Prepare Yourself for Promotion

A significant reason why new EMS leaders struggle is not because they’re not smart enough or they don’t have the skills—it’s that they’re not familiar with the resources available to them. There are tools and classes that can help; they may just not know what’s available.

Being promoted doesn’t make you all-knowing and infallible. Finding that right balance of education and experience is important for your promotion, but it is an ongoing process, one where you never stop learning.

Clinical Care

Understanding your clinical care and your quality improvement process is essential for the aspiring EMS leader. QI touches every facet of your organization. When we talk about QI, we concentrate on three functional measures:

• Prospective measures—The selection, training, policies, and clinical protocols implemented before anyone is placed in the field. It can also include the equipment and supplies we use.
• Concurrent measures—The back-of-the-ambulance guidance we provide. It is what we do to assess quality in real time: rides with field training officers to provide oversight, clinical review, and feedback.
• Retrospective measures—The analysis of patient care reports and outcomes to demonstrate our prospective and concurrent processes work.

We apply all this using a model of care named after University of Michigan physician Avedis Donabedian. Developed to assess quality of care in clinical practice, the essential model is: Patient plus structure plus process equals outcomes.

We cannot control the patient we receive, but we can improve the structure (ambulances, equipment, deployment, staffing, system components, training) and process of care (diagnosis, treatment protocol, aftercare) to improve outcomes. If we want to improve trauma scene times, for instance, we may look at where ambulances are deployed (a system measure) and the time interval they spend responding to and staying on scenes (a process measure) in order to improve survival (the outcome).

How do we acquire this knowledge, find the essential tools, and apply the benefit to our own organizations? If you haven’t promoted yet, I suggest you begin participating in any QI processes your organization currently has. Sit in on committees, review trauma calls, join receiving hospital QI meetings and STEMI activation reviews. Any of these programs will provide you a chance to learn about the QI process and gain valuable experience.

You may be one of those people whose eyes glaze over when talk about performance charts and QI begins. If you are newly promoted to a chief’s position, you need to speak to your current QI person and medical director. Understand the process and how feedback is provided. Then talk to your staff—or, if that is too contentious, provide a forum for your field members to let a neutral party know what they think of the QI process.

If they view QI as an exercise in futility or a tool for intimidation, you will need to start your program over from scratch. Quality improvement and by extension education should not be viewed as punishment or discipline. If they are, as a new chief you need to address this immediately.

Talk with the QI people at other EMS systems with reputations for quality care or at your trauma, STEMI, stroke, and pediatric centers. Find out what they are doing and see how your activities may dovetail. Remember Donabedian: It is about patient outcomes at the end of the day. Understand the tools they’re using to perform calculations and examine data, but most important how they make improvements.

What if you don’t have a QI plan, or your QI plan is entirely based on retrospective analysis of PCRs (a huge no-no!)? Ron Roth, MD, is the EMS medical director in Pittsburgh. He has a down-and-dirty guide for EMS QI here where he provides examples of forms and other tools to use as well as a short PDF explaining QI for the non-QI person. It is all free, and it’s a nice set of resources. You could stand up a program in short order using these guides and forms.

NHTSA’s Office of EMS published an essential guide some years ago called A Leadership Guide to Quality Improvement for Emergency Medical Services Systems. It may not provide all the detail new leaders require if they’re trying to start up a new program, but it offers some valuable information.

Another outstanding resource is the Institute for Healthcare Improvement (ihi.org). The IHI has an entire learning platform that will help you understand QI. If you start with Roth’s tools, you can transition over to the IHI material and develop a more robust plan.

Clinical care and performance are areas we as leaders need to get our heads around. It is essential to understand the quality of our clinical care and be able to explain it to the public, elected officials, and staff.

Budgets

Nothing will get you in hot water more than dropping the ball on your organization’s finances. If you aren’t looking to go back to school for some basic accounting and finance, there are ways to acquire the competence required to perform your job. If you are a new chief or looking to promote, do you know:

• What a line item is and why it’s important?
• What kind of budget your organization uses?
• Is your budget based on a calendar year or fiscal year?

If you don’t know, you should. Many organizations, public and private, will provide potential managers with courses on budgeting and purchasing. They will utilize forms and formats specific to their organization, but these are also excellent opportunities to acquire baseline knowledge. If you’re looking to promote, it will show you have initiative and familiarize you with processes within your company. Sign up for these programs! They are free and will allow you to acquire knowledge and the chance to speak to people in your organization who can become valuable resources for your continued success.

Overseeing budgets for department programs or educational offerings is a good way to gain experience. Start small—small mistakes are easier to absorb than larger ones.

Do you teach classes for your organization? PHTLS? ACLS? There are some basic budget worksheets you can use that will give you general ideas of the costs of such programs. The Texas A&M Engineering Extension Service (TEEX) has a simple budget prep sheet you can find here. Use it as a starting point.

Is there an opportunity for you to manage a program for your department? Tactical EMS? Vehicle extrication? Hazmat team? Programs like these come with budgets for expenditures, revenue recovery (billing), and the other endemic parts of budgeting. The best part is that if you are looking to advance within your organization, the essential formats and documents should all be the same; you’ll just be operating on a smaller scale.

Take a class. Acquire an understanding of the terminology and basics of what a budget is and how to read a balance sheet. Online courses can provide the background you need. You can find free classes on finance, accounting, economics, and budgeting at Coursera.

Another free resource is This guide, developed byA Systems Development Guide for Rural Emergency Medical Services: A Systematic Approach to Generate Budgets for Rural Emergency Medical Services. the National Center for Rural Health Works at Oklahoma State University, should be in every EMS chief’s reference library. It provides a great overview of EMS budgets and finance and can apply beyond rural systems.

Conclusion

You may be the best EMT or paramedic in your organization, providing outstanding clinical care. The promotion to supervisor, clinical chief, or EMS director requires an entirely different skill set. You have a chance to develop those skills as you prepare for your next promotion. Competence is based on education and experience. Use whatever opportunities you have to develop those talents. Remember, the people who have selected you, your staff, and your community all want to see you succeed.

Daniel R. Gerard, MS, RN, NRP, is EMS coordinator for Alameda, Calif. He is a recognized expert in EMS system delivery and design, EMS/health-service integration, and service delivery models for out-of-hospital care.