The uniform section of this particular policy manual was five pages long and included rules like “the tail of your uniform belt shall extend two inches” past the edge of the buckle. They rigorously enforced this, along with a host of other rules. Field supervisors actually carried rulers (I am not making this up) to measure the amount of belt sticking out of employees’ buckles. The policy also listed corrective action: on first offense, the employee was to be sent home for four hours without pay to correct the deficiency; second offense was a two-day suspension; and third offense was termination. Yes, they actually fired people because their belts didn’t conform to the rules.
This is an extreme example and most rules-based organizations do not slip this far off the rails. In fact, most rational people would agree that some rules make good sense–drive on the right-hand side of the road; if you intubate the patient, put them on capnography; don’t drop the baby, and so on.
Excessive Rulemaking
There are several problems that can occur within a rules-centered EMS organization. Many rules are written in response to one specific incident. There may as well be a photo of the person who inspired the rule right next to it in the policy manual. For example, I know of one fire/EMS department with a printed rule that says, “There will be no masturbation while on duty in the firehouse.” You know that the human resources manager did not make this one up out of thin air. Some people still have a copy of the infamous “no slouching” policy implemented by a certain private ambulance service.
Some rule-based managers and supervisors think that an issue cannot be addressed unless there is a rule for it, and employees can be quick to take note of this seeming weakness. Back when it was common for paramedics to place nasotracheal tubes, one crew (in a city I will leave unnamed) responded to a young man who had overdosed on heroin. The EMS crew had a difficulty finding a vein. The patient was barely breathing and was nasally intubated just as an IV was secured. A gentle dose of Narcan improved the patient’s respiration and woke him up. He tolerated the tube without gag or discomfort, so the paramedic talked the patient into playing a little joke on the emergency department staff. You can imagine the surprised reaction when the patient walked into the department on his own two feet, intubated, bagging himself. When the offending paramedic was brought before administration in this rules-based organization he defiantly said, “Show me in the policy manual where it says that patients are not allowed to assist with their own ventilation.”
Some managers believe that if they have a rule then it’s iron clad, everyone understands it, and it will be easy to enforce. We would all do well to remember Franklin Roosevelt’s take on the highest set of rules we have: our national laws. In a March 1930 address as governor of New York, he said, “The United States Constitution has proved itself the most marvelously elastic compilation of rules of government ever created.” If laws were easy and straightforward, we would not need lawyers and courts to interpret them.
In most organizations the rulebook is only pulled off the shelf when something goes wrong and there is an urgent need to fix the blame on someone. When Mrs. Dawson brings a tray of cookies to thank the crew that resuscitated her husband, the supervisor doesn’t reach for the policy manual to figure out what to do with the cookies.
Many EMS organizations spend endless time writing, rewriting, and enforcing rules that are not needed by the majority of the workforce. The former chief talent officer of Netflix Patty McCord, who is often credited with turning traditional HR model upside-down, has said, “Over the years we learned that if we asked people to rely on logic and common sense instead of on formal policies, most of the time we would get better results, and at a lower cost. If you’re careful to hire people who will put the company’s interests first, who understand and support the desire for a high performance workplace, 97% of your employees will do the right thing.”
So what’s the alternative to rules?
Values
In a values-centric organization the belief is that, since every situation and interaction is different, it’s more effective to have some guiding principles to help people make sound and ethical decisions than it is to write a rule for everything. It’s easier to remember and have a deep understanding of a handful of values than it is to memorize and be able to act on a long set of rules. Values live in the culture and the actions, conversations and thoughts of the people working in the system.
The most widely published set of EMS values, written by Thom Dick in 1990, are abbreviated as the STAR CARE guidelines–Safe, Team-based, Attentive to human needs, Respectful, Customer accountable, Appropriate, Reasonable, Ethical.
My mentor, Frank Staggers Sr., MD, passed away in late 2013 at the age of 86. I always keep with me a list of the values he taught, and they have served as a rock solid leadership framework for my personal and professional life:
“¢ Always be yourself.
“¢ Treat everyone with respect.
“¢ Help others whenever you can.
“¢ Whatever people are under, help them get over.
“¢ Don’t worry about who gets the credit.
“¢ Be patriotic without being blind.
“¢ You can fnd knowledge anywhere.
“¢ Take time to enjoy life.
Now, Dr. Staggers didn’t hand me this list on glossy paper with his hospital logo and a photo of a happy puppy bounding through a field of poppies. He showed me these by living them every moment of every day. What would people say are the values you’ve shown them?
