Friday, March 14, 2003

Neglect Ambulance Crews at Your Peril—Whether Volunteer or Paid

The signature card collection effort has failed, but it sure has me upset because it confronted me with an unpleasant realization—I’d neglected the men and women of our ambulance department.

Changes in the ambulance department, which reports to me, have come quickly and continuously. Three ALS and two BLS ambulances dispatched by NYC*EMS and a seven-day a week transport ambulance are staffed by a mix of approximately 100 full-time, part-time and per diem paramedics and EMTs and were they ever unhappy. Enough had been sufficiently unhappy; that the union collected some signature cards and gave the hospital notice under the terms of the bargaining agreement, alerting us that the unionization effort was underway. We received this notice during the week the JCAHO was onsite for our triennial survey.

I was initially startled, then angry and then depressed. How could “they” do this to “me?” What had I done to cause this? Well, the answer was what I hadn’t done. I hadn’t paid attention to the needs of the EMTs and paramedics and hadn’t adequately supported the department director.

Distance from the action is always a risk when one becomes a chief. For our ED, I’ve been relying upon—thus far successfully—five day a week or more “visits” to the ED, regular communication with staff at all levels and the twice monthly fractional shift. Enough staff members at enough different levels talk to me about what’s going on in the ED nearly every day and I’ve (finally!) learned to listen, feel their pain and often do something about it.

The ambulance department, in its garage 14 blocks away, was another matter. A newly appointed ambulance department medical director was in place, having just started in this role. The previous medical director had not been much engaged for most of 2002 and I had been focused on the electronic medical record and other projects. The ambulance department director, a well-intended man plucked from the field and given the responsibility and authority for managing the department was doing fine managing the budget and other “things,” but was increasingly anxious as he discussed personnel issues with me and our department administrator.

Shortly after the JCAHO survey team left, we posted notice of a meeting at the ambulance garage. Several of us from the department along with the VP for Human Resources spent nearly three hours listening. It was revelatory.

I learned that a large stainless steel sink with contiguous drain boards appropriate for washing equipment (such as backboards) had never been installed in the garage. I learned that per diem medics bought their own uniforms and hadn’t had a raise in their hourly rate for three years. I learned that full-time medics got uniform shirts and pants in alternate years and a field jacket every three years. How shortsighted. Common sense should have altered this practice at any previous budget cycle, but foolish economy blinded us.

Given that we had received notice of the unionization effort, we had limited ability to respond while remaining within the parameters of both the National Labor Relations Act and the hospital’s bargaining agreement with the union. But as the manager responsible for the ambulance department, I could still take appropriate management actions unilaterally.

It’s never pleasant to learn of your failings, but what matters for the organization is how you as the leader respond to the problems; it’s not about you, it’s about the organization’s and the worker’s needs. We’ve only just begun our remediation efforts with our ambulance department. The issues noted above are being addressed and others besides. The paramedics and EMTs as a group have suspended disbelief sufficiently, giving us a chance at regaining credibility by solving their real issues. Our ambulance director and ambulance medical director are both engaged and getting the support that well-intended, but inexperienced leaders require and at least in the case of the department director, had been too long overlooked.

When I arrived at Maimonides in August 1995, our local volunteer ambulance services brought us barely 90 patients/month. Today they bring us over 400 patients/month and given our community’s demographics, many of these patients are elderly and many of these patients are admitted. The volunteers tell us that they come to us because they think we aggressively care for their patients from their community and because we listen to what they—the volunteers—tell us about the patients and about our own ER. It wasn’t always thus—certainly not in August 1995.

Listening to Hatzolah volunteer medics, EMTs and their coordinators has become an engrained aspect of my work. I meet them in the ER, I meet them in their ambulance garage periodically, I call their coordinators and discuss cases and issues—sometimes concerns with ER staff and sometimes concerns with volunteer ambulance staff. We have built a degree of trust over more than seven years. Yet, with my own employees, I had relied upon the formal chain of command and had little day-to-day engagement with them.

Unionization of EMS field staff may not be an issue for you at your hospital; but your relationship to EMS as an ER and as that ER’s leader can help or hurt your practice and affect your longevity as leader. Urban and suburban geography usually allows for multiple transport destinations for the ambulances that serve your community. Hospital administrators looking for admissions are increasingly recognizing the importance of an effective relationship with the community’s EMS providers. Senior administrators may engage briefly, but you and your ER form the continuing bond. Excellent processes for receiving ambulance patients and good patient care are both necessary, but insufficient. Regular attention to the concerns of your field EMS personnel, whether hospital based, volunteer or county/municipal employees can only benefit your practice and your hospital in the long run—neglect the relationship at your peril.