Strategizing for Success

It’s a typical board of directors meeting at the North Boro Volunteer Ambulance Corps, and it seems the same questions keep coming up about the agency’s future. There is discussion about its strengths and weaknesses and opportunities, yet no one seems able to speak knowledgeably about these areas. You think to yourself, What’s wrong with this place, and can we do anything about it? You feel as though everyone else on the board is paying attention to the here and now and not focusing on larger issues that may occur in the future. You mention the possibility of developing a strategic plan to help guide the organization, and your suggestion is met with blank stares and a comment of, “What do we need that for?”

What Did You Sign Up For?

In volunteer EMS organizations, people with regular lives and full-time careers spend countless hours providing services for their communities. These dedicated professionals are responsible for the most intricate parts of running organizations, and most did not have these intricacies in mind when they joined. Their thoughts were on answering emergency calls.

The number of emergent and nonemergent calls answered by EMS rises every year. This increases administrative responsibilities. The majority of EMS organizations are run by volunteers who, due to the nature of their positions and the overall need, have the potential to become more wrapped up in administration than patient care. Whether volunteer, career, non-for-profit, fire-based or third service, every EMS agency organization should, in its strategic planning process, continually reevaluate its standing, mission and vision. Volunteer EMS agencies face all the same stressors (operational and administrative) as career EMS agencies, but they do so without a paid staff to act as a support structure.

The ABCs of an Organization

Common required management tasks of EMS organizations can include finance and budgeting, strategic planning, human resources and training. If these functions don’t look familiar, they should. They are essential for running almost any business in America. For the most part, volunteer EMS entities fall into the pit of not viewing their organizations as businesses that incorporate the above tasks. But why should running an EMS organization be different? Why should emergency services suffer by not having the benefits of straight-line communication, a well-researched strategic plan, or the advantage of earnings as a byproduct of appropriate budgeting and finance?

Proven quality improvement programs, such as ISO 9000 and Six Sigma, can be helpful to an organization that hopes to run more efficiently. However, before you spend a lot of money training individuals to implement these programs, there are more fundamental steps you can take.

EMS providers are trained to examine patients’ signs and symptoms and determine the best treatment course. Evaluating your organization and determining its best treatment is not much different. There are three essential components to an organization that can be evaluated in a way similar to how we evaluate patients: staffing/personnel (airway), call volume (breathing) and organizational structure (circulation).

Adequate staffing provides the means to deliver patient care, much like an adequate airway allows for the delivery of oxygen and removal of carbon dioxide from the human body. Staffing can be paid or volunteer. When a combination of personnel is utilized, make it clear there is one standard expected of all personnel, much like there is only one way into and out of the lungs. Without proper staffing, your EMS organization cannot provide a pathway to deliver the care it intends.

A well-staffed organization that is unable to adequately manage its call volume or complete business for any number of reasons indicates a problem. Call volume is analogous to breathing in that it dictates the tempo of an organization. The inability to complete or manage work suggests something is wrong. There are only 168 hours in a week. That’s 14 12-hour shifts. Most small agencies have a call volume that requires one or two ambulances per shift; therefore a total staff of 20 people could manage the volume if each person dedicated 36 hours per week.

Circulation is the system in the body where the work gets done. If your organization’s circulatory system resembles Figure 1, you have a dysfunctional system and an increased chance of failure. The problem with this type of organization is that there are no clear lines of authority, and without clear lines of authority, people are not sure to whom to report, action items aren’t followed through, and no one is held accountable to an established standard. Mismanagement of an organization like this will eventually lead to disaster. Possible outcomes could include misallocation of money and mismanagement of personnel and/or resources.

A Plan for Change

After careful assessment, the leadership of an organization may determine that in order to prosper, it needs to change. This process consists of many steps, which start with planning. This is also an excellent opportunity to retain a well-qualified and knowledgeable lawyer to assist.

Step 1: Schedule and hold open planning meetings.

One of the hardest barriers to overcome is the thought that this process is being managed without the help, assistance or input of the general members. Remember, members are the ultimate decision makers in most agencies, and they need to be included, not alienated.

Step 2: Set realistic goals and stick to a plan.

Goal setting is one of the more useful tools for an organization. Set short-term, realistic goals with the overall health of the organization in mind. Build milestones into the process that force the planning committee to stop and evaluate progress. Think about how frustrated and disappointed your committee and planners would be if you were three or four months into the process before realizing a mistake was made in the first month.

Step 3: Communicate.

Communication is essential in any process that yields change. Leaving stakeholders out of the loop on the progress or speed bumps is a sizable mistake. Leaving people in the dark suggests that the planning group or members affecting change are hiding something or building power holds within the company. This point should be the highest priority for not-for-profit EMS agencies, because most of these types of organizations enlist their membership as a voting authority. Hiding information from the voting authority may bring this process to a halt.

Step 4: Enlist additional support.

An organization fortunate enough to have retired or currently employed business executives among their membership or boards may only need to enlist minimal assistance from legal counsel or accountants. For organizations consisting primarily of volunteers from different career fields, this may be a new process. Requesting outside support from county or town managers, professional consultants or other agencies that have completed this process may increase efficiency. Don’t be afraid to ask for help.

Step 5: Manage governing documents.

A thorough review of the organization’s governing documents is mandatory when making changes. To change leadership or responsibility, an organization may need to change its governing documents. Furthermore, if the organization expands, it may need to change its corporate purpose as well. Utilize legal assistance when making changes to protect the corporation, thwart conflicts and ensure all necessary paperwork is filed appropriately.

Characteristics of Efficient Organizations

EMS agencies face a myriad of challenges, both short and long term, some of which have the potential to significantly impact their mission. These include funding/financial challenges, personnel and staffing issues, and compliance and regulatory realities, as well as others. An efficient organizational structure—one that includes an eye on these issues through development of short-, medium- and long-term plans, as well as careful financial management—will help deliver the tools necessary to appropriately manage call volume and other programs an organization decides to deliver. Well-planned organizations work efficiently because they have clear lines of communication and authority. Each position in the organization is responsible for a piece that fits into the larger puzzle. With a clear mission and vision from the board of directors, each subordinate office or person can complete the tasks at hand. Ensuring board members chair committees will assist those committees in completing requested tasks with the overall mission and focus in mind.

Similar to the incident command system, each level of management needs to determine its effective scope of leadership. That is, how many people can one line leader effectively manage? Many organizations grossly overestimate this figure. For example, putting one captain and one lieutenant in charge of 10 paramedics and 15 to 20 EMTs is unrealistic. The burden of training and record-keeping for up to 30 people would rest on the shoulders of just two people. If being a squad captain is not your full-time job, this responsibility could lead to mistakes, misjudgment or burnout. Becoming comfortable with the number of people being managed helps make an organization efficient.

Stay the Course to Ensure Success

During the change process there are many roadblocks and seemingly difficult tasks. However, staying the course ensures an EMS organization will not only meet the needs of its community, but be able to share its benefits with its members while increasing morale and developing systems that ensure survivability.

Take a minute and assess your organization the same way you would assess a patient. Have you stabilized the ABCs yet? If not, the organization cannot grow and will eventually be unable to maintain what it provides.

Finally, understand that effective organizational awareness and management starts at the very top and filters its way down. All levels of supervisory and management level personnel—on both sides of the operational/administrative divide—will undoubtedly benefit from a strategically thought out, well planned and properly managed organization.

References

National Highway Traffic Safety Administration. A Leadership Guide to Quality Improvement for Emergency Medical Services Systems, www.nhtsa.dot.gov/people/injury/ems/leaderguide/index.html.

Barishansky RM. Strategic planning for EMS agencies. EMS Magazine, April 2005, www.emsworld.com/print/EMS-World/Strategic-Planning-for-EMS-Agencies/1$1864.

Virginia Office of Emergency Medical Services. EMS Agency Management Series: EMS Strategic Planning, www.vdh.virginia.gov/OEMS/Files_page/OEMS_general/Stategic%20Planning.pdf.

Daniel E. Glick, BPS, NREMT-P, is an aeromedical evacuation operations officer for the 139th Aeromedical Evacuation Squadron, New York Air National Guard, and a practicing paramedic in upstate New York. Contact him at deg3142@gmail.com.

Raphael M. Barishansky, MPH, is chief of public health emergency preparedness for the Prince George’s County (MD) Health Department and a member of EMS World’s editorial advisory board. Reach him at rbarishansky@gmail.com.