Learning to Manage EMS Efficiently
departments
Over the last 15 years, there have been many dramatic changes in emergency medical services. Formerly, the term “emergency medical services” (EMS) was synonymous with ambulance or rescue service. In recent years, the term has taken on a broader meaning, linking the medical services of pre-hospital, in-hospital, inter-hospital and rehabilitative care.
While the American fire service has been in the forefront of many of the changes in emergency medical services, not only in the pre-hospital phase, the evolution has created serious concerns for fire service managers. Since so many fire services are involved in emergency medical services, it is too late to ask whether the involvement is appropriate. Instead, fire chiefs and fire service officers must learn to deal effectively with this vital public safety function.
In general, managing modern EMS in the fire service does not differ greatly from managing any other aspect of the fire service, such as fire prevention, communications or training. While the same principles of management can be applied to effectively manage EMS in the fire service, the fire service officer must also be aware of certain characteristics common primarily to the emergency medical services area. These characteristics are more similar to health care and medical services than to public safety services. Using the four major functions of management, planning, organizing, leading and evaluating, let’s look at some of the distinguishing features of the EMS aspect of the fire service.
Planning
Planning in EMS is vital in order to maintain control of events, rather than being controlled. Probably more than any other aspect of the fire service, EMS requires coordination with numerous outside agencies, some of which are entirely new to the fire officer.
The fire service-EMS officer not only has to contend with developing a plan that will work for the fire service, but a plan that also will coordinate with other emergency medical service plans involving the community. For example, the state and regional EMS plans, health systems agency plan, and civil defense and hospital disaster plans. The coordination of planning with outside agencies can, initially, be overwhelming to the EMS officer. It is helpful in the beginning if the officer develops a list of agencies involved in emergency medical services in his jurisdiction. The list should include agencies involved in advising, policy making, providing service, certifying personnel and coordinating services. The responsibilities of each of these groups, along with their relationship to the fire department, should be defined on the list.
In preparing such a document, it may become apparent to the fire officer that roles, responsibilities, and relationships have never been clearly identified, legally mandated, or formally approved by various agencies directly involved with working together on a frequent basis. If this is determined, then the fire service officer needs to see that either letters of agreement or contracts are developed and signed by agencies with which the fire department provides or receives services. Having the roles and responsibilities defined in writing will help prevent misunderstandings, breakdown or duplication of services, and even legal actions between the fire department and the other provider groups.
EMS planning is necessary for the initial implementation and must be revised periodically to provide direction for growth and expansion. There are now several training programs and guides available to help the fire service-EMS officer in program planning. One of the best guides available is the “Fire Service/EMS Program Management Guide,” developed by the Acute Coronary Treatment Foundation under a grant from the Office of Planning and Education, United States Fire Administration. The guide identifies 26 distinct fire service profiles, using the following parameters:
- Personnel: Dual role, cross trained, civilian.
- Type of service: Career, career/ volunteer, volunteer.
- Level of service: First responder, basic life support with emergency medical technicians, advanced life support with paramedics.
- Transport capabilities: Transporting vehicles, non-transport vehicles.
- Engine or truck company first response, no engine or truck company first response.
The options for initial design and expansion of EMS in the fire service are endless. As the fire service officer seeks to identify a profile most appropriate for a particular fire department, there are numerous factors that must be considered: physical characteristics, medical needs and expectations of population serviced, current medical services available (pre-hospital and hospital), existing communications, jurisdiction’s political and organizational structure, and community and fire department resources.
A planning resource often overlooked by fire officers is the experiences of other departments that provide EMS. Both the positive and negative experiences of other jurisdictions can be valuable to the fire officer. The information can be obtained by contacting other EMS managers, either by phone, survey questionnaires or personal visits.
Organizing
The organization of an emergency medical service in a fire department depends on which profile is utilized, but all profiles have similar requirements: a person in charge of day-to-day operations, a personnel structure and operating standards.
The size of the department and its involvement in EMS will determine whether EMS will be the sole responsibility of a fire service officer. If not the sole responsibility, EMS should at least be identified as a primary work program of the individual to whom it is assigned so that the emergency medical service receives the necessary supervision. Identifying the percentage of fire department operations which involve EMS can aid a fire service officer in justifying the amount of time spent in managing the service. In most areas of the country, emergency care incidents account for anywhere from 40 to 80 percent of the fire department responses.
The personnel structure within an EMS system should be designed not only around the profile of the emergency medical service and the fire department, but in such a manner to prevent some of the problems that are inherent with the practice of providing emergency medical care. Numerous systems, especially those that have been offering EMS for a number of years, have been experiencing a high attrition rate among emergency care personnel, due to the burnout syndrome. Since much has been written about the many factors that contribute to burnout among emergency care personnel, the fire service-EMS officer should take these factors into consideration while designing or reorganizing the personnel structure.
For personnel to function effectively within the organizational structure of fire service EMS, performance standards—both operational and medical—are vital. Generally, operational standards for EMS personnel are the same or similar to those of other fire service personnel. The standards of performance for emergency care practice must be developed in concert with the the medical director and appropriate medical agencies. The enforcement of the medical standards is generally delegated by the medical director of an emergency medical services system to supervisory personnel within the providing agency. This requires that the fire service-EMS officer work closely with and be accountable in part to the medical director of the EMS system. While some fire service officers perceive the medical community as a threat or intrusion in their operations, the medical community can be just the reverse. Fire officers who have cooperated with the medical community have found physicians and hospital personnel to be extremely supportive. In many jurisdictions, these people have assisted the fire department with efforts to increase personnel and fight budget cuts.
Whatever standards are developed within an emergency medical service, they must uniformly apply to all emergency care personnel, whether career or volunteer, uniformed or civilian. In some combined fire services, there are different standards for the various types of personnel. This cannot exist in an emergency medical service since citizens’ lives depend on emergency care personnel having the same level of training and standard of practice.
Leading
In many fire departments, the status and success of the emergency medical services rests primarily on the officer in charge of the service. The fire service officer can fulfill the challenge this presents by being
Informed and keeping current. The fire service EMS officer must be familiar with all aspects of fire service operations, the goals and objectives of the fire department organization and the principles of EMS management. Training is available for the fire officer in EMS management. The National Emergency Training Center offers a two-week resident course, Management of EMS for the Fire Service, and a twoday field program, EMS Administration. Numerous seminars such as the ACT Foundation Born of Necessity series offer emergency medical services managers the opportunity to keep current in the field. If the resources to attend these programs are not available to the officer, he can keep up with innovations and changes by reading professional newsletters and journals, maintaining communication links with other emergency services personnel, and by being involved with other community health and safety agencies.
Innovative. For EMS to progress and the manager to maintain control, the EMS manager must be willing to take risks and implement innovative concepts.
Objective and Supportive. All too often, EMS officers lose their objectivity about the role of EMS in the fire service. There is a tendency among fire service officers involved in EMS for long periods of time to become paranoid regarding the fire service not recognizing EMS needs and value. It is important that the EMS officer work with other fire service managers in allocating the resources available to the whole department and be realistic in their request for a piece of the pie. In working with the other fire service managers rather than against them, the EMS officer will eventually win more support and more equitable distribution of resources for EMS.
Self-Confident. If the EMS officer is all of the above, then self-confidence should flow naturally. This is an important attribute in EMS officers so that they are not easily intimidated by comments, either personal or against the service. Self-confidence will help the EMS officer in accepting new ideas and change, which is constant in emergency medical services, and will encourage open communication. EMS officers who are confident in their capabilities will help promote the growth of subordinates who will eventually become emergency medical services managers.
Evaluating
Evaluating in EMS consists of individual evaluations, evaluation of daily operations, and of system effectiveness. The mechanisms for each of these areas of evaluation should be addressed in the planning stage.
With an established standard of operational medical performance, individual evaluation is a matter of procedure. In a good EMS system, personnel are accountable for their individual performance and it should be made clear during personnel orientation that critique is necessary and not always negative. The purpose of critiquing an individual’s performance should be to help improve performance capabilities and not to impose discipline.
The EMS manager must provide for evaluation of daily operations. This task must be performed by the manager in a small system or delegated to other field supervisory personnel. The individuals performing the daily operational evaluation must be knowledgeable and experienced in emergency medical services to make valid performance evaluations.
One of the most frequently overlooked areas of EMS evaluation is that of system evaluation. Is the emergency medical services system really effective? Is it meeting its goals? Individuals involved in health care frequently assume that since lives are being saved, all services and expenses are justified. With the continued decline in the economy and budgetary resources, it is even more important that the emergency medical services be evaluated as to their effect on the mortality and morbidity within the community. This data is vital to future planning, justifying requests for additional resources and, in some instances, to maintain current personnel and budget resources.
Effective management of EMS in the fire service is complex but not necessarily a Herculean task. This has been demonstrated in numerous EMS systems throughout the country where the fire service’s emergency medical service has been documented effective and the fire service is recognized as a leader in the system.
