How to Build a Great EMS Agency

Last October I had the honor of standing on stage with my Allina Health EMS colleagues to accept the Dick Ferneau Career EMS Service of the Year award before several thousand people in Las Vegas. The honor was part of the National EMS Awards of Excellence program established by EMS World and the National Association of EMTs.

In the months since, I have thought a lot about why our agency was selected for this honor and what Allina experiences might be beneficial to share with other EMS colleagues. 

As I reflect on what we’ve built at Allina, some things stand out to me as foundational. I have been a paramedic since 1985 and have been at Allina Health EMS for the past 21 years, and over those years I have seen many changes.

But one thing that has remained the same through the years is the commitment of emergency medical technicians, paramedics, dispatchers, and support staff to provide exceptional care to the communities we serve.

As cliché as it sounds, without dedicated, passionate people, you can’t get out of the starting gate. 

That said, those people need a supportive environment in which they can do their work and succeed. Following are eight guiding principles I believe are must-haves in supporting your team and building a top-notch EMS agency.

1. It Starts With Culture

Developing a healthy and growing organization requires articulating the organization’s values and leading based on them. As part of a large healthcare system, my organization has a set of shared values that apply across our system, including to hospitals, physician groups, and clinics as well as EMS. Every one of us who works here, regardless of position, is expected to live our values. Healthcare—and EMS as part of healthcare—is a caring profession.

The “why” of healthcare starts with caring for people in need. Our values statement contains words like respect and integrity.

But values are more than words—values are about behavior. For me the real difference becomes how you demonstrate them.

I have a colleague, the president of a local hospital, who has a great way of talking about this. He says, “When I was growing up, it was fairly easy for my sister and me to understand our family values, because my mom and dad discussed them at the dinner table.” Most organizations don’t have a collective “kitchen table,” but the concept is the same. It really is important that everyone in your agency knows what is expected from them in terms of behavior. If we allow the people we work with to show up late, leave a dirty ambulance, or treat each other with disrespect, we have established this behavior as the baseline for our organization. 

Being a value-driven organization is about setting the standards for behavior and establishing possibilities and rewards.

2. Commit to Leadership Development

A keen focus on hiring, promoting, and mentoring the right leaders is crucial. Bad leaders are corrosive to organizations. A recent Gallup poll found that one in two people have left a job to get away from a bad boss.¹ So if you’re a leader, listen up: If someone has left your team, there is a 50% probability it’s because of you.

Historically leaders in EMS have been high-performing EMTs, paramedics, or dispatchers who were promoted with a hearty handshake and a shiny badge and ordered to go forth and do good. Too often they’ve been given little or no training about how to be a quality leader.

Yet with guidance and support, many of them are capable of becoming the kind of servant-leaders who engender growing trust and engagement. It is worth investing in developing good leaders because they inspire loyalty and will retain the majority of their staff. It’s not easy, but organizations that commit to developing their leadership teams will reap the rewards of employee retention, an engaged workforce, and better-quality performance.

3. Transparency Is the Key to Trust

Several years ago, during a particularly challenging contract negotiation with our labor union, a new and out-of-town business agent called me and threatened to reveal some financial information we had disclosed at a bargaining session to all our union members. He seemed to have the impression that if his members understood our financial situation, it would somehow give him the upper hand. 

But he did not understand the culture of our organization, the value we place on transparency, or the relatively positive relationship we had cultivated with our union partners. 

When I told him we routinely post our monthly financial information on our internal website, he yelled that I was “[bleeping] with the wrong Marine!” and hung up the phone. As I recall, that was the last time we spoke. But the point is if employees, communities, and other stakeholders feel their agency is secretive about what goes on, they are not likely to trust leadership or the direction of the organization. It is my belief that there is very little information that leaders should not make available to staff—mostly HR stuff.

Even when people aren’t necessarily interested in seeing the details of operational and clinical performance data or financials, knowing they have access if they want it is a huge differentiator.

4. Embrace Healthy Conflict

There’s an African proverb that says, “Calm seas don’t make skilled sailors.” When organizations ignore—or, worse yet, dismiss—concerns and complaints, they put themselves at risk of obsolescence. In contrast, agencies that welcome debate and disagreement are likely to thrive.

The key, of course, is that expressions of discord absolutely must be respectful. But when you create a culture in which employees, external stakeholders, and even patients feel it’s OK to disagree, much can be learned. As a longtime EMS leader, I’ve had plenty of experience with discontented EMTs and paramedics just backing up dump trucks of complaints. That’s not very helpful. But when those same EMTs and paramedics are encouraged to raise their concerns knowing someone will really listen, those complaints can become a gift, and they often bring solutions with them.

EMS luminary and organizational psychologist John Becknell, PhD, talks about this in terms of “listening in such a way that you are willing to learn something and maybe even change your mind.” Of course there are times when minds are not changed, but just knowing the exchange is genuine is often enough.

5. Raise Quality at Every Opportunity

From the hiring of new recruits to partnering with medical directors, it pays to keep trying to improve your operation.

In January 2016, at a time when EMS agencies across the country were facing critical staff shortages, Allina Health EMS decided to raise the minimum qualifications of our paramedic candidates. Some of my own leaders thought we were crazy for doing this. But we established a requirement that all new paramedics either hold an associate's degree, be eligible to complete their degree shortly after joining us, or have a minimum of four years of 9-1-1 experience. We set the bar higher than anyone else in our region, which could’ve put us in a tough position in terms of competing for talent. After more than two years, here’s what we know: Our candidate pool has changed for sure, but not like you might imagine. Hiring managers report we are now seeing better-qualified candidates.

I will be the first to acknowledge that having a degree doesn’t inherently make you smarter or more qualified, but in our experience it has made a positive difference in the characteristics of people who join us. If we truly want to advance our field, we might take a lesson from our law enforcement and nursing colleagues who addressed the issue of minimum qualification standards long ago.

An organization that focuses on quality improvement is one that is committed to continuously learning. Our thinking is that most people truly do want to be part of something bigger then themselves. We try to give our caregivers a place to do that.

6. Build Relationships With Community Stakeholders

Agencies of every tax status have a vested interest in the relationship they have with the communities they serve. The focus may be slightly different if you’re a fire department or a hospital-based agency or a private service, but regardless, strong relationships with community stakeholders are key to our ability to care for our communities. 

Allina Health EMS is a hospital-based system, so we have strong built-in collaboration with our hospital and physician community. In contrast, we spend a lot of energy building and maintaining relationships with public safety and political leaders across the 121 independent municipalities in our service area. It can be a lot of work, but having strong relationships with community leaders and public safety colleagues helps us be better prepared and better trained and enhances our capacity to manage critical situations.

Municipal agencies may have the opposite experience, with strong ties to city or municipal leaders but a need to strengthen relationships with the medical, public health, and hospital communities. Whatever the construct, strong working relationships with key stakeholders in the communities your agency serves are critical. 

7. Be Willing to Try New Things

At Allina Health EMS we have adopted the posture of trying to be the most forward-thinking EMS agency we can be, which means trying out new thinking, care models, tools, and technologies. This approach has been driven by our associate medical director, Andrew Stevens, MD, and the passion of our senior medical director, Charles Lick, MD, who has long encouraged our team to be early adopters. 

Of course, this can be risky. We all know the difference between leading-edge and bleeding-edge. However, as Lick would advise, you can be forward-thinking without being foolish. Chasing the newest shiny thing is different than having a thoughtful debate and making a calculated decision about where to spend your time and resources.

Our mind-set around innovation has led to Allina Health EMS’s reputation for being on the leading edge of paramedicine. Over the years we’ve been among the first large EMS agencies in the country to implement advances such as 12-leads in the field, embrace and implement mechanical CPR, use impedance threshold devices, and more.

With careful consideration and planning, we’ve seen far more successes in our innovation efforts than setbacks, and it’s allowed our service to be an exciting and pioneering place to practice prehospital medicine.

8. Conduct and Participate in Research

Conducting and participating in research is an important way for agencies to give back to the EMS profession by helping the industry understand what contributes to better clinical outcomes, patient experiences, and provider/patient safety.

Allina Health EMS has been fortunate to support an in-house research team consisting of an epidemiologist (team leader), two physicians, an analytics program manager, a graduate student research assistant, and a staff EMS chaplain. The team has published papers, posters, and other academic articles.

For example, the research team recently published an article on the success of the HEARTSafe Communities program in increasing bystander CPR and AED use in Minnesota² and shared an abstract on provider burnout, stress, and coping mechanisms at the 2018 National Association of EMS Physicians conference.

And the real value of this work has been its direct impact on the care crews provide in the field and the dissemination of information among others within the paramedic discipline. The goal is not to hide their work in the shadows but rather share it broadly to be critiqued, replicated, and built upon. 

A Bit of Irony

I began this essay by recounting the elation of being on stage last October to receive the 2017 EMS Service of the Year Award. That was wonderful memory I will always cherish. But here’s the reality: Over the past weeks, as I’ve written this article, I have also been working through a handful of new challenges my organization faces: a labor dispute, some unhappy staff, performance issues, budget pressures, and more.

By nearly all objective measures, my organization is doing better than ever—yet we still have our detractors and challenges. Sound familiar? The point is this: While Allina Health EMS may have had our 15 minutes of fame on the national stage, we are no different than any of you who are reading this. The real secret of building a great EMS agency is being humble enough to know that none of us have all the answers and we need to earn it every day.

I often think it’s not because of our successes that we excel; it’s much more about how we overcome our challenges. Remember, calm seas don’t make a skilled sailor.

I challenge anyone reading this to share your stories of building your agency and embrace the “abundance mentality” Stephen Covey wrote about, which is “the paradigm that there is plenty out there and enough to spare for everybody. It results in sharing of prestige, of recognition, of profits, of decision making.” 

This approach is foundational to advancement of our career field and ability to serve. Our patients, staff, and communities deserve nothing less. 

References 

1. Harter J, Adkins A. Employees Want a Lot More From Their Managers. Gallup Business Journal, 2015 Apr 8; https://news.gallup.com/businessjournal/182321/employees-lot-managers.aspx.

2. Boland LL, Formanek MB, Harkins KK et al. Minnesota Heart Safe Communities: Are community-based initiatives increasing pre-ambulance CPR and AED use? Resuscitation, 2017 Oct; 119: 33–36. 

Brian LaCroix, FACPE, NRP, is president/EMS chief for Allina Health EMS, St. Paul, Minn. Allina Health EMS serves a population of more than a million people with a team of more than 600 caregivers, responding to an average of more than 300 requests per day. LaCroix serves on the board of the National EMS Management Association (NEMSMA).