Bob Ramsey

“How many of you experience daily unwanted an unintended consequences of good intentions? I do. Those consequences usually happen by either good people making decisions generally based on experience, training, instincts, deductions or perspectives, or it is usually a result of an organizational policy, practice, procedure or institutional memory put into practice with good intentions.


Sometimes bosses and members of organizations jump to conclusions that unacceptable actions are caused by self-interest. And a few times they do, as we all know. But divergence from a mean or an acceptable behavior or practice is neither uncommon nor usually caused out of pure self-interest but rather unacceptable behaviors or actions usually occur naturally. Neither an individual nor the organization is able to take into consideration all of the subtle differences and uniqueness of the actual needs of an entire situation prior to its occurrence or it’s outcome.


In addition a natural erosion of organizational procedures, rules and internal agreements that occur between diverse service sectors or in an individual’s workflow practices daily. This erosion occurs naturally at different rates, even if it is not perceived throughout all sectors, processes, behaviors and actions.

Like a musician or sportsman that does not practice his skills frequently they will diminish. The fusing of individual or organizational agreements are not physically made products, but are individual or group concurrences or agreements integrated and processed within architecture, tools and technologies. The vision, mission, processes and best practices must be managed, practiced and re-inspired in daily workflows.


How an organization, such as an ambulance service or EMS agency, discovers and develops systems and better tools for enhancing processes, workflows, skills, judgments and actions, as well as implementing good organizational behaviors and intuitive systems for better service outcomes has been our organization’s mission and our strategic driving force for decades.


The following represents some of those discoveries we have found along that path to design and implement high performance services for Ambulance Services and EMS by marring organizational behaviors with new technologies. I will discuss a new Active Management approach. Later I will continue the discussions in Concurrent, Retrospective Management and Prospective Management Systems.

I’m not suggesting from our discoveries or designs that other management approaches or systems that others prefer are not correct or are better suited for their uniqueness. I just want to share my thoughts and perspectives and our organizations personal experiences that propelled us to high performance” ……….Bob Ramsey

Developing managing processes in real time for service enhancements.

Ambulance services and EMS are usually governed by disciplined on of off switches, practices and clinical protocols, like ritualistic routines for response and delivery of service. At the time of on set a request for EMS and ambulance service. Incidents or situations usually have in them some unknown, wild or uncontrolled environments, human conditions, behaviors, or factors surrounding the need. Sometimes those conditions are somewhat chaotic or dysfunctional and need to be uniquely and individually controlled or managed in very short real-time frames of interaction for better service outcomes.

Historically disciplined protocols and the experience of a hands-on team deliver the needed service and then hand off the patient to others in a workflow chain of links in service and care. Many times service incidents may be reviewed afterward in quality assurance programs (Q&A) for possible insight, patterns of outcomes or corrective actions. Issues for customer service or clinical improvement require additional response after the fact.

We have found that this historical disciplined approach of “Prospective and Retrospective Management” serves EMS very well but has some inherent weaknesses in synchronized service within active timeframes for the continuity of care, quality choices and the interactions of out of hospital and in hospital multiple service teams in connecting to the better outcomes.

Designing, reliable consistent delivery models, for an overall system to assess an incident or situation and developing the communication, informational and control loops in real concurrent time frames for the required interactions and adjustments of service delivery need to be achieved and well grounded on recognized organizational and cognitional behaviors. This new and additional realm of managing change processes in real time workflows between service teams require distinct new approaches in the way we use technologies, communicate, form behaviors and manage EMS.

In a logistic or agile service organization such as an EMS ambulance operation versus traditional structured brick and mortar operation, many more decisions for service actions by individuals in the organization need to be made within a situation in quick real time frames. Even though pre-hospital EMS services grew out of the traditional management processes of brick and mortar organizations the methods of managing in quick time frames have always had their impediments. High performance 24/7 services require the search and development of new intuitive non-traditional logistic systems.

The new systems are organized by a disciplined electronic coordination of proper service delivery by a variety of individuals in an incident or a situation and between service partners in different organizations. Such as: dispatch centers and protocol, response vehicles, ambulance services, support services, fire departments, police departments, medical administration and control, hospital emergency departments the patient, family members, third party payors and legal, clinical and government security controls. Additionally the correct practices of service today can be greatly improved through enhanced electronic command that touches all care givers such as: confirmed communications, alerts, notices, messages or indicators throughout an incident or situation to help deliver the best possible service.

This new integrated approach and design establishes an intuitive assessment culture. The design model, in EMS, joins quickly different departments of senior, middle management and staff together with the hands-on scene clinical teams for advanced service delivery. Seeing and performing by the assimilated teams throughout the organization during an incident helps to communicate and manage through difficult situations. The service teams actively working together gentling a situation in real time frames keep the EMS system available, prepared and reliable for the continuity of service and help provide the best possible outcomes for the patient. Gentling a situation in a workflow of real time frames also lead to positive feelings and actions by the participants of service delivery and the customer. The “Gentling Way” delivers superior service and improves the skills of the practice.

We believe that the way an individual mind stores information is by an act of split second acknowledgements, agreement(s) or fixing and fusing thought, either consciously or subconsciously onto a back ground, middle ground or fore ground in the mind.  Individual actions within an event or incident of response and service are usually based on a series of many quick automatic reactions as well as quick and overt decision-making. Individuals quickly need to make good and correct decisions as well as new mental acknowledgments, agreements and change bad choices quickly or mistaken mental agreements.

This ability to change thought and choices in near real-time by confirming correct decisions quickly in the mind lead to changing behavior and culture quickly and subtly producing an impeccable organization of service while perfecting an individual and overall team performance.

Transcending an individual or organization requires a unique focus or re-focusing of the mind on the driving vision and mission of the organization through out the workday and workflow in thousands of small decisions by an individual, teams and departments delivering a seamless service. In incidents or situations of real time response, an individual can accomplish these mental reinforcements by receiving continuous alerts, messages indicating deviation from accepted thresholds.

These mental and sensitive signals can immerse correct acknowledgements or agreements in one’s mind and reject false or bad agreements quickly. This action by the mind of an individual to focus and fuse thoughts on correct actions is reinforced by emotional assessments confirming the correct actions and situational needs along the unique journey of the mission.

The fastest acceptance and proper performance of correct behaviors require that continuous emotional rewards in the individual teams, working together, are not only desired by all but proper performance essentially needs to be individually confirmed throughout the timeframes of workflow for success. An individual’s personal attraction to immediate emotional positive rewards confirms the correct path while creating a renewal and sustainability for the organization and more importantly the individual’s quality of service performance.

Experience has demonstrated to us that to change or prevent potential or unacceptable behavior along the journey of a situation in the delivery of service require individuals to choose correct practices quickly by making new agreements and acknowledgements in their mind and through communications, conformations and actions to change operational practice and behavior.

Even though at many times the beginning moment of service starts out in a personal fog of non-alertness surrounding the environment. Team members need to become alert, ready and move quickly into actions of individual high performance working together in synchronized service teams that allow the organization to serve others for their best possible outcome. Under an e Motion Command Network words, small indicators, alerts, measures and directions by active management systems verbal and electronic awaken the mind of a team continuously for proper actions.

Subtle corrective actions and emotional rewards of accomplishment need to fuse and be stored quickly in the mind by communication, personal confirmation and proper actions for accepted actions to be repeated along the time frames in a workflow of service delivery. In EMS, ambulance service and pre-hospital care there is a continuous workflow of bundling, unbundling and re-bundling of information, conformations and service team’s interactions to deliver seamless service for the best possible outcomes in distinct environments that are diversely located and through cooperative clinical protocols. This is accomplished by a variety of teams interacting through variety of technologies in diverse circumstances. Continuous communication loops of information, mental focus and confirmation on correct actions and service behaviors will bring greater success through an “Active Management Process”.

We believe that high quality performance in a company requires correct actions that are delivered through out the organization and to customers, clients and service partners. The focus on achieving service delivery can be successful if the cultural behaviors of the company and its management systems are active in real-time, mind and body synchronization. Retrospective and Prospective management processes and systems support this Active Management Processes.

These management processes and systems even if distinct in their prospective when applied appropriately operate with precision in the organization through a variety of service area levels or functions such as: Command, Controls, Communication, Staffing, Materiel, Accounting, Continuous Education and Quality Assurance, Training and Record Management.

Establishing a correct map, mission and organizational behaviors as well as organizational structure requires an understanding of how the individual and the organization need to relate both through personal interactions, controls and electronic operability. A key to that vision is the way in which individual and an organization confirm agreements; accept workflow handshakes and those are made repetitively, respectfully and continuously.

Transformation and growth is a challenging yet rewarding process for perfecting both the individual and the organization. It requires a continuous process of both individual and organizational evaluations and assessments focusing on positive confirmations and correct guidelines.

Continuous individual and organizational transformation encourages both the individual and the organization to reject negative beliefs and false or bad actions while fusing correct actions of service throughout a work day which results in the best possible service practices and helps to insure the organization’s vision and mission.

Positive change, growth and success can come quickly by effectively utilizing and engaging in Active Management, Retrospective Management and Prospective Management processes appropriately.

Ambulance services today can achieve new standards for high performance through implementing integrated design methods and programs in concurrent time frames. These new processes need to stimulate system wide responses and focus on the synergies of human interactions and organizational behaviors in face-to-face, voice and complex electronic communications as well as traditional systems of formal policy and procedures. An Active Management design and the individual’s commitment to distinct behaviors, communication techniques and organizational practices will enhance care in all situations for the best possible outcome.

Active Management Communications need to expand its interactions into a series and levels of electronic indicators that measure, guide or nudge, both proactive and reactive, the direction of actions and other systems of control in real time frames of workflow through out the time of day. Visual, verbal and audible messages awaken an individual or function out of a microenvironment of non-alertness, which may sometime surround a member, or area of function in an organization.

In 2005, we well understood that real time communication loops motivate or move individuals, team members or a service area into proper actions for high performance. We initiated early many ePCR active reports throughout our system to alert service sectors with the implementation of our EMS model in Scottsdale Arizona. We proved we could enhance response times from greater than 10 minutes 90% of the time by past competitors to better than 8:59 in 92% of the time by the changes in the enhancements of both prospective and retrospective processes. Little did we know then that we could also improve the national heart save rate four X. And the first to do so in standard operations within a public private EMS service.

Active Management System
The natural pace of deterioration and intersection of different technologies, multiple controls and proprietary codes could have caused some difficult and unreliable integration without intense manual oversight. Updates, changes, new systems, their controls and uses of the differing technologies only added to what seemed a never-ending dance of musical chairs that impacted the affect on the micro situational needs of service delivery. We had to design a new way to integrate distinct technologies in an Active Management system to deliver even better response and high performance service as well as increasing skill levels.

Our approach was to design fundamentally from the service needs and how these features relate to each other in open communication loops to complete handshakes in workflow processes of not only our organizational service levels but for the appropriate needs of our anticipated service partners. We essentially saw these varying needs or features for integration as essentially one; and needed to establish an infrastructure that could leverage common communication technology.

This common communication technology or format needs to be a funnel for a variety of IT systems that may be added or subtracted in the overall network for all integrated partners. For us a concept of a hub wheel methodology for service delivery cannot be based from a single technological tool or system.

Our needs was better suited for a model that was designed from the needs of integration; marring the appropriate technologies when necessary with the needs of the organization, it’s teams, extended service partners, clients, customers and patients as well as the workflow within the interactions of required timeframes.

We found that, additionally EMS and an ambulance service need to choose wisely their technological partners for system integrity and reliability of the equipment, devices, ePCR products, and tools in operating an active 24/7 system that never rests. This includes choosing and developing software, codes for communication loops of electronic handshakes, confirmations and establishing continuous measurement processes of Q&A. The combined efforts of technology, continuous education and training of management and staff needed to be proficient and reliable in the interaction of best possible service outcomes. This proper engagement of workflow in required time frames immersed the organization in the quest to raise the bar of service delivery.

As described earlier the need to manage variations in workflow service between the needs of service sectors and synchronize service delivery in very quick timeframes requires design, retooling and expanding command processes electronically.

The approach led to developing and marring new behaviors and technologies in active processes constructed from the needs or features of service that is commanded for continuous integration in real-time frames. First by multiple interactive subtle controls and by chain of command networks engaged in the workflow and followed by rigorous reviews by the appropriate retrospective quality assurance loops. Thirdly our prospective analysis and training process became quicker in modifying the required changes for the organization and have contributed efficiencies, financial sustainability and the perfecting of individual competencies.

Our subtle interactive controls are accomplished today through our eMotion Command (eMC). The eMC is an electronic intuitive command network that operates throughout the organization, similar to nervous systems in an organic body, they actively connect the operations in real-time for synchronized workflow management and service actions. The following are some of the features and operating systems of our eMC:

A. Development of Command Queues to reduce variations in handshakes between service sectors.
B. Control Loops integrated from varying technologies.
C. Dashboards utilizing mobile and desk top devices.
D. “Sam” an electronic voice and text personality.
E. Video conferencing and surveillance portal.
F. MOM an intelligent vehicular monitoring system in real-time.
1.Standard GPS.
5.Intelligent Mechanical monitoring/diagnosis.
6.Electronic patient care charting/reporting (ePCR).
7. Mobile IP (Internet Protocol) infrastructure.
8. Via mobile telemedicine conferencing.
9. Radio, communication and medical devices.
10. Wi-Fi/Bluetooth asset tracking.
11. Multiple wireless devices.
G. Command alarms and alerts.
H. Service line notices in workflow timeframes.
I. Interactive reporting canned and ad-hoc.
J. System Status Snapshots and flash reporting.
K. Digital voice recorder portal systems.

Implementing Intuitive Active Management Processes
In designing code, portals, wiki’s, email processes, driving wheels, dashboards, e-displays, programs or eCommand Systems for individuals and management systems either electronically; or through ideas that design policies, procedures or practices and organizational controls for checks and balances remember the following guide points:

1. Be impeccable or clear as possible in creating the language, communication for the mind of the receiver(s) in real time actions.

2. Within change processes do not take things personally.

3. Help remove any personal emotional virus from yourself and the organization.

4. Don’t make assumptions help communicate clearly and throughout…walk one step at a time.

5. Do your best because you want too…

6. Be persistent, consistent, fair and respectful.

7. Take actions over and over outside of ritualistic routines…. don’t avoid or ignore actions

8. Resistance or push back is a natural environment reaction and is just part of the individual’s process of ownership.

9. Emotionally reward in real time actions of workflow.

10. Use situational assessment techniques instead of gathering information or investigations.

11. Respect the way that everyone is developing and growing in new ways while managing and working together through difficult situations.

12. Do not let the exceptions of unique real time situations create change in organizational policies and procedures without confirmation by the organization’s Prospective Management Process. And

13. Respect the boundaries and distinctions in the practices, methods and behaviors of the Active Management Process, the Retrospective Management Process and the Prospective Management Process of the organization.

14. Always be guided by the map of Organizational Behavior in service delivery and workflow interactions.

This exciting and new way to manage and respond to any circumstance or situations within a daily mode or service incident is accomplished by using new technologies, data and people engaging to size up an overall situation of service. Designing an intuitive assessment culture in “Active Management” with the proper electronic communications, visual templates such as driving wheels and live action dashboards, ePCR applications, telemedicine and tools join the links of service delivery together by expanding the service team top to bottom in concurrent real time. This ensures communication, connectivity, accountability and reliability in every aspect of interactions, duties and responsibilities within teams, support command services and between organizations and agencies. Implementing intuitive assessment processes in an ambulance service result in service enhancements for any incident or request for service while perfecting overall team performance.

By identifying, assessing, and communicating the back ground, middle ground or fore ground of service concurrently and by working together in service teams we have found the following situational assessment criteria essential in an EMS environment. The assessment criteria can be used as a guide or standard for developing active workflow tools, reporting platforms and automatic electronic notifications for live real time actions. The criteria can be used for assessing an inquiry of service delivery from customers and service partners within a retrospective review fact finding processes through Situational Assessment Reports.


• Request for service: the incident and the environment of the situation.
• Availability: resources and alertness of personal.
• Controls or processes: Statutes and Rules, policy and procedures, protocols, algorithms and program codes.
• Command: leadership structures, internal and external, including Medical Direction.
• Time frames: measurements of service delivery.
• Materiel: vehicular, equipment, resources and supplies.
• Communications: face-to-face, radio, electronic, hand written, voice and confirmations.
• Clinical staffing: assessment and treatments.
• Scene and destination: the environment and condition.
• Workflow Team: Interactions of hands-on crew, service partners and participants.
• Outcomes: perceived and completed.
* Documentation: accurate & complete documentation, data exchange records.

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