Spare Some Change?

This post can also be found at

With EMS Today right around the corner, I got thinking the other day about the past conferences that I have been to.  This year’s gathering in Washington, DC marks my ninth consecutive major conference that I have attended.  I’ve been to Baltimore three times, this will be my second appearance in DC, Las Vegas twice, New Orleans, and the first conference that I attended back in 2010 in Dallas.

That year in Dallas, Had quite the opportunity drop in my lap.  One morning, I had the chance to sit down and interview a person who I very quickly came to admire because of his involvement in the National EMS Management Association, Skip Kirkwood, who at the time was the chief of Wake County EMS.  Even before I had a chance to meet Skip the words “Well, in Wake County. . . ” were a constantly used phrase in my vocabulary.  I admired the changes and strides that they had made in their quest to provide the best possible patient care for the residents of Wake County.

More than that though, I admired Skip’s approaches to problem solving.  For years to follow, presentations that I have given have involved little pearls of wisdom that I have obtained at the hands (and fingers) of skip over the years from e-mails and posts that I have received from him, so while I had a long standing admiration for Skip, having the chance to sit down with him as a captive audience and pick his brain was quite the opportunity for me.

One thing that stood out to me was how he approached change and progression in Wake County.  As I read about his service it was clear that things always seemed to progress quickly there.  Skip’s answer to me was that he always promotes an environment that is comfortable and welcoming to change.  He wanted his people to be ready to walk in one day and find a new piece of equipment, or a new policy change.  By doing this, when major changes were rolled out his staff was more welcoming and willing to adapt.

I cannot tell you how much that stuck with me.  Far too often, I have seen paramedics, EMTs and even services becoming complacent with the “norm.”  They get themselves into a rut, and allow life to just carry on day to day in their same routine.  Response becomes automatic, treatment becomes automatic, and then when someone suggests doing something differently there is significant pushback.  I have seen it through my own experiences as a supervisor, I have seen it as a street medic both from myself and from my peers, and I have seen it through my friends in other services.  It is a consistent trend.

It goes without saying, and has been stated repeatedly in the virtual pages of my blog that we are at a major crossroads in EMS.  The care that we provide is slowly moving away from simply providing emergency care, and we are evolving into what MedStar and Matt Zavadsky are calling “Mobile Healthcare.”  We are being asked to relearn the EMS alphabet, and but “C” before “A” and “B” all in the name of saving more lives.  It’s change, and for most people who have adapted their own way of doing things and their own rhythm, it’s is terrifying.

Every service and every manager has their own challenges for how to promote and allow their people to become comfortable with change.  For example, one of the major ones that I dealt with at my former employer was having a diverse work force that was around 40% part-time and per-diem employees.  Getting the word out to these people and getting them proficient to the point where they could just seamlessly transition into the workforce was difficult.  Dispatchers had to be convinced that no, that crew is not dogging it at the hospital, they’re learning our new computer system.  Managers had to learn that we might have to put an extra truck or two on to let our people adapt, and give them a chance to apply what they learned in a classroom (or on a memo) hands on.

The important thing to remember though is that while fresh ideas can be born at any level from the newest EMT right on up to the medical director, the key to how that new treatment or policy is received is up to the leadership team.  Implementations need to be methodical.  No one should ever say, “Just do it, make the change.”  Memos should not be rushed out.  Rollouts on major changes need timelines.  With every new policy fails, is not followed, or is simply imposed with an iron fist on a work force, you can expect the next one to be that much more difficult.  While I am certainly guilty of contributing to the problem as well as the solution, all that I can do is learn from my mistakes, and more importantly, embrace Chief Kirkwood’s ideas and values.

Promote the change, embrace the change, and be a champion of the evolution of EMS.

To read my full interview with Chief Skip Kirkwood, check out Part 1 and Part 2 at

Extending the Career Ladder

I remember the first time that I watched Mother, Juggs, and Speed and saw Larry Hagman walk into F&B Ambulance for the first time, and put his resume on the table.  After barely even looking at his resume, Mr. Fishbine hired him, with barely an interview.  No selection process, no nothing.  A guy with a card, getting a job.  Many might see that as a Hollywood shortcut, but sadly in my experience in many places, especially the private industry, the vetting of prospective employees is far too brief.  You then are introduced to the rest of the “team” at F&B ambulance which includes the veteran, Mother.  The guy who is really in charge, seemingly because he is the guy who has been there the longest.

I point out this great 70’s movie because it was actually the first exposure to EMS that many people who are my age had.  Sure, I’m 35, and this movie came out the same year that i was born, but even nineteen years later when I was a freshman in college we watched it as part of one of our EMS management classes.  Although my two full time jobs have been with pretty large, put together organizations I have plenty of friends who have and do work in the smaller mom and pop sized section of the industry.  I have heard plenty of stories about people being sent out on the street as fast as they come in the door.  It is time for EMS to take a good look at their career ladder and hiring processes.   First though, we need, as an industry, to decide who we want and decide what a career ladder really entails.  Should the evolution of BLS to ALS really be considered part of that ladder, or is it possible to move “up” the chain in EMS without having a paramedic patch on your sleeve?

Can a BLS provider be qualified to be a section leader on a major incident?  Can they receive and utilize the training necessary to deal with day to day personnel and scheduling issues that always seem to pop up?  Far too often, we associate a person’s ability to manage people with their ability to provide care to people and those two do not intersect as much as we think they do.

Think of an example of workers on a production line.  The worker who can do their job fastest and most efficiently might not be the most qualified to step off of the line and manage the company’s books.  The same rings true for EMS.  The best paramedics are not always the best managers, and the best managers are not always the best paramedics.

This provides quite the conundrum for anyone who is seeking to take their opportunity to get off the streets as many of us have done throughout our career.  Sometimes it is quite the challenge to have to wear two thinking caps: one that helps us with drug dosages and extrication techniques, and another that gives us the ability to manage a UHU, or know not what is going on with one patient but what is going on with six, seven, or twenty units you are responsible for.  Twice the learning, twice the responsibility, and twice the headache.

Sounds great, doesn’t it?

Now, here is where the employer comes into play.  The employee, regardless of level, shows an interest.  We cannot as an industry expect them to figure everything out on their own.  They must be let in on whatever trade secrets that a department has, because personally, I feel that there are NO trade secrets.  No secret sauce.  We just choose to lie to ourselves and say that there is.

Giving someone the opportunity to see what goes on behind the scenes and on a more macroscopic level can change their impression of the entire business.  I remember one day I had an employee riding with me on my supervisor unit for a few hours, and when I dropped him back off for his shift, he said “man,  I did not realize how much you actually had to deal with.”  That impression was after just a couple of hours of driving from one end of the city to the other, and a phone ringing off the hook.  Emails were answered, and a complaint or two was handled.  In the time that he was with me, we only made it to one call, and during that time, I did not pick up the radio mic.  I am sure that at least one of my 20 or so units on the street probably thought that I was tucked away hiding somewhere, but in reality I was working my butt off, and frankly, I would come home more tired from a 12 hour supervisor shift than I would a 16 hour ambulance shift.

The moral of this post is we need to remember that when we have that position open up and we are ready to move someone up the chain, whoever throws their hat into the ring might be walking into a position blind.  They can read the job description and requirements all they want but there is so much more to learn and understand, and it is the leader and the manager’s requirement to prepare them for what is to come.

This post can also be found at EMS in the New Decade

5 Ideas For Celebrating Victories

No matter how small we may think it is, we need to celebrate our victories. Here are 5 ideas for recognizing and commencing that celebration with your providers:

  1. A Written Letter of Commendation from “The Boss – Telling someone they did a good job is important, but taking the time to put it in writing helps increase the value of that message. Not only is it great that they can show their co-workers that you truly value their service, that’s something they can take home and show their friends and family. It can even be something that they display in their home, a source of professional pride, for others to see for years to come
  2. A “Thank You” Card – greeting cards have traditionally been used for close friends and family on special occasions. Isn’t a positive customer service report such an occasion? Don’t you want those who report to you to feel as if they are a part of something bigger, like an extended family? “Thank You” cards can go a long way to deliver that
  3. A Cup of Coffee with “The Boss – It will cost at most $21 (if you go to Starbucks) and 15 minutes of your time and undivided attention to make your Providers feel great about their performance, their career choice, and your Agency. Want to know the funny thing? Your time and undivided attention will often be appreciated more than the coffee…
  4. A Public Posting of Praise – It’s important to be sure that your Providers are recognized among on another. Whether it be a memo, flyer, or copy of the letter of commendation that you’ve written put up on a bulletin board, crew room, or locker room goes a long way to achieve that. It not only provides some recognition for those who have done a good job, but provides some incentive for others to do the same
  5. A Mention In Your Agency’s Social Media Stream – Is your provider on Facebook? Is your agency on Facebook? Hopefully they both are (if you’re agency isn’t, then read this post) and then posting a photo on your Agency’s Facebook Page and tagging your provider in it does two things simultaneously. First, it recognizes the Provider to your Agency’s audience as well as the Provider’s friends and family. Second, it gives your Agency some content for their Social Media Presence. It’s a win-win for all those involved

What does you agency do to celebrate the victories? Let us know in the comments…

Understanding Unit Hour Utilization

Unit Hour Utilization (UHU) is one of the most widely used and misunderstood measurement metric used in the vast majority of EMS Agencies today. The metric has gained notoriety thanks to Jack Stout’s System Status Management solution for ambulance deployment. It has become the universal EMS measuring metric for agencies to gauge performance regardless of agency type or primary goal.

How To Calculate UHU

Blackboard / chalkboard texture. Empty blank black chalkboard wiThere are actually a couple of different ways to calculate UHU but the simplest way (what we will call Simple UHU) is calculated by dividing the number of hours a unit works into the number of assignments it handles. For example, a unit that works 10 hours and handles 5 assignments would have a simplified UHU of a .5. Generally the higher the number is the more effective and efficient the system is considered to be.

There are a few other ways to calculate UHU that you may need to understand.

Payroll UHU – For the budgetary minded system there is the Payroll UHU. To determine this UHU you take the total number of hours worked by your field providers, divide that by 2, then take that number of hours and divide it into the number of reimbursable assignments handled. This type of UHU is generally used for specific garage locations

For example: You have a total of 20 Medics who worked 10 hours for a total of 200 hours and have completed 50 reimbursable assignments. We divide 200 by 2 for 100 Unit Hours (it takes two to make an ambulance crew) and then divide that into 50 to get a Payroll UHU of .5. If we took the same numbers and did a Simple UHU, we would have 10 units working 10 hours (100 hours) and completing 50 assignments for a Simple UHU of .5 as well.

Suppose that out of those 50 assignments there were only 45 reimbursable assignments (for argument’s sake there were 5 Refusals) then we would be dividing 100 into 45 for a .45 Payroll UHU.

Now let’s say that 1 of those 20 Medics didn’t come to shift due to an upset stomach. Instead of sending him home you used his partner for the 10 hours in Logistics fixing regulators and stocking trucks. If we calculated the Payroll UHU, we would divide 190 (because one person of 10 hours is out) by 2 for 95 Unit Hours divided into the 50 assignments to get a Payroll UHU of .53 (it’s 0.52631579 rounded up to the nearest one hundredth). If only 45 of the assignments were reimbursable then the Payroll UHU becomes .47 (it’s .47368421 rounded down). If we calculated a Simple UHU, we would have 9 units working 10 hours (90 hours) and completing 50 assignments for a Simple UHU of .55.

Notice the difference? When you start adding the variables of a unit not being out there but still paying for half a crew and having assignments that are not reimbursable, the UHU starts to get worse and worse.

In Service UHU – For the performance minded system there is the In Service UHU. Unlike the other UHUs, some systems do not consider a higher number as being better. To determine this UHU you take the total number of hours your units are in service and divide it into the number of assignments handled. This type of UHU is generally used for system-wide assessments.

For example: You have a total of 10 units scheduled to work 10 hours each and they handle 50 assignments. This would give you 100 unit hours divided into 50 for a Simple UHU of .5. It takes each unit 15 minutes to check out their ambulance and come in service with the dispatcher, so that is 2.5 hours (150 minutes) of time where they are technically out of service. That means that your In Service UHU is actually 97.5 unit hours divided into 50 for an In Service UHU of .51. If one of your units breaks down for 2.5 hours, your In Service UHU becomes .53 because now you only have 95 hours of in service time.

Which UHU Is Right For You?

The type of agency and the goals of the service will direct you towards which UHU is best to use in order to measure your agency. Many managers misunderstand UHU as the be all end all of efficiency and that simply is not true. UHU provides the metric to measure and compare efficiency when planning to meet the needs of your system and is only one tool that the successful EMS Manager and EMS Leader needs in their toolbox.

System Status Management 101

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Many EMS systems are designed around a model called System Status Management (SSM). It was introduced in the 1980s by Jack Stout as part of the Public Utility Model for EMS systems[1]. SSM has become the most widely accepted management methodology for managing EMS resources. The fundamental concept has two major pieces that shape the lives of the Medics it manages, Dynamic Deployment and Peak Demand Staffing.

Dynamic Deployment becomes utilized once you are already on the shift. Depending on probability trended over time, your unit will be assigned a posting or a place at rest. This location is considered to be in an area where there will be a demand in the immediate to near future. As units are assigned calls and the day progresses, these postings will change with the probability of a need increasing or decreasing for a potential assignment nearby. A truly dynamic system will see the fluid movement of units from posting to posting to ensure the entire area is covered with maximum statistical efficiency.

Peak Demand Staffing requires schedules that put the appropriate number of resources into the system to meet the anticipated demand for those resources. Shifts (referred to as tours by some agencies) in EMS can vary widely depending on where you are in the country, the demands on the system, and the type of agency that you belong to. Your shift can be as short as 4 hours and as long as 24 hours. I haven’t heard of an agency with a 36-hour or 48-hour shift but I wouldn’t be surprised that it exists somewhere.

Demands on the system often dictate the schedule type and shift times for an agency. Agencies in urban centers often see peak call volumes during the “9 to 5” timeframe, when the urban centers are open for business and people are at work. Agencies serving suburban areas may see peak call volumes both before AND after the “9 to 5” timeframe, catching the members of the community before they travel to their workplace in an urban center and after they return home from a typical “9 to 5” job.

[1] Public Utility Model

The Shrinking Difference Between Leadership And Management

The difference between management and leadership used to be very easy to delineate. Alan Murray, the author of The Wall Street Journal Essential Guide to Management: Lasting Lessons from the Best Leadership Minds of Our Time, writes that “The managers job was to plan, organize, and coordinate. The leaders job was to motivate and inspire.[1]” Managers managed resources through edict or memorandum to a metric or a set of metrics, leaders led resources through inspiration to achieving an outcome or a goal. Some Agencies would go so far as to bestow titles on both their managers and their leaders, while others opted for a less structured organization.

In today’s world leadership and management have lost some of that separation. Murray contends that, “People look to their managers, not just to assign them a task, but to define for them a purpose. And managers must organize workers, not just to maximize efficiency, but to nurture skills, develop talent and inspire results.[2]” I can’t help but agree with him based on just the past 5 years of seeing freshly minted providers come into the field with less preparation as those who came in before them, and even the providers 10 years back really weren’t coming in too prepared.

When writing this post I originally titled it “Leadership vs. Management“. After drafting it, pondering, and editing I decided to change the title. Leadership and Management are not in opposition to one another. A leader does not necessarily have to be a manager and, similarly, being a manager does not automatically make you a leader. To be truly successful in this day and age you do need to have skills from both toolboxes.

What remains dangerous is the assumption that because someone is good at one, that they would automatically be good at the other. A good manager is not necessarily a good leader, and a good leader does not necessarily make a good manager. Making this assumption in terms of the food service industry, a good server does not necessarily make a good chef, and a good chef does not necessarily make a good server. While they both work in the food service industry, their roles in a restaurant are quite a bit different.

This is an assumption we often make in EMS. We think that a good provider who can manage an airway will make a good supervisor. We promote them, give them some basic instruction, and then wonder why they don’t know everything there is to managing people. We forget that they’ve had plenty of practice in the classroom managing airways to meet the standard of a model airway. When they got to the field they were able to manage the airway. Granted, that first, second, and probably third managed airway may not have been the prettiest airway, but they managed it, learned from it, and improved upon it. Each improvement brought them to the point where they were able to match the model of a managed airway that was already presented to them. If we just judged their ability to manage airways by that first and second airway, we’d be wondering why they don’t know everything there is about managing airways.

As the differences between managers and leaders shrinks we need to be able to marry the two. While it may not be pretty the first few times, we need to believe in those who have been selected to lead AND manage others. More importantly is that we must give them a model to strive for and set the example for them at every chance we get.

If the providers have been coming out ill prepared for the reality of working in the Emergency Medical Services, then we need to make sure their Manager/Leader is prepared to help them succeed. The failure of one results in a failure, at some level, of all.

[1][2]What Is The Difference Between Management And Leadership?
The Wall Street Journal
Alan Murray