“BOLO” is a pretty easy term to understand, even for us “civilians” who may not have a background in law enforcement. It indicates that you should be looking out for something—a vehicle or person typically. We can apply the same BOLO principle to EMS, or even everyday life.

Sometimes, not being on the lookout has a less than desirable outcome. Consider the following scenario: It’s 9:00 p.m. and one of your units has been dispatched to a potential hostile scene with instructions to stage until local law enforcement declares the scene safe. The crew finds a nice safe spot, two blocks north and two blocks west of the scene. After 10 minutes pass, PD clears the scene as safe and, just as the crew is about to move toward the scene, a large freight train proceeds onto the railroad tracks located between the staging area and the scene. Uh oh, blocked. The crew tries frantically to circumnavigate the train, but to no avail. After 15 minutes of trying, the crew radios they cannot make the scene and another ambulance is dispatched from the south and east to the call with a significant response delay. Clearly, the crew failed to realize that staging with an active railroad track between them and the scene is not a good idea.

The ability to identify, process and comprehend the context, circumstance and consequence about what is happening with regard to a mission is crucial, not only in successfully completing the mission, but sometimes even for survival—ours, or the patient’s.

You may recognize this description by its more common name: Situational Awareness (SA). In an article published by Northwestern University’ Master of Engineering Management program,¹ the authors help us understand situational awareness by identifying three main elements:

Context: Understanding the forces that are shaping your world and your decisions. Who or what is pushing for a decision? Circumstance: What has happened? Where is momentum going and who has the advantage from a momentum perspective? What can recent and longterm history teach us about where we are and how we got here?

Consequence: What could happen in the future as a result? What are the possible and likely outcomes? What are the implications and extrapolations from the decisions we and others are making?

Most of us in EMS understand the basic concepts of SA because they have been drilled into us from day one of EMT school—concepts such as BSI, scene safety, resource management, etc. On the micro level, SA is necessary to make sure you can effectively get to a call, as in the previous example scenario. But in today’s rapidly changing healthcare, economic and political environment, the concepts of SA go well beyond assuring a reliable response to an EMS call.

Healthcare SA: Are you perceived as a valuable partner by your customers? Are there competitors who are doing a better job than you at meeting customer needs? Is your organization responsive to the changing needs of your stakeholders? Are you involved in problem-solving initiatives that impact your customers and community? Or, are you just tooling along, happy thinking that you are?

Economic SA: Are you routinely evaluating your accounts receivable to identify trends that may impact cash flow? Have you run scenarios based on insurance shifts in your market to high deductible health plans that make the patient responsible for a larger portion of their healthcare dollar? If you are tax supported, are you scanning the economic horizon to see what future public budget issues may arise in order to position your agency as high value? Are there Accountable Care Organizations (ACOs) or other strategic alliances occurring in your market that may align financial incentives that may impact your services?

Political SA: Are you monitoring the political landscape for legislative initiatives (local, state, national) that may impact your agency? Are you active in a trade association that represents your industry in the capitol? Are you actively proposing legislation that meets the desires of your patients and your agency, but also of elected officials, especially in the era of increased accountability and transparency coupled with improved services at reduced costs? Have you shifted some of your priorities to align with these changes? Are you certain that initiatives you’ve undertaken (or have asked others to undertake on your behalf) will have a warm reception and not be met with a buzzsaw?

Planning for Icebergs

Being situationally aware requires that you focus simultaneously on the future and the present. The future could be minutes or years from now. Think of it like driving a car. Short-term awareness could be the driver next to you on the highway who appears to be distracted and drifting. It could be the person driving the car three lengths ahead of you who just applied their brakes. Longer-term awareness might be knowing the distance you can travel on the fuel reserve you have, or knowing when you need to safely change lanes to prepare for the next exit.

The same is true for EMS management. Are your critical systems backed up regularly in the event of failure? This applies to both infrastructure and human capital. Are your CAD and billing systems continuously backed up? Are your vehicles maintained using aircraft-style maintenance philosophy (knowing that an alternator generally fails after 20,000 engine hours, you replace it at 18,000 hours to prevent the failure)?

Have you invited an outside technology security audit to assure your systems are not only compliant with HIPAA’s security rules, but are secured from unauthorized downloads? An outstanding CEO of a well-respected EMS agency recently shared with me his experience contracting for such an audit. Within 30 minutes of the outside contracted cyber-hacker arriving on their campus, unannounced and without an ID badge, he was able to download an entire day’s patient care reports, with PHI, onto a thumb drive he then handed to the CEO.

On the human side, have you prepared everyone in your organization to make decisions that are consistent with your organization’s core values? Have you prepared your management team members to be able to make the right decisions to handle an incident that may occur in the next 30 seconds? Have you prepared them to step in for you during an absence (planned or unplanned)?

Doug Hooten, executive director of MedStar, has a standard question he asks his management and executive teams at the end of virtually every meeting: “Are there any icebergs out there we need to be aware of?” This is a great method for practicing and teaching SA. It invites team members to think about the future and analyze what’s happening that we need to be aware of.

So I ask you: Are there icebergs out there that you need to be aware of? Are your key managers and leaders able to even identify them if they’re out there? Are you asking the right questions? Do you have your telescope focused on the future?

Or, is there a train blocking you from your future that you did not anticipate coming?

References

1. MEM Northwestern. (Jan. 12, 2013) Situational Awareness: What it is and how it can transform your managing style. Northwestern University’s Master of Engineering Management. Retrieved on Oct. 13, 2014, from memnorthwestern.wordpress. com/2013/01/12/situational-awareness-what-it-is-and-how-it-can-transform-your-managing-style/.