THE BUY IN
June 12, 2014
By Art Braunschweiger
Dispatcher attitudes to implementing the medical, police, or fire protocols can vary considerably depending on staff makeup. As a regional software instructor for Priority Dispatch Corp. (PDC), I get to watch dispatchers’ first-time reactions to protocols as they go through them in ProQA. At some comm. centers the staff is clearly enthusiastic and can’t wait to use them. In most places, the dispatchers are cautiously optimistic and there are usually a few in the group who get excited over a particular feature or two that they like. The majority of implementations go smoothly, with emergency dispatchers quickly realizing that they’ve gained a powerful tool with some significant advantages, compared to doing things the old way.
There is, however, the occasional comm. center manager who despairs over the staff’s apparent reluctance to accept the new protocols. My former dispatch center was one such example. The Medical Protocols were met with significant resistance from some of the dispatchers and their resistance ultimately held us back from our goal of being accredited. Interestingly, the very strengths that contributed to our center’s success were responsible for the problem, teaching us some good lessons that I’ll share.
Some dispatch centers either require or encourage their employees to be trained to a field responder level. In practice that means that the fire dispatchers are firefighters, and the medical dispatchers are either Emergency Medical Technicians (EMTs) or paramedics. In our case, every applicant had to be either an EMT or a firefighter with first responder training. It was also a requirement that applicants had a year of public safety experience. Largely because of a word-of-mouth chain that resulted in most of our hires, almost everyone had a significant amount of field experience in patient assessment. As a regional EMD center this was a big plus for us; our dispatchers could readily understand and visualize the majority of complaints reported to them. More importantly, they had an intuitive understanding of what calls required Advanced Life Support (ALS) and why.
Giving experienced field responders who are dispatchers the Medical Priority Dispatch System (MPDS) to use (or the Fire Priority Dispatch System, FPDS, or the Police Priority Dispatch System, PPDS, for that matter) is putting a hugely powerful tool in their hands that streamlines the information-gathering and decision-making processes. But that was from the perspective on the side of the administrators and the “Qs.” What we failed to anticipate was that our dispatchers weren’t all looking at it in the same way. After implementation, it turned out that a significant percentage of our dispatchers were distinctly unhappy with the change. Comments were frequently made, some in the spirit of tactful debate and others not so tactful.
Now let’s pause to put things in perspective. Not all of our staff felt that way; many were ambivalent about the protocols and others were quite positive about them. Attitudes generally fell along the typical bell curve, although outspoken criticism from some quickly quenched the optimism initially displayed by others. Occasionally I encounter the not-so-happy participant in ProQA courses I teach for PDC; typically, it’s a firefighter or EMT in the room who doesn’t say much but, when asked, admits that he or she isn’t enthusiastic about what the respective agency is moving to. The question is why, and as trainers and administrators, how do we deal with it?
My experience in implementation is with EMD, so I’ll speak to that particular protocol system. EMS is a fast-paced, challenging profession. It’s often a life-or-death business, quite literally, where split-second decisions leave no room for second-guessing.
The best EMTs are the ones highly confident in themselves and their skills. Therein lies the root of the problem. In our case, it was multiplied several times over because our EMDs (pre-implementation) were allowed to ask whatever questions they thought best, providing they were focused on the chief complaint and “triaging” the call ALS or Basic Life Support (BLS). And most of them were very good at determining the need for ALS with a high degree of accuracy and a minimum number of questions. Now, we were telling them that they couldn’t do it their way, and had to follow a scripted protocol. “I can do it better and faster” was their complaint.
In retrospect, we should have recognized that implementation of MPDS was going to result in a huge culture shift. With the proverbial hindsight being 20/20, we should have better prepared for the changeover with some pre-implementation education. This would have laid the foundation for developing positive attitudes early on rather than letting negative ones take root later. The following lessons we learned might be helpful for those with similar employee structures and/or situations.
Point out that there are a hundred different ways of doing EMD, and doing it your own way doesn’t necessarily mean you’re doing it wrong. Could someone’s personal way of handling a specific call be as effective as using protocol? Yes, but you can’t guarantee that every dispatcher’s personal approach would be as effective. We can, however, guarantee that if everyone follows the protocols, then everyone’s way of handling the call will be highly effective. In the realms of medical assessment and treatment, many procedures have long since been standardized. As the International Academies of Emergency Dispatch (IAED) notes in the textbook, Principles of Emergency Medical Dispatch (Fourth Edition, 2009, pg. 1.20), “There could be a million ways of doing CPR, but there aren’t. The AHA/ILCOR unified method of resuscitative practice is widely, if not universally, embraced.”
Plus, the reality is that no emergency dispatcher, regardless of knowledge, skill, or experience, can expect to handle every 9-1-1 situation as effectively as the same dispatcher using the MPDS, PPDS, or FPDS. The dispatcher might be able to handle some calls as well as the protocols, but not every one, every time. It’s also a fact that 10 dispatchers—even experienced dispatchers—will have 10 different ways of handling the same call based on what they think is the best way of doing it. The EMS field long ago recognized the need for standardized protocols for patient assessment. As the Academy notes: “The practice of pre-hospital medicine [and in fact, any type of time-critical medicine] is not guideline—or judgment-driven—it is protocol-driven. Judgment by all pre-hospital care providers is a function of deciding which protocol applies and how to apply it in specific situations.” (Principles, pg. 13.5)
This is a point that anyone who works in EMS can relate to. Law enforcement and the fire service also have long-standing procedures for doing things. Whether it’s how an officer should take down and handcuff a suspect or how firefighters should conduct a primary search for occupants in a burning building, all follow procedures that have evolved and are taught within those professions as the proven, best way of performing those actions or tasks.
Taking the above point one step further, it may help to explain that the architects of the medical, fire, and police protocols within the IAED are professionals in each discipline, working directly in those fields. They include fire chiefs, paramedics, law enforcement professionals, and other industry experts whose careers have been largely devoted to advancing the science of dispatch in their respective disciplines. These are the individuals who make up the IAED Councils of Standards and the International Standards committees. As a result of their efforts, the protocols are continually evolving and advancing based on research and case data from high-volume call centers, and they’ve been around for a combined 60+ years: 35 years in the case of the Medical Protocols, 14 years in the case of the Fire Protocols, and 12 years for the Police Protocols.
Proposals for Change
It’s also likely that experienced dispatchers might express frustration over their perception of having no say in the set of protocols that’s been handed to them. Surprise them—that’s not the case. Introduce them to the Academy’s Proposal for Change (PFC) form. The form—as the name suggests—gives protocol users the opportunity to recommend changes and forms the basis for a great in-service presentation. Most dispatchers have no idea that an agency can submit recommendations for change. “Really? We can do that?” was the surprised response from one of my dispatchers when I informed him of the process.
While you’re at it, note to your dispatchers that we’re moving to version 13.0 of the MPDS, having introduced version 1.0 in 1979. Since that first edition, more than 4,000 changes have been made, the majority identified by dispatchers at user agencies. Widespread use of the protocols unifies a comm. center into a “users’ group” with thousands of others around the world. This, according to Principles (pg. 13.17) allows the MPDS to be “built on knowledge and experience that is wider in scope and deeper in content than could be generated by even the largest communications center. ”
When asked questions about protocol, always—always—take the time to follow up and find the answer. Emphasize that just because the reason for a protocol question or its wording isn’t immediately apparent (or you can’t tell them why) doesn’t mean it’s a dumb question. Your Quality Improvement Unit (QIU) is the first place to go for answers, and, in addition, there are several other avenues for inquiry—writing to Dr. Jeff Clawson (the Ask Doc column in The Journal) or Brett Patterson (the FAQ column in The Journal), the Q Forum on the Academy’s website, and the highly popular Q Forum Live at NAVIGATOR, to name a few. Without exception, I’ve found that once I explain the reasoning behind a particular question or the way it is worded, a dispatcher is far more likely to appreciate why it’s here. Building acceptance with the protocols starts early, and it is a never-ending job.
In retrospect, knowing the culture of my former dispatch center—one that encouraged initiative and expected dispatchers to rely on their good judgment—we should have taken the time to identify the challenges and plan the best way to address them when introducing and implementing new protocols and/or ProQA to dispatchers. As we teach in Q classes, protocol implementation must be viewed from a project management standpoint. Your dispatchers’ world is about to change, and you’re giving them new tools to use. You can’t just plug in the protocols and expect dispatchers to accept them because you say so.
Remember, despite a wealth of skills and expertise, emergency dispatchers typically view change with the greatest reluctance. In the middle of the stress and chaos that characterize the job, falling back on the tried and true offers some degree of predictability. Take that away, and you’re taking them out of their comfort zone.
Prepare in advance
Start preparing for the arrival of your new protocols well ahead of the first EMD, EFD, or EPD classes. Let your dispatchers know what to expect. Address their concerns, and ask them what they’ve heard about the protocols. Correct any misconceptions. Allow them to express their concerns, and answer them directly and honestly. Don’t blow smoke their way. Dispatchers are smart people who respect an honest answer. Be up front and acknowledge what they might not like about protocol, and turn the negatives into positives. For example, dispatchers might not like the idea of losing their freedom to ask whatever questions they want. Turn that around by pointing out that scripted questions allow them to focus their expertise on managing the caller and evaluating their responses, rather than dividing their attention to consider where to go next.
Protocol implementation isn’t a science, and it’s not something that happens because you put a policy in place that says so. It has to be approached as an art. It means taking the time to understand your employees and educating them about the pending changes before their first protocol class.
Do you need to sell them to your staff? You better believe it. If you’ve got good dispatchers, they care about what they do and take pride in doing it well. If you can get them to understand that you’re giving them a powerful new tool that will let them do their job at a whole new level—with a whole lot of benefits to your customers, your responders, and your agency to boot—they’ll be ready for the change when it happens.
The PFC can be found at here
1American Heart Association / International Liaison Committee on Resuscitation.