis mode, jumping from one priority of the moment to another. This leadership style can result in poor system performance, low employee morale, poor job satisfaction and missed opportunities. It can also lead to organizational paralysis, which can have long-term, long-lasting negative consequences downstream.


One contributing factor to this problem is that some EMS managers have not fully developed the leadership skills necessary to be successful. They got promoted because they elicit behaviors desired by the incumbent leadership team, such as promptness, a strong work ethic, industry experience, excellent clinical care, good customer service skills or a good rapport with their peers. Unfortunately, these qualities alone are not good predictors of success. Rather, they are the foundation upon which a manager should then be educated, mentored and further cultivated.


Managers are often expected to perform immediately upon being promoted to the position, without time being taken for education, mentoring or cultivation, thus setting these individuals up for failure. So what does a new manager have to fall back on? Their clinical experience as a reactive crisis manager. That is why some managers prefer this style of leadership, as this is what they learned on the streets as EMS providers, and have never been challenged, mentored or educated to look differently at the world or think otherwise.


The goal of this article is to hopefully provide you with a best practice tool that can be used by EMS managers in order to shift from reactive crisis management to proactive leadership. In doing so, managers will be able to anticipate and react to problems before they happen, and thus provide for a better patient care experience and a better, more proactive organization for staff.


“Iceberg, dead ahead!”


If you are the captain of a ship, these are not the words you want to hear. As the captain of the Titanic tragically learned, anticipating obstacles with enough time to react is a foundational strategy that all leaders must learn if they are to avert disaster and have long-term success. In the EMS field, this foresight is a necessary tool that the entire leadership team must learn if an organization is to successfully navigate its icebergs.


So how do EMS managers look ahead in order to anticipate and appropriately navigate problems and, thus, shift from reactive management to proactive leadership? The captain of a ship uses radar, lookouts and sightings from other ships to gain situational awareness for decision-making purposes. EMS systems require a slightly different tactic: a concept known as the after action review (AAR). What is an AAR meeting? For EMS purposes, it is a short daily meeting (15-30 minutes) of key staff who look at key performance indicators (KPIs) of the EMS system’s prior day’s performance, with discussions of what went right and what went wrong. Additionally, other input variables are used to predict the current day’s performance and anticipate issues in the near future (typically a rolling five to seven days in advance). Finally, an outlook of the next month and quarter is performed to see what operational icebergs might be looming.


The types of KPIs used by EMS agencies in an AAR depend on the type of EMS system being operated, however there are several some common themes:


On-time performance: One of the most important factors that can help to assess operational (not clinical) performance and success is that of response times. Poor response time performance is either the result of something that went wrong in the EMS system’s execution of its operational response plan, or is an indicator of a bad operational response plan, or both. This KPI can be used to help identify the overall output of your operational plans, how they were executed and their effectiveness. This data is typically assessed in a rolled up format as well as a granular format (individual).


System failure root cause analysis (RCA): When something goes wrong with any system or process, you must find the root cause before it can be fixed. Many EMS systems that perform some form of AAR also perform RCA. This is typically applied to late responses, critical failures (an inability to treat or respond) as well as unproductive time. Over time, the trending of this data provides the clarity necessary to identify and then fix the underlying problems in a system. The trends and outcomes from this data are typically assessed in a rolled up format as well as a granular format (individual).


Productivity: Assessing the productivity of a system (sometimes called unit hour utilization, or UHU) can help benchmark system performance output and act as a good financial predictor/indicator.


Call processing times: The amount of time spent on an EMS call can be broken down into individual measures and then reported on and benchmarked. This is important for understanding whether the processes and culture are keeping pace with operational expectations and goals. Call times can also be a red-flag indicator that a problem is occurring if trending indicates a special cause variation or aberrancy.


In addition to these KPIs, other common variables that are assessed for future insight include:


Production schedule issues (for the day and week): Are the EMS, dispatch and support schedules full? If not, what needs to be done to correct this, or would the system be OK if the units are run down because demand is anticipated to be low?


Headcount capacity and constraints (performed every two weeks or so): Is headcount adequate for full-time, part-time and per diem staff? Is the agency anticipating any full-time equivalent (FTE) losses due to discipline or normal employee churn?


Scheduled call loads: What is today’s prescheduled call load and is it manageable given the capacity of the system for the day? If not, what is the plan to mitigate the problem?


Fleet capacity and constraints: Are there enough ambulances to perform the day’s mission? Are there adequate reserves for all of the day’s shift changes?


Supply and equipment capacity and constraints: Is there enough equipment to perform the day’s mission? Are there adequate reserves for all of the day’s shift changes? This would include items that could place a unit out of service such as portable radios, cardiac monitors, stretchers, critical equipment, etc.


Upcoming special events: Are there any upcoming special events that need to be staffed or may impact operations due to size, street closures or other factors?


Weather: Accurate weather forecasts should be closely monitored to anticipate adverse impacts to operations as well as call volume.


Traffic: This would cover any street closures, new construction, new traffic patterns, etc. that drivers and staff should be made aware of.


Other concerns: Any item that could have the potential to impact EMS operations should be brought to light in this daily briefing.


Although this may seem like a lot to cram into a 15—30-minute meeting, it can be done as long as the team is disciplined, follows an agenda, has the necessary information ready to go before the meeting begins, and is not allowed to get scope creep or get bogged down with details or war stories. Some agencies, including Paramedics Plus (all divisions); Regional Emergency Medical Services Authority (REMSA) in Reno, Nev.; Life EMS in Michigan; Richmond (Va.) Ambulance Authority; and many others all have this down to a science and use technology to make the process efficient and effective in improving system quality and identifying the most effective means to resolve problems.


Keep in mind that the purpose of this meeting is to improve situational awareness and implement a quality improvement (QI) process. Since clinical and dispatching services typically have some sort of QI process associated with them, shouldn’t operations as well? Without this, how can your organization ever find its flaws and improve upon them?


Remember that the process is also designed to air internal dirty laundry in a safe and protected environment, thus providing a catalyst for improvement. Managers may shield their superiors or laterals from the root cause of problems due to the fear of seeming incompetent, being embarrassed or fear of losing their jobs if they are seen making mistakes. In a truly transparent and quality framed process, the faults of the systems and trends of poor performers can be seen with 20/20 vision, thus helping to create the roadmap necessary for improvement and refinement. The AAR process should never be used for retribution or punishment. Chronic poor performance teased out by this process should be remediated (if it is truly not a systems-based problem) and, if still unresolved, the individuals’ involvement within the organization should be reassessed.


According to Mark Postma, chief operating officer of Paramedics Plus, the key to AAR success, which his organization calls performance utilization late-call system evaluation (PULSE) process, is “to ensure that these meetings happen every day, run on time, and are consistently and habitually followed so that they become woven into the fabric of the organization. This way the performance improvement aspects of the process become a part of the management team’s daily routine, which promotes healthy competition that leads to continuous quality improvements and process refinement.”


In closing, the AAR process is just one tool in a leader’s toolbox that helps empower the shift from reactive management to proactive leadership. When properly applied, the process can take an organization from mediocrity to greatness while improving patient care, employee well-being and financial sustainability–the triad of EMS system success. As Postma puts it, “It’s kind of a no-brainer.”

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