Lawrence on Leadership: Ray Creen

Rob Lawrence is a featured speaker at EMS World Expo 2014, scheduled for November 9–13 in Nashville, TN. Register today at EMSWorldExpo.com.

In my first submission on a subject dear to my own heart—leadership—I chose to look at leaders around the EMS world. These people are all very appealing—they are of great character and principle, they have “command” presence, and a grit and determination to get the job done.

They say the behavior, approach, attitude and manner of a leader sets the tone, style, direction of travel and, ultimately, determines the results and success of any organization. While many study leadership and the tenets of leading a successful organization, I have reverted to the method of study from my days at both Sandhurst and the Army Staff College: Examine the leader and not necessarily the leadership.

Leaders over history have all offered something unique, be it eccentricity, brilliance, vision or just downright evil. By studying them, one can extract the lessons—those aforementioned tenets—that are the nuggets that help us all shape the destiny of the organizations we are in, no matter the level. My own studies took me from Sun Tsu, Mao Tse Tung, Horatio Nelson and the Duke of Wellington through Churchill, Guderian, Rommel and, yes, even Stalin and Adolf Hitler.

All had good, bad and ugly lessons to ingest, but they were lessons nevertheless. In my own career I have learned as much from bad leaders as I have good ones. So the study of leaders themselves is just as important as the actual study of leadership. There are great leaders out there in the EMS world—I intend to find them in my own travels and bring them to you.

Imagine if Texas had only one EMS system across its vast expanse of 268,000 square miles, instead of its current 1,100 EMS agencies. Further imagine the skill, leadership and management prowess needed to head up such an organization. Such a place and person exists. At 312,000-square-miles, the place is New South Wales (NSW), Australia, and the person is Chief Executive Ray Creen.

Based in Sydney, Australia, Creen is a British transplant and a veteran of the UK's NHS Ambulance Service. In 2005, UK ambulance services reorganized and merged as a result of the Taking Healthcare to the Patient¹ paper, and downsized from 32 to 11 regional organizations. Creen took advantage of an opportunity to trade the 900-square-mile territory of the Kent Ambulance Service NHS Trust, where he was the director of patient services, for the desert expanse of South Australia, with a colossal 600,000-square-miles of real estate.

Viewed as the “Pom” import, his first task as CEO of the South Australia Ambulance Service was to address service delivery. He noted that across the operational area there was almost a 100% transport rate. The breakdown of callers appeared to be no different than that of any other service, with 10% of calls being truly life-threatening, 50% in the non-life-threatening category (all EMS appropriate) and 40% with a need that may not necessarily require ambulance support.

Echoing a common EMS problem worldwide, he found his ambulance service was the health, social and primary care safety net. After identifying the health and response needs of his population at risk, he instituted an existing program from the UK, one that’s currently emerging in the U.S.—community paramedicine. Unlike anything on either bank of the Atlantic, this was of an unimaginable size and scale.

Creen transformed the service into a modern, innovative model of service delivery. He introduced previously non-traditional approaches to care, including out-of-hospital programs such as treat and discharge initiatives, where paramedics treat patients in their own home or care facility, potentially sparing the patient very lengthy trips to hospital emergency departments. He also opened up and reinforced clinical pathways, particularly in the disciplines of pharmacy, physiotherapy and exercise physiology, with the overarching aim being to improve patient care and ensure the patient got the right care in the right place the first time. For his hard work and dedication, Creen was nominated in 2013 as a state finalist for Australian of the Year for his transformational efforts—no mean feat for an Englishman.

After five years in charge of South Australia, in March 2013 Creen moved onto his next challenge, New South Wales. Another massive operational area, his arrival was heralded not as the immigrant from the antipodal point on the planet, but as a successful CEO with a track record of delivery.

A year into his new appointment, the Sydney Morning Herald² described Creen as a tenacious leader and great mentor, who is positively worshipped by his employees. In mentoring staff, he offers key views for any new manager or junior leader seeking his counsel. He immediately recognizes people should “be themselves” and not adopt the airs and graces of someone they are not.

Creen is a believer in leading from the front and setting behavior by example. NSW paramedic, EMS traveler, writer and broadcaster Benjamin Gilmour notes, “Creen is a true visionary. When he speaks, it really is impossible not to fall under the spell. It’s almost as if he’s been somehow privy to every problem road staff have ever complained about in private and made a note to address the issues. It was quite remarkable how quickly he won over a severely disillusioned and skeptical workforce.”

Gilmour goes on to observe that a key part of Creen’s appeal is his ability to be an active listener. “I think he did this by demonstrating himself as a fine listener, and where he listened most intently was at the coalface. Even a year later, in his ‘action’ year I guess, it is not uncommon for Creen to still show up on a job, not to check on you, but to help out, help lift the patient, carry your gear, keep that taste of reality. That’s something unique I think for a chief executive of 3,000 paramedics.”

Creen believes no matter what the difficulties or challenges are a good leader needs to be positive, as reaction and behavior in turn impacts the behavior of those around you. He maintains leaders must be great communicators, but not in a “one way street” sense—great communication also requires the leader to be a great listener as well. Creen acknowledges knowledge comes from multiple heads, but as the single person in charge it takes a different type of courage to do the right thing, a moral courage, he notes, that, “You may have to upset, to make a decision that affects the few for the benefit of the masses.” When asked who inspires him most, he gave an answer typical of the man. He says, “It is not the person that inspires me, it is the personality.” The key character traits he admires are individuals who are people-focused, who “get in amongst it” and essentially do what’s right.

Creen is intent on taking NSW Ambulance on the same upwardly mobile journey as he did in South Australia. His next big ticket item is a whole new service, one that is centrally coordinated, but locally delivered. In a service area that takes well over a week to get around to all the stations, it is easy to see how this will be a good idea. Geography also plays a major part in not only response, but equipment, where one size of ambulance doesn’t fit all—a paramedic in a rural area has a different need than one in an urban area. To this end, he is examining the emergency crew capability in remote areas where vast distances require vast solutions—the switch to air medical retrieval and change to rotary medical services. He’s expressed a wish to elevate provider health and safety high on the agenda. As with every other global EMS system, the risks of muscular skeletal injuries are high and better protecting staff is also a priority.

Creen is now firmly into his second year in NSW and the programs and projects he has initiated are coming to the fore. This includes initiatives based on an auditor general’s report,³ which found paramedics should be able to refuse transport to patients who were in need of a band-aid and not a hospital bed. The report said the public had “unrealistic expectations about the role of the ambulance service,” including that an ambulance will fast-track people to the hospital, and that ambulances can be called for minor ailments.

Previously in New South Wales, like the U.S., paramedics have been unable to refuse to transport a patient to the hospital if they insist on going. Creen has instituted a trial on the NSW Central Coast, authorizing paramedics to refuse to transport a patient to a hospital emergency department where it is clear that transport is not warranted. The flat refusal will be accompanied by a referral into an alternative care pathway.

Most recently, Creen and NSW Ambulance launched the “If You Hurt a Paramedic”⁴ anti-violence campaign to raise awareness and stamp out the problem of violence toward paramedics. The campaign notes verbal and physical assaults of paramedics increased from 89 reported incidents in 2012 to 133 incidents in 2013. Creen very publically stated, “This is unacceptable, and I will not tolerate this behavior. Educating community members is one of the steps in eliminating this behavior.”

The campaign features four posters of paramedics, highlighting that they are more than just people in uniform; they’re also mothers, sisters, brothers or grandfathers. The posters have been placed in ambulances, hospital waiting rooms, emergency departments, hotels and clubs throughout the state. The campaign also reinforces a zero tolerance policy toward verbal or physical assault of paramedics. Offenders will be reported to police; obstructing or hindering a paramedic incurs a maximum penalty of two years imprisonment, increasing to five years if an act of violence is involved.

Ray Creen is clearly an inspirational leader in the true sense of the word—to lead, one must have followers and he has them by the thousand. He has won friends and influenced people as he has improved the lot of every service and medic he has come into contact with. His leadership style is to be “playful with serious intent” and maintain service morale, listen and ensure common sense ensues. He is a world-class EMS leader, one to be watched, because whatever he does next will always be for the good and benefit of both providers and patients alike.

References

1. UK Department of Health. Taking Healthcare to the Patient: Transforming NHS Ambulance Services, https://ircp.info/Portals/11/Future/NHS%20EMS%20Policy%20Recommendation2005.pdf.
2. Dapin M. NSW Ambulance Service CEO Ray Creen has his eye on the bigger picture. Sydney Morning Herald, www.smh.com.au/nsw/nsw-ambulance-service-ceo-ray-creen-has-his-eye-on-the-bigger-picture-20140418-36w0l.html.
3. NSW Auditor General’s Performance Audit – Reducing Turnaround Times at Hospitals
4. NSW Ambulance “If You Hurt a Paramedic” anti violence campaign