Broken Windows

Management of today's EMS systems requires knowledge of both administrative and operational aspects of the delivery of prehospital medicine. The challenges inherent to satisfactorily choreographing these types of complex organizations can be as daunting as any seen in the business world and require a blend of formal education, experience and on-the-job training. Quality management, overall performance, human resources issues, as well as a host of other trials and tribulations, are all part of day-to-day operations for EMS managers.

This month, EMS Magazine introduces a bimonthly column sponsored by the National EMS Management Association (NEMSMA). While laying the foundation for more expansive thought on management concerns, the column will also prepare readers to analyze important public-policy issues that confront EMS systems, as well as combine theoretical and practical experience and a knowledge of the healthcare industry as it applies to EMS.

One of the most influential concepts of modern policing is referred to as the "broken window" theory. When what seems to be relatively minor evidence of decay appears in a given neighborhood (a broken window, accumulated trash, graffiti on building exteriors, etc.) and is allowed to accumulate over time, the people who live and work in the area feel more vulnerable and begin to withdraw. They become less willing to intervene to maintain public order (for example, to attempt to break up groups of rowdy teens loitering on street corners) or to address physical signs of deterioration. Sensing this community dissociation, the local criminal element becomes bolder and their unlawful activity increases. As a result of the rise in crime, residents become yet even more fearful and withdraw further from community involvement and upkeep. This atmosphere then attracts offenders from outside the area, who now see that the neighborhood has become a less risky site for more insidious and violent crime, such as drug dealing and robbery. This theory has been field-tested in major cities throughout the United States such as Los Angeles, Seattle and New York.

Although it may seem like a strange connection at first, this same theory of progression may be applied as a cautionary tale to the realm of EMS system supervision and management. Once evidence of decay in our systems (sinking employee morale, chronic equipment problems, unaddressed protocol/patient care violations) occurs, our employees, like the residents of the city, begin to withdraw. They become less willing to communicate personnel and operational problems. The level of customer service (toward both internal and external customers) begins to decline. Sensing this, the more disgruntled EMS workers take the opportunity to become more verbose about their occupational dissatisfaction, but usually in just a surreptitious manner and not constructively bringing the now-emerging issues to management for resolution. The cycle continues to feed upon itself until ultimately there is a mass exodus of employees - including those at the supervisor and manager levels - from the system. Additionally, the distinct lack of a positive customer service-oriented corporate culture can cause the company to lose long-held contracts. In either case, the organization essentially implodes.

To prevent going down this path, we must be able to define what the EMS system "broken windows" are, so that we may better gauge when problems, even seemingly minor ones, are occurring, and act to correct them immediately. In addition, we need to empower field training officers, supervisors and line personnel to intervene and make them feel safe in their work environment. As management, if we see something "broken" or in a state of decaybe it m - orale, operations, patient care, training - we have to ascertain what occurred and why. Don’t look to assign blame or ask "who." The effort should instead be aimed at finding out the "why" and then getting to work fixing it with input from all levels of employees.

While this concept of progression may be abstract, it seems reasonable that sensing the smaller cracks in the façade of an EMS system is an integral part of an EMS manager's job. If these seemingly minor problems are not repaired early on, they have the potential to grow into larger problems that can affect the organization in any number of ways. By resolving what may seem like a relatively unimportant annoyance today, you can help prevent it from causing the crisis of tomorrow.