Human resources (HR) deal with the hiring, training, compensating, managing, and unfortunately, at times the disciplining or terminating of employees. Human resources managers are expected to have expansive knowledge of these fields. However, all individuals in supervisory roles must have a basic understanding of the agency’s HR framework. Physician medical directors bring extensive medical knowledge to an organization, but often have minimal business training or experience. Unlike their counterparts in dentistry or chiropractic medicine, physicians are given little, if any, education in the business world. While all of these functions do not fall directly under the purview of medical direction, an astute medical director should have an understanding of their role within an organization’s human resources structure.

Emergency medical services is a unique profession, straddling the worlds of public safety and allied health. Like other public safety professionals, prehospital care providers respond to emergency calls from the community 24 hours a day, 7 days a week. Providers often feel a special kinship with the firefighters and police officers alongside whom they work. However, the medical education they must possess distinguishes them from these colleagues and aligns them more closely with nurses and other health care professionals. Limited resources exist for dealing specifically with human resources issues in emergency medical services. By examining allied health and public safety references, one can better navigate these minimally charted waters.

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  Define the role of the medical director as a part of the EMS or fire agency administration.

  
  
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  Contrast the HR/ER roles of the medical director against those of the agency director or fire chief.

  
  
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  Contrast the terms remediation and discipline as they relate to a response to EMS provider performance issues.

  
  
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  Describe the proper method for instituting remediation, probation, and suspension of privileges.

  
  
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  Describe liability issues for medical directors related to labor laws.

  
  
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  Give examples of pitfalls related to the handling of HR/ER issues.

There are various models for the relationship between medical directors and the agencies they oversee. These models may alter the expectations, functions, and protection of the medical director. In an employee relationship, the medical director serves as a member of the agency’s management team. He or she, like any other manager, may be hired or fired based on relevant employment law. The medical director’s status as an employee may afford him or her a degree of liability protection. As independent contractors, however, medical directors may not have these same protections. The scope of their authority, protection, and subsequent liability will vary greatly based on their contracts.

A medical director may also provide oversight for an agency as an employee of a third party. Hospitals, physician groups, or academic programs may contract with outside organizations to provide medical direction. In these cases, the medical director has some degree of employee protection, but not from the EMS organization he or she is overseeing.

Many medical directors provide uncompensated services to the agencies they oversee. In general, organizations expect, and get, less support from uncompensated medical directors. This is a common model for volunteer and other smaller agencies. In some cases, this lack of compensation may offer additional protection to the medical director. In New York State, noncompensated medical directors are protected from liability by New York State Public Health Law: Article 30 Section 3013, which states that

Medical director involvement varies widely among agencies. Some ­medical directors provide little more than a signature on a page, while others are a full-time presence at their agency. The more involved a medical director becomes, the more important it is to define his or her role within the agency’s overall structure. This should be defined early in the relationship to avoid potential problems. Medical directors can be very influential, but they rarely have any direct subordinates. The role is frequently depicted as an offset box below the agency’s CEO (Figure 27-1). There may be many actual or implied dotted lines representing influence over clinical personnel, education, CQI, and other relevant departments.

As the chief medical officer of the organization, ensuring quality patient care and employee safety should be the medical director’s primary role. The agency’s CEO, on the other hand, must balance a litany of concerns, including financing, staffing, external politics, and, in some agencies, fire suppression. Ideally, the medical director will serve as a strong advocate, while still respecting the CEO’s other concerns. By understanding these other concerns, the medical director can advocate for his or her goals within the broader organizational goals. A collegial relationship between the medical director and the CEO is valuable for the smooth operation of the agency.

Medical directors who respond to calls should also understand their field rank. Field rank refers to their role in the on-scene Incident Command System. Medical directors may respond to the scene as part of the agency, part of another agency, or on their own. Issuing a medical director a response vehicle may not always be practical, but an agency may provide their medical director with a radio and call sign at a negligible cost. While on scene, the physician medical director has the final say on any patient care decision in the form of online (on-scene) medical control. However, based on field rank, he or she may defer to another on-scene incident commander for control of the scene and other big-picture issues.

Hiring new employees is arguably the most important HR role in any organization. Hiring clinical personnel can be challenging, and is further complicated when the hiring pool is limited to already certified (or licensed) individuals. By limiting the pool of applicants to those who have already completed certification, agencies may miss potential employees who would excel in the long term. A company limiting itself to personnel already certified will often look for potential employees who are either currently employed by a competitor, trained but working in another field (this is often true of volunteers), or perhaps unemployed with existing certification.

In a municipal system, new civil service employees are typically put through a formal examination process. In some regions, a single civil service test may feed new applicants into multiple municipal agencies. Initial qualification standards may include a high school diploma, college credits or degrees, residency or the ability to obtain residency, a driver’s license, specialized training or certification. While the core of this process is a written examination, follow-up testing and additional points for qualifications such as experience or residency shape the final pool of potential hires. These secondary steps are useful for weeding out applicants who are strong tests takers, but poor fits for the position. Unfortunately, due to the nature of the process, it can be difficult to hire those who are poor test takers but would be good fits for the position.

CREDENTIALING EMPLOYEES

Once hired, employees must be credentialed prior to beginning work. An orientation and training period before new employees are able to function at their appropriate level of care is common. Ideally, the hiring process screens out employees who will ultimately not be able to be credentialed. Training employees who cannot be utilized can be costly for agencies. Nationally, 28% of paramedics meet with their medical director as part of this process.¹

PERFORMANCE REVIEWS

Clinically and nonclinically minded managers may have different opinions when it comes time for reviewing an employee. An agency’s best workers may not be their best clinicians. The best workers are employees who are team players, rarely call in sick, have no disciplinary actions, and always obtain complete billing information. The best clinicians rarely have QA issues, are constantly working to grow their practice base, and consistently provide superb patient care. Unfortunately, while attendance, billing compliance, and bad patient care are often easy to quantify, excellent patient care is often very difficult. The absence of clinical disaster does not always equate to excellent care. The ideal employee excels in both areas. Depending on the job in mind, the relative importance of these qualities may vary. It is important that these issues be critiqued separately to give a fair portrayal of the employee’s work and of the areas needing improvement.

RECOMMENDATIONS FOR PROMOTION

The most important promotion in EMS is the step between EMT and paramedic. Companies may incentivize this training by covering enrollment costs, paying employees while attending school, or extending them full-time benefits while taking course work full time and working part time. Factors that improve a provider’s chance of success on the NREMT-paramedic exam include EMT-basic exam score and length of time as an EMTbasic.² Nonclinical personnel, such as dispatchers, billers, or supply techs, may apply for clinical positions. Promoting a well-known employee from a nonclinical to a clinical position may be less risky than hiring a new employee. The medical director can serve an important role in advocating for the clinical side of the position in relation to the relative importance of that new job role.

EMPLOYEE TRAINING

In order to obtain and maintain certification/licensure, minimum training standards must be followed. These standards may include national “alphabet soup courses” such as ACLS, PALS, CPR, ITLS, etc. Larger operations often offer these courses to their employees. Employers may pay for, and in some circumstances pay employees to take, these courses. Additional medical training beyond the minimum standards offers ­further opportunities for provider development. Beyond ­medical ­training, education in emergency driving, patient maneuvering, and company policies round out the new employee’s education. The cost of training a new employee can be significant, making employee retention an important goal of any organization.

EMPLOYEE COMPENSATION

Companies must find a balance of offering employees an attractive compensation package, while still remaining fiscally responsible. If a ­company can do this successfully and can increase the percentage of payroll dollars allocated, it will be a strong recruitment tool for the best and brightest providers.

Salary is the most basic form of compensation, and varies among region, job type, and provider model. The Bureau of Labor Statistics has the nation’s most comprehensive employee database; however, in the case of EMS, its data are muddied because they does not distinguish between paramedics and EMTs. The annual Salary and Workplace Survey by Fitch and Associates, published in the Journal of Emergency Medical Services, makes this distinction. When corrected for a 40-hour work week, the 2010 survey revealed higher average compensation in the east coast regions compared to the rest of the country. However, while correcting the data for a fixed work week is useful for comparison, the mandatory or expected overtime built into many providers’ schedules becomes part of what they consider as their base pay.¹ Municipal positions tend to have higher salary and compensation packages, often including pensions, compared to the private sector.³