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System Solutions


      As EMS systems face down the global economic crisis and headlines scream daily of departments scrambling for what to do, questions emerge about the ways we run our systems and utilize our existing resources. Are more resources needed, or must we do a better job with what we have? It's a common question on the minds of EMS managers and elected officials.

   For this month's column, I spoke with David Williams. Dave is a senior consultant with the well-known EMS consulting firm of Fitch & Associates. He is an EMS systems expert and process improvement advisor, and has served as a provider, educator, researcher and leader in almost every size and model of EMS organization. Before joining Fitch, he was quality management commander for Austin-Travis County (TX) EMS.

   Williams is an alumnus of Springfield College in Massachusetts and the University of Maryland, Baltimore County, where he respectively earned undergraduate and graduate degrees in Emergency Health Services Management. He is currently writing his dissertation for a doctorate in Organizational Systems from Saybrook University. His research is focused on patient- and customer-centered EMS system design.

   Where would limited financial resources best be directed to improve an EMS system—toward additional manpower and equipment, or toward better systems development/research?

   In a recent national survey, EMS organizations large and small from across the United States reported the economy is affecting them, and half had experienced budgets cut by as much as 10%. What a lot of people don't realize, though, is these decisions were made when the impact of the economy was a prediction. Next year's cuts will be a result of reacting to the true, experienced shortfalls, and more is expected. It is critically important that everyone be focused on meeting the challenges in the coming years. Unfortunately, many systems continue to repackage or tweak themselves, but few are evolving to their already-changed environment. The current economic situation will bring out either the worst in those who are unable to change or the best in those who are.

   When a leader suggests the answer to an improvement problem is more people, more resources or more money, there's a strong chance they're not getting it, because those are rarely the true fixes. EMS leaders who get it start with a strong understanding of their core mission. This was recently wonderfully articulated at the Fire Rescue International conference by Renton, WA, Fire Chief and IAFC leader I. David Daniels, who made the case that the fire service's primary mission has shifted to EMS over the last 30 years, and that EMS was his No. 1 business. He argued fire departments needed to be focused on being necessary and community-oriented.

   Strong EMS leaders have clear aims for moving forward based on objective thinking. In the coming months, they will be reevaluating their organizations from top to bottom. With every position, activity and line item, they'll ask themselves, "What am I trying to accomplish?" and "How does this directly benefit our patients/customers?" If the answer isn't clear or directly tied to the core mission, then they must responsibly determine how to change, give away or discontinue it. Only through studying what's needed and what works and then redeveloping the system can you navigate the waves of the economy.

   EMS systems need to reliably deliver the most appropriately trained person to the patient's side in a timely manner. Sadly, a large number of EMS systems (even those with all the resources, money and people power imaginable) can't deliver this on a daily basis. The answer is rarely more, but rather to use objective data, peer-reviewed research and current best practices to design systems and processes around the needs of those who call for help. Sacrificing what we want or think for what the data says or what's directly important to the next patient is the right answer.

   In addition to the core mission, what should an agency's priorities be in cases of limited resources? What sort of areas would make the most difference?

   In addition to the core mission, there are three key considerations: training, data and employees.

   One of the first things to get cut or scaled back is training. This looks easy on a balance sheet, but is a critical error. Training is essential to providing clinically solid service, and Gallup research has shown it is very influential to employees considering your organization and for retention. I recommend agencies revaluate their training offerings and confirm they meet continuing education requirements and provide instruction in the calls crews do every day (e.g., geriatrics, falls, etc.), not just the emergent or special cases. Remember also that good learning doesn't have to be flashy and expensive; it just has to add knowledge and understanding.

   Measure your performance. No excuses. The vast majority of EMS organizations I've reviewed and worked with track fewer than half a dozen measures, and usually they're presented in formats that provide zero value for monitoring performance. Every organization, regardless of its technology, can track data if it has the will. Only through data can you see whether changes you make result in improvement. Instead of guessing, get in the habit of asking, "What's the data tell us?" Then track it over time and display it in a run chart.

   Finally, front-line employees are going to feel the squeeze personally, within your organizations and through the calls they run. Traditionally, they don't get the attention they need when times are tough. If you have an extra minute, spend it with a crew. If there's an opportunity to thank someone or pass forward appreciation, take it. If there's a time for leaders to roll up their own sleeves and pitch in, do it.

   Items that should be cut are the extras or nice-to-haves not directly tied to the core mission, that duplicate services provided by others, or that may be delegated to others.

   How can EMS leaders look for ways to operate their systems more efficiently and do more with less?

   Don't attempt to reinvent the wheel. Look to those already doing a solid job. Visit them and meet with their people. Learn about their operations. Ask questions. Currently, EMS system operations and budgets are all over the map. Cities with nearly the same populations, demographics and volumes can be regularly found with big differences in their operating costs and zero differences in performance and outcomes. In many cases the leaner systems are producing better results.

   The Coalition of Advanced Emergency Medical Systems ( is a good place to start. These organizations aim to run outcome-focused, efficient systems and frequently host organizations interested in learning about their practices. I also encourage people to read EMS trade journals. There are a lot of great articles about various practices that can be helpful. I must add a caution to this recommendation, however, because there's a lot of information published that is based on one experience, a limited view of the industry or one person's opinion, and it's often difficult to filter what's good advice and what's just interesting to read.

   One document I encourage every EMS leader to read and study is the EMS Structured for Quality guide published by the American Ambulance Association. This guide is a must-read regardless of organization type, and is packed with information about system design, operations, finance and performance. Another resource I recommend for anyone trying to improve performance is The Improvement Guide (by Gerald Langley, et al.), which provides one of the best and most accessible methods for data-driven enhancement of organizational performance.

   Finally, ask your people. One of my favorite questions is to ask, "If we couldn't do this the way we do it now, how would we do it to meet our aim?" Those closest to the process will surprise you with some amazing ideas that can improve performance and reduce costs.

   As an agency's call volume rises, is throwing an ever-increasing number of people at it a viable long-term solution?

   Call volumes are going to continue to rise. Resources and people need to be added as volumes increase, when appropriate. Note the "when appropriate"! Additions should only be made based on achieving the core mission and better serving the customer. This means continually conducting call volume demand data analyses to determine where and when you may need resources. In spite of popular practice, you may only need a truck on for a peak time, not 24 hours. It means understanding the research and your customer needs so you can add the right resource. The right resource might be a BLS ambulance or specialist vehicle for high utilizers or special-situation patients. The key is not to take what you've always done and try to force it on what's needed, but to ask, "What am I trying to accomplish here, and what changes do I think will result in it?"

   As agencies look for ways to operate more efficiently, how can they prevent overwhelming their crews and help them keep up with demand? Is there an optimal balance between these interests?

   The primary goal is to reliably deliver the most appropriately trained person to the patient's side in a timely manner. If that person arrives at the patient's side overworked, exhausted or distracted and can't follow through on the mission, the system has failed.

   Two primary concerns I have directly tied to crew safety and well-being are deployment and shift scheduling, which both have major implications as volumes increase. When most people in the industry hear the terms "deployment" or "system status management," they shut down and get resistant. Often that's a symptom of not having knowledge of the root concepts or having been a victim of a system that applied the tools poorly. Every fire department, community ambulance, private provider, volunteer squad and hospital-based service is doing deployment right now; the only difference is to what degree. Organizations doing it at either extreme are going to quickly burn out their staffs. These include the lean, mean, trolling-for-trauma-with-my-Big-Gulp-in-the-cup-holder systems and the station-based fire-rescue units that run 22 calls in 24 hours and are pros at backing into the station, but rarely get to put it in park before the next call. Both extremes are burnout-producing, and systems need to focus on being in the middle, where resources adequately match demand in the right place at the right time.

   Year after year 24-hour shifts remain the most common ambulance shift pattern. If you're in a low-volume environment, this may be appropriate and economical, but in many communities—especially cities—they are a result of tradition, staff resistance and management ease. These shifts represent a major safety risk, burnout generator and do not have anything to do with matching demand and achieving the core mission of delivering service to the patient. It's impossible to explain to a patient or the public how 24-hour shifts are in the best interests of patient care or performance. Organizations that are workforce- and patient-focused need to seriously revaluate the use of extended shift schedules regardless of their economic situations, but it would be a positive if budget reductions freed the industry from widespread 24-hour shift use.

   The issues of efficiency and crew well-being are often debated as if they're mutually exclusive, but they aren't. A one-size-only model cannot be efficient and cost-effective, and also means some employees will be happy and some won't. Working with employees to create ways to achieve the mission and be employee-friendly should not be in conflict.

   Finally, and I can't say this enough, talk to your crews. Survey them, listen to them and figure out what they need. Sometimes it's not another ambulance, but a potty or meal break. Frequently it's not badges, baseball caps or t-shirts, but a thank you and cold bottle of water between calls, or fixing the broken microwave in the station. Only through engaging crews can a leader serve them and help them be most effective. Employees aren't motivated by money and stuff; they're inspired by leaders who support them and work that's purposeful and rewarding.

   Raphael M. Barishansky, MPH, EMT-B, is program chief of Public Health Preparedness for the Prince George's County (MD) Health Department and a member of EMS Magazine's editorial advisory board. Reach him at


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