Why You Need to SWOT Your Agency

"The essence of strategy is choosing what not to do." —Michael Porter, 1996

You are the VP of development for ABC Ambulance, Inc.. You receive an e-mail from a regional healthcare consortium for an urgent meeting. As you have a good relationship with the consortium, you are unconcerned.

When you arrive at the meeting, you see that there are only two issues on the agenda: the first being the need for more EMS units, as there always seems to be a backup of ambulances at the local EDs; the second being high readmission rates to local acute care facilities and Medicare repercussions associated with these readmissions.

The CEO of the consortium asks if your agency’s strategic plan included either of these issues in its SWOT analysis and what you plan on doing to assist the consortium in addressing these problems. You realize it has been quite a few years since your agency has updated its strategic plan and neither of these two are items are covered in your SWOT analysis.

You ask the consortium for some time to get back to them. One of the attendees says, “Because of our good working relationship with you, we can give you a month, but a few of your competitors have been sending us proposals and we are very interested.”

The Four Pillars of SWOT

Strategic planning is traditionally thought of as an evaluation of the strengths, weaknesses, opportunities and threats, known as a SWOT analysis, facing any company or organization and then mapping a path forward that addresses those four areas.

EMS agencies have never been in more need of such analysis, as they attempt to move forward in an ever-changing world where operations and the delivery of clinical care are being redefined on a regular basis.

Strengths and weaknesses review internal factors that impact the ability to obtain a goal. In EMS this could include recruiting more volunteers, adding non-emergency services or managing the operating expenses.

Strengths might be:

• Solid community support;
• Meeting response time standards on a consistent basis (time period of 3 or 6 months);
• Collaboration with other stakeholders.

Weaknesses can include:

• Lack of a consistent funding stream that isn’t dependent on billing;
• Lack of volunteers/other staff;
• Antiquated equipment/trucks;
• Poor relationship with acute care facilities resulting in backups of resources at EDs.

Opportunities and threats focus more on external factors impacting an EMS agency and its future development.

Opportunities can include:

• A mobile integrated healthcare initiative based on conversation with other stakeholders in the healthcare arena to fill perceived gaps in service;
• Transition from an all-volunteer unit to paying personnel for specific shifts when necessary;
• Better integration with the existing healthcare system to address gaps (e.g., mental health resources);
• Analysis of regionalization efforts in conjunction with surrounding EMS agencies.

Threats can include:

• An unclear understanding of how healthcare changes like the Affordable Care Act will impact the EMS system;
• Neighboring EMS agencies being more proactive in their efforts than your agency;
• Other stakeholders not understanding the uniqueness of the EMS system and not utilizing your agency to its fullest potential;
• Lack of a complete integrated approach to the healthcare system (i.e., political challenges, priorities, resistance to change, competing interests, silos, different views).

A SWOT analysis is not a static process but something re-examined on a regular basis in light of potential changes in the EMS system. Strategic planning is rooted in future-oriented, proactive thinking that anticipates change and adopts long-term strategies to meet the demands of that change. In other terms, a strategic plan is a “master plan” for your EMS agency. It is a management tool that will assist your organization in focusing its energy.

Where To Begin

Successful strategic planning effort is predicated on an agency's ability to approach it in three distinct phases.

Phase 1

The first phase is “intuitive thinking.” This seeks to answer questions such as: Why are we in business? Who are our customers? What do they want from us? What do they get from us? What matters most to us? What are the values that we want to drive the way we do our business? Where do we see our company going in the future?

These are big-picture questions. At the beginning of the strategic planning process, people need to deliberately and thoughtfully think about how to respond to these questions. This is also where you can take the opportunity to craft your agency mission statement, which, optimally, answers the question asked above.

A good example of am EMS-specific mission statement comes from the San Diego (CA) Health and Human Services agency, which states: “To ensure that all residents of and visitors to San Diego County receive timely and high-quality emergency medical services, specialty care, prevention services, disaster preparedness and response.”¹

Phase 2

The second phase is long-range planning. Instead of being intuitive, this is very analytical. This phase is about understanding such things as where your company fits in the marketplace, what your strengths are as an organization, where your limitations are, and how you relate to customers and competitors. It also includes understanding the regulatory environment and how major trends in the EMS world affect you.

This is also where you would want to take the opportunity to craft your agency vision statement so that it conveys how your organization wants its future to look. A good example of a vision statement comes from the Riverside County (CA) EMS Agency and states: "The Riverside County EMS system’s vision is to be the exceptional, outcome-focused EMS leader in the nation.”² A vision statement is a declaration that conveys the image of how the organization wants its future to look

Phase 3

The third phase is operational planning. This is when your strategic planning team takes a 30,000-foot view of previously discussed concepts to make them as practical and specific as possible.

This entails reviewing the issues discussed and realistically determining what your EMS agency can afford to do without overreaching. For those things your agency commits to, now is the time to develop your plan for implementing and executing on those issues, which includes understanding who is responsible for what, what guidelines they’re going to be functioning under, what resources they’re going to have available to them, and what milestones or review points you need to have along the way to make sure everyone is staying on schedule. These are your agency goals and their defining objectives.

An example of a goal would be “to ensure the long-term financial solvency, stability and cost-effectiveness of the EMS system” and the objectives that support this goal could include:

• Establish methodologies to identify the baseline costs of the current system;
• Identify current funding sources for first response, ambulance transportation, education/training, disaster medical preparedness and response and other EMS-related services;
• Develop a mechanism that identifies funding that can sustain system improvements implemented under this strategic plan;
• Define and quantify the potential funding changes driven by the Affordable Care Act for traditional EMS delivery models.

Current Challenges

The world of EMS is in a constant state of flux. Currently we are looking at changes as a result of the Affordable Care Act (ACA), potential reimbursement changes based on value-added payments, staffing issues, clinical modifications based on peer-reviewed research and a dearth of volunteers.  

Forward-thinking EMS agencies will examine the issues confronting them in the immediate, short and long term and, reflecting back on their SWOT analysis, draw up goals and objectives to decide where they want to be and how to address those issues.  

Here are some examples of such activities:

• Mobile Integrated Healthcare/Community Paramedicine: In order to ensure your agency is in compliance with the Affordable Care Act and continues to get paid for the services it provides, you may be thinking about developing an MIH-CP program. Have you done a SWOT analysis? Do you know what the weaknesses are, e.g. finding a reliable, consistent funding stream? Have you thought about home health agencies not wanting to partner with your EMS agency to deliver a service they may feel they have been already delivering? Is this a strength, since your EMS agency already employs healthcare providers and has a fleet ready to deliver mobile services?
• Volunteer recruitment and retention: Judging by the number of headlines in the media regarding a dwindling volunteer pool and many EMS volunteer agencies becoming partially, or fully, paid, it’s clear the nature of volunteer EMS is changing. Does your agency have a plan for when the number of available staff no longer allows for effective, timely response? Have you met with neighboring towns/municipalities to explore regionalization? If funds are needed for personnel, where will you get those funds from?
• Regionalization of efforts: A logical next move for agencies experiencing staffing issues may be the development of a regional EMS entity comprised of multiple EMS agencies with similar missions. Although this may sound simple, a SWOT analysis is a necessity. Are there strengths that all of the EMS agencies share? What are the threats? Could one be a less-than-clear understanding of how leadership of the regional entity will be handled? Will a stipend be needed from the municipalities shared and, if so, will the stipend be the same for each municipality?

Tips for Successful Strategic Planning

Here are some key practices to follow during the strategic planning process:

• Ensure all voices are heard during the planning process. It is key to include field providers, line supervisors, managers and executive-level personnel in the planning process, as each will have a different perspective to offer. This will also ensure that personnel from all levels will go back to their peers and make the plan understandable.
• Do not let the strategic plan become just another document kept in an office or on a bookshelf somewhere. This document should be given to new employees during orientation, as well as regularly referenced at senior-level management meetings. If the plan is going to be effective, it needs to be used and updated constantly.
• Keep your feet on the ground. Make sure that your goals and objectives are as realistic as possible. One of the primary reasons a strategic plan fails is that it has too many goals and objectives, creating a plan that is, as a whole, unfocused. It is also critical to ensure adequate resources are available to accomplish those goals and objectives outlined in the plan.

Conclusion

Every day we read news of fire departments taking over EMS operations, private EMS services going out of business due to an inability to weather economic downturns, or a volunteer ambulance squad failing to recruit or retain sufficient numbers of volunteers to staff its operation. Rarely is it considered that one of the significant contributing factors may have been the organization’s lack of focus and direction. Perhaps such events would not occur if an agency had a well-thought-out, long-term strategic plan.

The author would like to thank the Riverside County (CA) EMS Agency for making its comprehensive EMS System Strategic Plan available here: https://remsa.us/documents/plans/140923FINALEMSSystemStratPlan.pdf.

References

1. Virginia Department of Health, Office of Emergency Medical Services (OEMS). EMS Agency Management Series. EMS Strategic Planning. June 2001.

2. https://www.sandiegocounty.gov/hhsa/programs/phs/emergency_medical_services/.

3. https://remsa.us/documents/plans/140923FINALEMSSystemStratPlan.pdf.

Raphael M. Barishansky, MPH, MS, CPM, is a solutions-driven consultant working with EMS agencies, emergency management and public health organizations on complex issues including leadership development, strategic planning, policy implementation and regulatory compliance. Contact him at rbarishansky@gmail.com.