"The greatest revolution of our generation is the discovery that human beings, by changing the inner attitudes of their minds, can change the outer aspects of their lives." --William James

Although leadership is one of the most relevant aspects of the organizational context, defining it has always been challenging. Defining leadership in EMS is no different, especially at a time when we are seeing a national healthcare reform effort, increasing pressure on EMS systems to accomplish more with less, and lack of a united voice on issues of major significance. Strong leaders, including those who don't view things through "we-have-always-done-it-like-this" glasses, are needed more than ever. This year's Emerging EMS Leaders, who come from backgrounds in education, operations, consulting and special operations/homeland security, take on these and other relevant topics in the article below.

BRANDON W. GRAHAM, BS, EMT-P, ASSOCIATE DIRECTOR, OFFICE OF HOMELAND SECURITY, THE GEORGE WASHINGTON UNIVERSITY, WASHINGTON, DC

What is your philosophy on EMS leadership?

My leadership philosophy, which has always driven my command vision, is relatively simple: Lead by example, and lead in all directions. Modern EMS leaders must articulate a clear and concise vision that embodies the goals, expectations and consequences of the organization, and they must exemplify that vision at all times. As coaches, mentors and facilitators, I expect the leaders in my organization to not only be role models for team members who work to support them, but also for those who are higher in the traditional chain of command. Leadership is contagious in all directions, and I have found that by being competent, fair and ethical, while constantly identifying and removing obstacles that impede success, others in the organization will join you in its pursuit. Specific to EMS, the focus of leaders today should remain on valuing the mission, providing the necessary resources to safely accomplish the mission in a superior manner, and truly value the most critical component of all EMS operations…our people.

What qualities do you see as critical for EMS leaders?

The most important characteristics for EMS leaders are competence, strong business and organizational acumen, consistency and an unwavering ethical compass. Without these qualities, we cannot meet the expectations of ourselves or our organization when we choose to take on the roles of coach, teacher, mentor and incident commander. You must have a blended balance of the skills you would expect from each of these roles. Also of greater importance today is having the ability to maintain a broad perspective on the “big picture” and leverage technology that provides real-time feedback on group and system performance to provide optimal situational awareness. The consequences of the failure of our EMS systems are of life-and-death importance, so we must better align our management systems with those of higher-reliability organizations. We must be better managers of dynamically changing environments and be better skilled at identifying opportunities for small leverage points that can be exploited so that a small input of resources yields large, positive outcomes for the team and the organization. This is so important, because EMS as an industry continues to be asked to do more and do it with fewer resources.

Whom in your career do you consider a mentor, and how did they assist you?

I have always tried to look for the best qualities in all of the leaders with whom I have had the pleasure of working. At a young age, I recognized the value of finding experienced role models and developing network relationships with those leaders whom I wanted to emulate. The most important of these mentors, though, has always been my father. As the son of a fire chief, I was fortunate enough to be exposed to emergency services leadership at a very young age. It was during these formative years that I learned the importance of compromising with external stakeholders, constituents and customers, while never compromising on your ethics or values. I owe my embrace of this critical aspect of real leadership to my father, who spent over 35 years of his life dedicated to emergency services. I still value conversations with him today about all aspects of personal and professional life in order to gain important insight that can only be gained from such extensive experience. It has been my experience that many underestimate the value of having a reliable mentor. In my case, I was the beneficiary of leadership provided by managers who understood the value in identifying and nurturing talent and ability. They knew how to motivate employees to recognize and nurture their greatest strengths for the success of the team. Probably the most valuable lesson I have learned from my mentors is the critical importance of empowering personnel to maximize their strengths and talents.

What career accomplishment are you most proud of?

Without a doubt, I take the most pride in knowing that I have been able to help make EMS providers across the nation safer as they confront the realities of a changing threat environment. EMS agencies have always been at a disadvantage when it comes to accessing preparedness and resilience resources and training, and I am proud to have been able to provide critically needed training to thousands of brave EMS personnel who otherwise would not have access to this critical preparedness training.

If you could change one thing you have done in your EMS career, what would it be?

This is a really difficult question for me to answer, because I find it hard to reflect on past experiences in the context of regret. It is the sum of the key decisions we make every day that shapes who we are as leaders. I do try to look to these past experiences for lessons learned in an attempt to make better decisions in the future. If there is one thing I could change, it would have been to support EMS at a broader level through engaging in activities that further our profession as a whole at an earlier stage in my career. Young providers and professionals new to EMS need to become more involved in the associations, educational opportunities and community outreach activities that will continue to advance the message and the mission of EMS across the country and the world.

What are the biggest challenges facing EMS in the future?

During these challenging times of fiscal constraints, when it is difficult for many EMS organizations to maintain service delivery on a routine basis, the current threat environment mandates that EMS organizations dedicate even greater resources to preparing for higher-consequence, lower-likelihood events. EMS, regardless of services delivery model, is still largely underrepresented at the federal and states level in terms of access to preparedness resources and funding. As health care and EMS operating costs continue to rise, and as reimbursement gaps widen, EMS leaders are going to be even more challenged to maintain an acceptable level of preparedness and response capacity for larger and more complex events.

How would you address those challenges?

As EMS leaders, we need to continue to raise our collective voice to ensure that the message continues to our state and national policymakers. We need to continue to seek dialogue as a united front with a united voice. Too often our profession and industry become polarized and fragmented because we focus on all of the differences between how EMS is delivered in communities rather than the similarities and needs that we all have in EMS. Until we unite the voices of special interest splinters of the many different groups that lay claim to EMS, we will likely continue to be viewed as many small groups with disparate interests and a lack of common goals.

What advice do you have for future leaders?

There are many different opportunities to become engaged in the improvement of EMS in our communities and on a national scale. Leaders need to be continually building and leveraging their professional networks, including working with diverse groups and associations for a common goal. I would caution future leaders to avoid the many opportunities that lead to polarizing positions that can be a distraction to our overall common goals. Stay focused on the messages that we can all agree on to improve EMS for everyone, from urban systems in our largest cities to rural systems in the most remote locations. From all service delivery models…we need to unite our voices.

DEBRA LEJEUNE, MEd, NREMT-P, DIRECTOR OF EDUCATION and PROGRAM DEVELOPMENT, UNIVERSITY OF PITTSBURGH SCHOOL OF HEALTH AND REHABILITATION SCIENCES, EMED HEALTH, CENTER FOR EMERGENCY MEDICINE, PITTSBURGH, PA

What is your philosophy on EMS leadership?

Great leaders in any field must have the ability to clearly communicate goals to their coworkers. Effective leaders must give themselves and the people they work with the flexibility to achieve those goals in whatever way best suits their talents and the particular situation.

What qualities are critical for EMS leaders?

People involved in EMS tend to have “take-charge” personalities, which can be invaluable when dealing with emergency medical situations where one voice needs to direct the scene and patient care. There are many ways to accomplish any task, however, and we need to allow employees the autonomy to make their own decisions. If leadership has clearly communicated the goal of any situation, they need to step back and allow people to make decisions on how to accomplish the tasks they have been assigned.

Whom in your career do you consider a mentor, and how did they assist you?

Walt Stoy has been my friend and mentor for the past 18 years. When I began my career as an EMS educator at the Center for Emergency Medicine, Walt took me under his wing from the very beginning. He helped when I needed help and was never afraid to push me when I hesitated to take a difficult step forward. Walt has inspired the people he works with to further their education and spread their wings, taking on new and different challenges both in and outside the field of EMS.

What career accomplishment are you most proud of?

I am always pleased when I get e-mails or phone calls from former students letting me know what they are doing in their lives. Many of them have gone on to further their education after completing paramedic school or their bachelor of science in emergency medical services. Some of our graduates are physicians, nurses, physicians assistants, physical therapists and dietitians, and many have stayed in EMS and are enjoying their careers in the field as educators, supervisors, etc. Others have left EMS entirely, but credit their experiences in EMS with helping them achieve their career goals.

If you could change one thing in your EMS career, what would it be?

I try not to look back with regret. I’ve made my share of mistakes and bad decisions, but each mistake presented an opportunity to learn and grow.

What are the biggest challenges facing EMS in the future?

Like many businesses, EMS is facing economic challenges. Most ambulance services are tied to a single line of revenue related to billing for patient transport. Rising costs for maintenance and gas, payroll and benefits may not be offset by increased reimbursement for care.

How would you address those challenges?

I work with Emed Health, a division of the Center for Emergency Medicine, to provide innovative programs for patients at home by using EMS personnel to deliver the programs. Emed Health promotes prevention and disease management using emergency medical service agencies and their personnel to deliver community, emergency department and home-based prevention and disease management services. We contract with ambulance services to use their personnel during downtime or when they are off shift to provide these services. This creates an additional revenue stream for ambulance services and an alternative line of work for EMS providers. EMS providers are well-received in the community, and the EMTs and paramedics who choose to participate in these programs enjoy providing a different type of service to their communities.

What advice do you have for future leaders?

Be flexible. The healthcare needs of the U.S. population are growing faster than ever before, and EMS can fill many roles that may not be considered traditional for EMTs and paramedics. We work closely with a health system that was in need of additional personnel to help provide influenza vaccinations for hospital personnel. It was very difficult for employee health to absorb the huge extra burden of providing vaccines while continuing to provide their usual services. Emed Health developed a program with this health system to provide paramedics with roaming carts that let them travel to patient care units to provide vaccines to staff without requiring them to leave the unit. We planned many night and weekend vaccination shifts so staff who do not work during weekday/daylight hours also had ample opportunity to be vaccinated. The hospital staff appreciated the convenience of getting their flu vaccine on their own unit, the paramedics enjoyed working in the hospital environment with different responsibilities and providing a different service, and the ambulance services enjoyed an additional line of revenue. Creative thinking will allow EMS to provide many such services.

PAUL MISASI, MS, NREMT-P, LT PARAMEDIC, SEDGWICK COUNTY EMERGENCY MEDICAL SERVICES, SEDGWICK COUNTY, KS

What is your philosophy on EMS leadership?

My philosophy of EMS leadership is servant leadership. It is my desire to not be a leader by virtue of a position or title, but through the relationships forged with coworkers and my service to the people I work for–the field providers.

I have served on various committees and worked among several groups in our organization with one goal in mind: to use my knowledge, education and talents to make life for my fellow medics better and make it easier for all of us to do our jobs more effectively.

I am also motivated to enhance and broaden the education and professional status of EMS among healthcare providers. I believe this can be best accomplished through formal education and degrees, continuing clinical education, and consistently delivering the best, evidence-based clinical care to ensure that we not only meet the needs of our patients, but those of other stakeholders, particularly the medical community.

Lastly, I strongly believe that all care providers must broaden their mission from simply ‘patient care’ to ‘patient care and comfort.’

What qualities are critical for EMS leaders?

Humility and integrity are critical. I have a passion for the nature of the work we do as care providers, and I have an even greater respect for the people who do the work.

When leaders are humble, they manifest their integrity and strength by their ability to admit to mistakes and fallibility, and to say they are sorry when things go wrong. When leaders do this, they are communicating the message that “my ego is less important to me than my relationship with you and the respect I have for your input.”

People want three things from their employer: to know that the work they do is worthwhile, that their work is appreciated, and that what they do makes a difference. It is the EMS leader’s responsibility to ensure that these needs are fulfilled to the best of our ability. So many healthcare institutions declare that their primary focus is on the needs of the patients. I submit (and research/experience have demonstrated) that when we focus on the people who do the work, they will take care of the patient’s needs to the best of their abilities.

Whom in your career do you consider a mentor, and how did that person assist you?

There are many people in my life who have influenced who I am. With respect to my professional development, I have been graced with the insight of a mentor who took interest in me several years ago. Jon Friesen, the education coordinator for the Wichita/Sedgwick County EMS system, asked me to lunch out of the blue one day. To this day, we continue to meet nearly once a month. His insight has helped me to mature as a person and a paramedic, and to understand the nature and importance of interpersonal relationships.

Another person I have learned from is Lyle Webster--a paramedic of 30 years, who is a man of humility and integrity. Of course, he has shared his thoughts and insights with me, but I believe I have learned more about service and customer accountability by following his example than from anyone else in the field. Although he does not seek the approval of his peers, he indeed has their respect. He is not outspoken, nor is his voice the loudest in a crowd, but when he does speak up, people listen to what he has to say. I hope that one day I can earn that kind of respect.

What career accomplishment are you most proud of?

It is difficult for me to rank the accomplishments in which I take the most pride, so I will list the top two.

I have had the privilege of working with several dedicated paramedics to establish our service’s first honor guard. The Sedgwick County EMS Honor Guard has developed from a fragile idea in 2005 to a strongly rooted and highly regarded group within our organization and the nation. We continue to assist organizations across the United States and Canada to develop their own honor guards (www.emshonorguard.com).

I also take great pride in the paramedic students I have had the pleasure of serving as preceptor. It is particularly entertaining when they get together and make fun of me. I get a kick out of laughing at myself and learning about the experiences they recall as having left a mark on who they are as medics and people.

If you could change one thing in your EMS career, what would it be?

I don’t know that I’m able to recall any moments in my career that I would like to do over. Perhaps my career is too short, but I hope that the more likely reason for the lack of regrets is a more intentional approach to the mistakes I have made in my life and work.

I embrace my mistakes as much, if not more, than the things that have gone well or to plan because of my love for learning. My favorite quote is from Will Rogers, who said, “Good judgment comes from experience, and most of that comes from bad judgment.” Mistakes are the best way to learn, and I treasure the ‘defects’ in my life as opportunities to learn, adapt and overcome, but, most of all, to forge relationships.

I believe pride is the enemy of learning. In overcoming obstacles in life or at work, I rely on my faith, as well as new and established relationships for insight and direction. I find the most stressful times in my life have been when I failed to recognize that I am not capable of managing everything on my own, and that the true test of my faith and relationships is when I have the courage to be imperfect and recognize my own weaknesses.

What are the biggest challenges facing EMS in the future?

We are in the midst of major healthcare overhaul, and my fear is that EMS will continue to be an afterthought of not just our nation’s leaders, but healthcare providers in general. I know there are many organizations whose purpose is to ensure that EMS systems are represented and our voices are heard, but I hope to see a day when we not only stand up for ourselves, but the people we work for and with (i.e., hospitals, physicians, the public, etc.) will speak with us and for us. In order to progress in this respect, we have to continue our work in establishing these relationships and meeting their needs.

How would you address those challenges?

Greatness in EMS can still be achieved in spite of the uncertain outlook and funding/reimbursement concerns. It begins with building a culture focused on people, service and quality, which is rooted in organizations that live by and hold themselves accountable to their values.

What advice do you have for future leaders?

I don’t know that I would have considered myself a “leader” in EMS, so I’m a bit at a loss for advice to future leaders. I do, however, believe that one of the ways EMS providers can earn the respect of healthcare professionals is to continue our formal education. Education is never wasted. EMS providers in general should obtain a bachelor’s degree, and those who look to advance into administration should have relevant management education as well. And to those (like me) who await the opportunity to advance in our organizations, I submit the following quote from True North by Bill George: “Follow your compass, not your clock.”

KEVIN M. SULLIVAN, BA, NREMT-P, EMS CONSULTANT, DECATUR, GA

What is your philosophy on EMS leadership?

Being a leader in EMS requires the ability to always put the needs of our patients first and to keep the needs of our providers as a close second. Everything else follows from there.

Because people having emergencies are not in the position to make informed choices about which EMS provider will respond to their needs, I believe that EMS leadership must be accountable to the community they serve, usually through engaged and informed public officials. This requires transparency and honesty on the part of EMS leadership. Organizations that deceive the public by distorting the cost and/or quality of the service they provide have no place in EMS.

What qualities are critical for EMS leaders?

EMS leaders must be process-oriented thinkers who are able to work collaboratively with people inside and outside their organization to ensure that their communities are well-served. The task also requires that one be fiscally responsible and proactive in nature.

More than this, all leadership requires a well-formed work ethic and a well-formed conscience. As my fellow Bostonian John F. Kennedy said in his ‘City Upon a Hill’ address, leadership is about courage, judgment, integrity and dedication; these are the qualities that define leadership and make a leader who he or she is. Those who operate without these qualities can only lead us astray.

Whom in your career do you consider a mentor, and how did they assist you?

I’ve been blessed with many mentors and role models in my career, each of whom has contributed to my leadership skills and clinical acumen.

For years, I’ve looked up to and received great advice from people like Chief Rich Serino, Drew Dawson, Gregg Lord, Jay Fitch, Dave Williams and Dave Shrader. Each has taken time, on more than one occasion, to offer advice and help me make connections with important people in the industry.

I will be forever indebted to the men of Fairfax County Fire & Rescue, Company 26 (A shift) – especially Matt Nacy, Jeff Lewis, Dave Tobin, Chester Waters and Tom Johnson. These guys taught me how to be a good medic, how to work well within a team, and how fraternal community is formed in professional environments.

I also learned a tremendous amount about how institutions work and about the difference system design can make in improving EMS from the folks I worked with at Grady EMS in Atlanta, most notably Drs. Eric Ossmann, Ian Greenwald, Jeff Salomone and Matt Bitner, and from Noah Reiter and Jim Bothwell.

What career accomplishment are you most proud of?

My career thus far has offered me the opportunity to be involved in some very significant projects. Most noteworthy were the efforts to sustain and improve EMS delivery in Atlanta following the elimination of all public funding for one of the oldest EMS programs in the county. That, however, is not the accomplishment of which I am most proud.

Though it may seem ordinary and simple in comparison, I hold the time I spent teaching EMT-B classes at Georgetown University as my greatest accomplishment. There’s nothing more exciting and worthwhile than helping newcomers to the profession learn how to practice with skill. Though I doubt many from Georgetown will pursue full-time EMS careers (though a few of us have), I have no doubt that our industry benefits when talented and motivated individuals come to feel connected with the delivery of prehospital care.

If you could change one thing you have done in your EMS career, what would it be?

Sometimes it feels like my career in EMS started at the top. I spent a number of years as a field provider, but then rose very quickly to top-level positions. Although I am grateful for the knowledge and experiences I have gained along the way, if I could go back, I might like to spend a few years in a field supervisory-level position. Having moved so quickly to the top, I often wonder if I missed out on some of the fun and rewarding experiences that come with that key mid-level position in our industry. The field supervisor has unique access to the challenges of management, while at the same time being able to stay grounded with the people and by the issues that we live with on a daily basis in the field. I’ve learned the lessons offered in this stage in other ways, but there are great advantages to rising through the ranks in a traditional way.

What are the biggest challenges facing EMS in the future?

The EMS industry is simultaneously dealing with two serious crises that have been worsening over the last five years.

The first crisis is financial. Most field-level providers probably do not spend their days worrying about reimbursement for EMS services, but the fact of the matter is that system financing is one of the core elements that allows an EMS system, and the EMS industry, to be successful, and the primary way we finance many of our EMS systems is based on reimbursement for services rendered. Unfortunately, the reimbursement we receive too often falls short of the amount of money required to run a quality system. As a result, the community and individual providers suffer, communities receive less than optimal care/service, and the amount of money each individual provider takes home for doing his or her job is less than it could and should be. Until we build a fairly universal mechanism to ensure that EMS is funded adequately in communities across the country, this problem will continue to prevent forward motion.

The second, and perhaps more important, crisis that we face is one of identity. In EMS, identity is largely tied to system design. It’s about who we are and how we provide EMS to the community. We’ve spent years arguing over this topic without coming to a resolution, largely because the waters have been muddied by special interests from every corner. These special interests have prevented us from creating systems that both best serve our communities and serve to advance our profession, for fear it may not be in their best interest. Until we can at least see these special interests for what they are, I’m afraid we’ll have trouble making genuine progress. Until we can speak with some semblance of a communal voice on issues that affect us, we’ll have trouble making concrete progress. I’m encouraged by some recent progress on this topic, but we still have miles to go.

How would you address those challenges?

It’s very hard to address controversial and sometimes emotional topics without objective evidence. Our first burden is to undertake critical research projects geared toward answering important questions about the effectiveness and efficiency of practices both old and new. This body of knowledge is starting to develop, and I hope it will continue to develop over the course of the next few years.

Once we have objective facts and evidence, the EMS industry needs to organize to create standards that can be applied in communities across the country. Thus far we’ve largely let others, including some of our special interest groups, create standards for us. Over the years, a number of groups have written some great policy papers on how we need to develop in almost all areas; unfortunately, these ideas have been slow to filter into concrete realities for our EMS operations. It’s time we follow the lead of other professions and industries that EMS is close to and create universal standards by which we judge ourselves.

What advice do you have for future leaders?

I would offer future leaders three pieces of advice:

First, get and stay in good physical shape. Not only will you reap the health and wellness benefits that come from exercise, but you’ll also have a healthy outlet for dealing with stress and will be better able to meet the physical demands of the job. More than all this, leaders must lead by example in all things. By being in good physical shape, you will be setting a good example for the people you lead.

Second, network at every opportunity. Whom you know (and whom they know) will enable you to find the best opportunities, get the greatest diversity of opinions and advice, and give you the chance to prove yourself to people at all levels in our profession.

Third, get a solid education. EMS is a sophisticated industry; we should not reduce the work we do to simply putting ambulances out and responding to calls when people need help. We’ve evolved well beyond the days of swoop-and-scoop ‘treatment’ to professionals with deep knowledge of medicine, economics and finance, system organization and problem-solving, among any number of other academic topics. As we continue to grow and develop, leaders who lack the operational and business sophistication to manage complex systems will stymie their organizations and impede industry-wide progress.

Raphael M. Barishansky, MPH, is chief of public health emergency preparedness for the Prince George’s County (MD) Health Department and a member of EMS Magazine’s editorial advisory board. Contact him at rbarishansky@gmail.com.