Six Easy Steps to Weathering the Financial Storm

Six Easy Steps to Weathering the Financial Storm

By Larry Boxman Jul 21, 2011

“He who cannot change the very fabric of his thought will never be able to change reality and will never therefore make any progress.”

-Anwar Sadat

It is often accepted as conventional wisdom that healthcare, the largest sector of the economy, is recession-proof. The belief is that people get sick and injured no matter what’s happening to the economy. Furthermore, many people presume publicly funded safety net programs ensure people who need care receive it. As a result, it is assumed that healthcare institutions will continue to prosper in spite of a declining economy.

As EMS healthcare administrators, we know this type of logic is a recipe for disaster. For the last several years, both public and private EMS agencies have faced significant financial challenges. Those challenges are caused by the fact that nearly 50 million Americans are without health insurance, and those who have it are struggling with cutbacks in what’s covered, higher copayments for services and rising deductibles for out-of-pocket expenses. Moreover, agencies have been plagued with Medicaid and Medicare cuts and squeezed by rising costs and decreasing reimbursements from insurers.

As we now know, healthcare and EMS are not so recession-proof. We have to treat and transport individuals regardless of their ability to pay. Now that we recognize this, how do we not only survive in this new economy, but prevail? How do we manage our declining finances while at the same time increasing the quality of services we provide? How do we become stronger as individuals and organizations at a time when many businesses and their leaders are capitulating to mediocrity or worse?

There is no one blueprint to answer these questions. However, this article provides insights and theories that will help EMS leaders build their own unique strategies. It does not necessarily provide answers, but rather poses questions intended to spark your curiosity and create dialogue. The people closest to the work know it best and therefore usually have the answers. However, they need somebody to ask the questions. The purpose of this article is to ask questions that will help EMS leaders find the answers inside themselves.

Beware of “Creep”

Get back to the basics—the most fundamental relationships we all share as employers and employees. This relationship can be summed up in one word: value. When an employee is first offered a job, he/she is promised a salary and benefit package. Every pay period, a check is issued to the employee, and benefits accrue. In return for the salary and benefits, the employee meets the expectations of the position for which he/she was hired. Both employee and employer receive an agreed-upon value from each other. In a weak economy when financial resources are scarce, squeezing every ounce of value out of everything we do is crucial.  

What happens if the employer violates the agreement and stops paying the employee? There are laws to protect employees and ensure they get the salaries they were promised. But what happens if the employee breaches their part of the agreement? If expectations were outrageously compromised, the employer has legal rights and may dismiss the employee from the organization. This is not the norm, however. What usually occurs is a slight continual decrease in performance over time that goes undetected until inertia sets in. This sliding decrease is similar to a slow, progressive contagious disease that isn’t identified until obvious signs and symptoms appear. I refer to this disease of diminishing performance as the “creep.” When creep infects employees, they violate the agreement they made with their employers. In other words, when an employee produces 95% of the agreed-upon expectations, he still accepts 100% of his paycheck. When employee performance drops to 90%, she still receives 100% of her pay and benefits. When employees are infected by creep, the basic principle of value is compromised. When that happens in a good economy, the impact is painful. When value is compromised in a declining economy, it can be deadly.

To avoid the damaging results of creep, early detection and aggressive intervention are essential. We all have (or should have) quality improvement initiatives and performance review mechanisms to measure everything from attendance to prehospital care report content. When was the last time you reviewed these programs and modified them to meet current demands? More important, do you methodically and consistently execute these programs? Do you hold employees as accountable as you would hold yourself if you were the employee? Do your employees generate value equal to the value they receive?

Become Customer-centric

Great employees produce great customers. During economic downturns, many organizations focus on improving financial measures (e.g., cost, revenue and returns) rather than measures like the quality of the customer experience. Enhancing customer satisfaction when finances are declining is as easy as it is in periods of great prosperity. That’s because excellent customer service does not require financial investment. The delivery of quality service is primarily relationship-based. Greeting customers with smiles, treating them with respect, protecting their privacy rights and attending to their needs builds solid relationships. Acknowledging that everybody, not just the patient, is our customers is essential to our success, regardless of the state of the economy.

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Most EMS organizations are performance-based and have clinical and operational standards that are measured daily, monthly and annually. We review IV success rates, intubations, protocol adherence, response times, scene times, etc. How many of us put the same level of effort into assessing customer satisfaction? Evaluating the delivery of basic services, such as reassuring the patient and effectively communicating with family members, is often more important than any clinical or operational indicator.

If your organization provides nonemergency interfacility services, you depend on repeat business from skilled nursing facilities, hospitals and care homes. You want to turn prospects who have never tried your service into advocates. Advocates are customers who are aggressively loyal. They will not only withstand temptation to call another provider, they will actively sing your praises. These advocates are your largest unpaid sales force. These advocates—more than marketing, promotions, even price—are fuel for sustained growth in a depressed economy.   

The most significant thing we own is the relationship we create with our customers. To be customer-centric, we must consider the customer in all decisions and actions. Activity in our organizations must be anchored around customers, and quality must be defined from their perspective. Tactics for weathering the recession must place greater emphasis on improving the customer experience.

Our clients need to feel positive energy from our staff, and our staff needs to always listen and respond to its customers. Are customers recognized and treated as assets throughout your organization? Do you work at community relations to establish a positive brand with the public? Do you continuously monitor and assess customer satisfaction?

Meticulous Execution

Execution is critical to success. It is the link between having goals and producing results. However, it is the most underdeveloped attribute of most organizations today. If there was ever a time to focus on meticulously executing everything we do, this is it. This recession has sent many leaders and organizations into chaos. The winners will be those who channel their energies toward the discipline of execution.

Execution is about translating strategies into action and measuring their results. It’s detailed. It’s complicated. It requires deep understanding of where the institution is today and how far it is from where it needs to be. It involves building measurable targets and holding people accountable for them. The ramifications of this recession require organizations to do something different, to value some things more than in the past, to acquire skills they don’t have and move more quickly and effectively in day-to-day activities.

Leadership without execution is incomplete and ineffective. No agency can deliver on its commitments and adapt well to change, especially the change associated with a recession, unless all leaders can execute at all levels. Being able to execute is a distinct skill. It means a person knows how to put a decision into action and push forward to completion through resistance, chaos and unexpected obstacles.

Great execution starts with clarity of purpose and a clear vision of what you want to accomplish. Without a carefully planned approach, organizational goals cannot be attained. It is better to have mediocre goals and great execution than great goals and mediocre execution. The bottom line is that great execution improves an organization’s operational efficiency and lowers its costs. Since execution is essential to success, especially during a recession, have you and your organization developed a disciplined approach to it? Do you spend time developing and perfecting processes that will help achieve desired outcomes? Have you seen good plans gone awry because of substandard execution efforts?

The Power of Curiosity

To thrive in this recession, leaders of EMS agencies must possess an intense curiosity that leads to consistently asking piercing questions about their current reality and future possibilities. Leaders who relentlessly ask questions create opportunities to turn unrealized potential into results. Curiosity allows people to bring flexibility and improvement to policies, procedures and practices that are stale and rigid, and it brings structure to the type of chaos created by declining financial resources.

Curiosity helps create a culture that motivates people to ask “what if” and “why not” questions, and it promotes a climate of “let’s try it” experimentation to inspire innovation. Curiosity is not just a way to harvest ideas; it’s also a process of involving people, and it encourages them to take responsibility for shaping their ideas. It’s a great method to inspire people to not just voice problems, but also to figure out solutions.

To practice the discipline of curiosity, you must keep an open mind. You must be open to learning, unlearning and relearning. If there are long-standing ideals you believe might be wrong, be prepared to accept this possibility and change your mind. Since the mind is like a muscle that becomes stronger through exercise, the mental exercise caused by curiosity makes your mind stronger and stronger.

Intellectual and organizational curiosity is essential in today’s world. Financial challenges associated with this recession require EMS organizations to constantly troll for fresh ideas and unfiltered knowledge from sources close to the work. Front-line personnel might have powerful answers to questions not yet asked, such as, “How can we control waste?” and “What type of cost-saving measures would you suggest?” Do you relentlessly pose questions to your staff? Do you have an intense desire to be curious, to dig deep into the underlying issues that rarely get solved? Are you ready to look below appearances and be open to what you might find? How many great ideas have been lost to a lack of curiosity?

Relentless Renewal

To succeed in this new reality, individuals and organizations must be able to deal quickly and resolutely with change. Declining financial resources and increasing market demands, such as bariatric transport needs, require EMS leaders and their agencies to renew, reinvent and continually transform themselves. For this to occur, knowledge is the most critical asset. The process of gathering knowledge and learning when and how to renovate can’t be relegated to specific locations or circumstances. Instead, learning and sharing knowledge must happen on an ongoing basis.  

In every EMS organization, there is an enormous amount of wasted knowledge. An EMT who works in a senior center or care home every day collects a lot of information about those customers. He learns things that even employees in those facilities don’t know. Some of that information and insight about these customers’ needs could be useful to leaders of their EMS agencies, but often it is lost because the EMT doesn’t recognize its value or is unable to get the information to the people who can use it. Individuals and organizations need to understand that gathering and sharing knowledge is critical if they are to recognize changes in the environment and respond appropriately. Responding appropriately may involve revamping services or altering the deployment of resources.

Responding effectively to change requires individuals and their agencies to be avid learners. Innovations remain unique and cutting-edge for a nanosecond, then are superceded by something newer or better. The challenge for us as leaders, therefore, is to design and build organizations where everything gets better and everybody gets smarter every day. Voracious learning that leads to relentless renewal is a key to sustained success in unfavorable conditions.

Learning at all levels is a way to keep generating knowledge and regenerating people. Do you relentlessly search for learning opportunities? Does your organization make sharing knowledge a priority? Can you recognize when it’s time to reinvent yourself and change course? Can your agency “see around corners” based on new knowledge and adjust its strategies accordingly?

Management Disciplines + Resilience = Excellence

When faced with difficulties, some companies and people not only survive, but thrive. Others simply fold. Why is that? More than any other characteristic, resilience determines who succeeds and who fails. Resilience, not perfection, is the signature of greatness, be it a person or an organization.

The signature of a great enterprise is not the absence of difficulty, but the ability to come back from difficult times even stronger than before. When our economy declined, companies like IBM, Nordstrom and Disney suffered setbacks, but were resilient enough to bounce back as stronger institutions, while some of America’s largest financial companies demonstrated just how quickly they can collapse in a turbulent world.  

Most EMS organizations have been negatively impacted by this recession. If your organization has taken a fall and is dealing with a crisis, be resilient and disciplined. Get back to practicing sound management concepts such as employee accountability, customer satisfaction, execution, curiosity and renewal. The bottom line is, a lack of management discipline and resilience correlates with decline. Passionate adherence to management discipline and resilience correlates with ascent.

We can’t control what the world does to us, but we can control how we respond to it. We have the capability to create our own future as long as we don’t give in to “victim” thinking. When you or your organization accepts that your current circumstances are outside of your control and thus surrender to their ramifications, you choose to become a victim, and you choose to fail. In today’s financially challenged world, failure is the willingness to accept mediocrity and do just enough to survive. EMS institutions and their leaders who are resilient, who retain faith they can find a way to prevail in pursuit of excellence, who maintain the will to do whatever it takes no matter how painful, will triumph. Do you have a never-ending inner drive for progress in good times and bad? Does your organization take necessary actions to shape its future whether facing threat or opportunity? Do you drive improvement when the world around you bleeds excuses? Does your passion for greatness remain constant whether facing danger or not?

Albert Einstein once said the problems we face cannot be solved by the same level of thinking with which we created them. Many leaders and organizations develop blindness to their own deficiencies. They do not suffer because they cannot resolve their problems, but because they cannot see their problems.

Constantly asking questions of yourself and your colleagues changes your level of thinking and produces solutions to problems you may not even know you have. To defy the odds and thrive in the face of severe turbulence and violent change, we must be inquisitive, fervently adhere to solid management principles and have a high level of resilience.

Larry Boxman has been involved in EMS for 28 years. He is currently the vice president of operations for Metro West Ambulance in Washington County, OR, and a volunteer paramedic with the Mist-Birkenfeld Rural Fire Protection District. Contact him at

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