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Self-Managed Work Teams at South Australia Ambulance
Service
Ray Main pondered the box of questionnaires received from the Ambulance Officers (AO’s).
Normally a 45% response rate would be a good response to a survey. But in 35 out of the 60
stations less than half of the AO’s in the team responded. Without the input of more than half of
their team members, he didn’t feel he could provide representative feedback to the station teams.
South Australian Ambulance Service
SAAS provides emergency paramedic and advanced life support services as well as routine
ambulance transfers throughout the state of South Australia on a self-funding basis. The service
is provided by 600 full and part-time staff and some 1100 volunteers in areas difficult to service.
Emergency calls go to one of 4 communications centres who pass the message to one of 19
metro teams in Adelaide, to one of the 20 rural teams or to one of the 60-70 volunteer teams.
Until the late 1980’s, SAAS was an integral part of St. John Ambulance Service (under the St.
John Priory) and was staffed by both full time AO’s and volunteers. Full time employees worked
Mon-Fri from 9 AM to 5 PM. Volunteers handled all evening and weekend work.
their professionalism and training. All full time AO’s were now required to complete a three year
program leading to a diploma through the TAFE college system.
2
In 1992, a new CEO, Ian Pickering was appointed to re-organize the service and complete the
separation of SAAS from the St. John Priory. His mandate was to improve the clinical expertise
in SAAS and to make it the best ambulance service in Australia. Shifting the organization from
the old military model to an empowerment one was a key part of his strategy to achieve
excellence.
In 1993 a strategic plan was developed. As one manager put it, “It was the first time we asked
ourselves, ‘What was our mission? Why are we here?’ Never before had we defined patient
service (as opposed to patient care).”
This strategic plan was reworked in 1995 (See exhibit 2 for a summary of the vision, mission,
key objectives and major strategies). The plan included a commitment to “an empowered and
accountable workforce”. Seven cross-functional project teams were established to help
implement the strategic plan: theWorkforce Empowerment Team, the Workforce Development
Team, the Information Technology Team, the Commercial Team, the Structure Team, the
Volunteer Team and the Business Development Team. Chris Lemmer, Regional Director
(Metro) headed the Workforce Empowerment Team with Ray Main seconded full time as project
coordinator.
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The Job of the Ambulance Officer
Two ambulance officers were assigned to each vehicle. In the Metro area, most stations had two
emergency vehicles plus one or two routine transfer vehicles. Each station had kitchen facilites, a
lounge, sleeping areas for night shifts and exercise rooms. When an AO began his/her shift,
assuming the previous crew was in the station, they would ensure that the vehicle was ready for a
call. A lengthy, detailed list of supplies had to be checked. Materials used had to be replaced.
A typical Metro morning shift is described in Table 1.
Table 1: A Typical Morning Shift for a Metro AO Team
0800
0800-0830
0830-0840
0840
0840-0900
0900 (approx)
0900-1030
Arrival
Checking and restocking vehicle
Relaxation
Communications moves the vehicle to a
central location in the service area
Wait at location
“Shortness of breath” call
Travel at high speed to call, attend patient,
take patient to hospital
Getting to a call was considered urgent and was carried out at speeds up to 100 kph. On arrival,
AO's unloaded the emergency equipment (in the cases above, oxygen and an electro-cardiograph
and stretcher) and entered the house. One AO took the lead in each case, making decisions on the
immediate response demanded by the patient's condition (e.g. if blood pressure was down,
should a saline drip be attached?)
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cardiac patients where speed was essential. As one paramedic described, “we can do everything
an emergency room can, only we do it sooner. If we can’t help the patient, they won’t survive.”
While AO’s were trained to present themselves as confident professionals to reassure anxious
patients and relatives, they were also able to listen closely to the patient and any others present to
understand the circumstances of the patients difficulty in order to improve their diagnosis. Often,
prior to any treatment, the AO would carefully explain what they were going to do and its
consequences. For example, if an AO was attaching a saline drip she would state why she was
doing this (“With your blood pressure a little low, you need some fluids and we are just going to
give you some.”) She would describe what to expect and the consequences of her actions. (“I
need to inject this needle. It will hurt but only for a moment. By giving you fluids, it will help
your blood pressure and you won’t feel so dizzy.”)
By 1997, SAAS had evolved a customer service orientation. Its definition of success went
beyond the survival rate of its patient to include thoughtful treatment of relatives, effective
relations with hospital medical staff, and considerate patient care. In terms of emergency
services, the aim was to have “a patient ready for ongoing treatment delivered in the best
possible condition with accurate information about the patient’s health”. Exhibit 5 shows the
cause and effect chart leading to having a patient ready for ongoing treatment.
The Evolution of Team Management
A key component of the strategy articulated for SAAS was an empowered workforce. Pickering
changed the structure of the organization as one of his first and one of his most dramatic moves.
The transition to team management was sudden and the organization was not fully prepared. As
one manager put it, “the catchword was empowerment. We didn’t know what it meant but we
told everyone.”
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Table 2: Key Performance Indicators and Success Measures
Key Performance Indicator
Measurement
Method of Measurement
Patient Ready for Ongoing
treatment
-Patient condition on
delivery
-monthly sample of cases
by peer audit and hospital
feedback
Cost Cost Relative to Best
Practice
-monthly figures from
each department
Revenue Revenue -monthly revenue
Preparedness for Disasters Preparedness for Disasters -rolling 3 monthly survey
to rate staff knowledge of
roles and availability of
equipment and supplies
Ian Pickering articulated the reasons for team management in an address to a community group.
(See Exhibit 6 for a summary of the speech.) One enthusiastic supporter stated, “ Team is the
only way I will survive. One peer of mine is looking so old. He does things I just won’t. For
example, he drove hundreds of miles just to discipline a person, to tell them off. My aim is to be
- 6 -
operate two ambulance teams 24 hours per day, seven days per week, including as well, time off
for vacation, illness, training and other absences. Because of the shift schedule it was very
difficult for Metro teams to meet. As one AO put it, "We suffer from a tyranny of roster that
prevents us from really forming and acting as a team." (See exhibit 7 for an example roster
rotation.)
Country AO's on the other hand had considerable time together. Calls were not as frequent. As
one manager described it, “if someone wants to study and learn, then they should come to the
country as there is lots of time if you use it. I got books and a laptop and began to improve
myself.”
Other teams decided to choose their team leaders by voting. It became a popularity contest. One
team dismissed their team leader because “they didn’t like him”. In this case, the union played a
significant role in reconciliation. They asked the team how they would feel if management
dismissed one of them because they didn’t like that person. In this case, the TL did resign – he
felt he could not be effective without the support of the team. But the union intervention was
critical in increasing the employee’s understanding of the responsibilities that went with
empowerment.
Bernie Morellini, the Staff Development Officer, held workshops on the concepts of
empowerment and quality management. In these two-day workshops, teams developed vision
and mission statements and began identifying key objectives for their team. (See Exhibit 8 for an
example team vision-mission-values statement.) While these seminars were greeted with
enthusiasm, AO’s often left them uncertain about exactly how to translate these ideas into their
operations. Who had what authority remained unclear.
Progress Toward Self Management across SAAS Teams
The progress toward self-management varied considerably across teams. Summaries of
interviews with three teams are given below.
Team Hodgson
5
,
Team Hodgson declared that “the team is us”.
In the first year our team had some personnel problems. The Team Leader was a nice guy
but he didn’t seem to be working for the team. He expected us to come up with concepts
and when we did he would say “that’s a silly idea”. Or when we brainstormed, he would
say “That’s not going to work!” There were some personal issues as well. He kept an
“I’m all right, Jack” attitude when it wasn’t. For example he would do all the
administrative work without help. He would be in here until all hours of the night
working. And even then, the paper work didn’t get done on time. He would ask our
- 8 -
The process started when we had a day session with Bernie. This got us going but we
needed another day to really put together some plans. We realized that if we want
something we have to cost it and put a proposal together. If we want a training day per
month, we have to show how it helps and how to get it done. If a member wants time off,
Team Boulder
The idea and concept is good but getting there could have been better. Two years ago
they started the team concept. We thought it was “about time” as we had hinted long ago
we shouldn’t have a boss. We were all sort of lost when teams started. We were told to
document what we did, make up the rules. So, we said “ok” and began meeting once each
week. Perhaps we needed more education to make the transition easier.
There was some attempt to educate us. Each centre sent 1 person to a course. But by the
time he got back, the message was confused. Most AO’s had been here a long time and
were confused by what was taught.
We are starting with our own mission and vision and standard operating practices. We are
starting to make our own rules. It used to be a computer would arrive and we would
wonder “why and when”. Now we talk about what need and put it in a budget. Before,
Team Crossover
We always ran as a team. The old Station Officer (SO) discussed things with us and we
had input. When the SO went away, one of the team got to see the administrative work he
did. Now we all see some of it and get a bigger picture. Now there is more input.
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At our team meetings, we solve problems. For example we had a communications
problem in the region and decided the best solution was a satellite phone (which wasn’t
budgeted for). So at the team meeting we figured out how to get support and raised $3000
of the $4200 cost.
We work on documenting our procedures. This gives us a benchmark against which we
can improve out practice. We create graphs and track our performance. Work practices
have been developed for 32 of our procedures. Other teams have asked for copies but we
have refused. If they just took ours, they wouldn’t own them. You can see on the wall our
Team Carleton
We are not sure what we are supposed to do with this team management stuff. We think
we do a good job as AO’s – our clinical performance is excellent, we think. And that’s
what our job is.
We are on the road most of the time responding so calls. That keeps us busy. I don’t
know what they expect us to do – come in on our days off to build a team with people I
never see from one week to the next? Most of the guys don’t want to do that. And how
will the Ambulance Transport Service AO’s fit in? They don’t even do the same job that
we do.
We are out there dealing with people who need our help. I find that by the time I am
finished my shift – particularly if it is a Friday night, I just want to leave this place and
- 10
-
The Role of the Team Leader
As was mentioned earlier, many team leaders were uncertain of their role. Some team leaders
became adept at talking team and empowerment language but not doing it. AO’S were used to
making decisions on the spot and continued doing so as team leader. Old autocratic habits died
hard, particularly when a station officer switched roles and became a team leader. In one team,
the station officer had been particularly dominant. That person continues that behaviour. The
team continues to look at him and ask, “Is this ok?” even though there was encouragement for
the team to take responsibility.
A more typical response was simple confusion over the team leader role. One team leader
commented, “ I had little experience and education about working in a team. And there doesn’t
seem to be any support for me when I need help. I know the vision and what we were trying to
do, but I don’t feel I have the tools to get there. I think some team leaders have no idea whether
they are doing well or not – they have nothing to refer to.”
One team leader questioned how he was to operate. “I can’t get my team together because of the
shifts we are on. How can I get team decisions? My guys want to do good AO work and they
aren’t certain how this empowerment stuff fits in. Finally, I just rented a hall and had everyone
come to a session where we talked about team issues. I just sent them (management) the bill and
said, “pay it”.”
- 11
-
This team leader was frustrated enough to summarize his feelings in a memo to AO’s in March
1996:
The honeymoon is over!! Team members feel that the Team Concept is failing –
dismally. Team members believe that the new Clinical Team Leaders are Station
Officers with a new title. The team does not believe they are empowered to make
any Team based decisions… Empowerment implies ownership. Ownership
implies responsibility. Responsibility implies that there is no one else to blame. If
the Team accepts empowerment, they also accept the responsibility.
How does my Team become empowered?
Team meetings will be held with the District Manager and Clinical Team Leader.
The purpose of these meetings is to establish what Station activities the Teams
are willing to take responsibility for. Once these areas are identified the Team and
The Work-force Empowerment Implementation Team
This cross-functional team headed by Chris Lemmer, Metro Regional Director, was created as a
result of the strategic planning sessions in 1995. Members had been chosen because of their
expertise and their interest in the project. Nine people were on the team, representatives from all
key areas of the organization (2 team leaders from operations, 2 district managers, a rep from the
training college, from the communications team, from the workshop and from administration).
Initially, the team met bi-weekly. Now with the survey being tabulated, it had been about 2
months since the last meeting. At each strategic planning review, each task force team has to
report on its progress.
The Work-force Empowerment Implementation Team stated its mission as: “We are committed
to the development of systems, processes and resources to enable work-teams to become self-
managed”.
- 12
-
Ray Main’s Dilemma
As a previous team leader, Ray had been frustrated by the apparent lack of systems and support
for the move to an empowered culture. Now he was in a position to create that support. But
where to begin? Should he work with the teams that want to evolve as a team and help them
- 13
-
List of Exhibits
1. Partial Organization Chart SAAS
2. Strategic Plan Summary 1996-2000
3. Performance Measures for SAAS
4. Financial Statements
5. Cause-Effect Chart for “Patient Ready for Ongoing Treatment
- 14
-
SA Ambulance Service
Ian Pickering
Chief Executive
Claudine Law
Executive Research
& Project Officer
Sue Smith
Executive Secretary
Roslyn Clermont
Corporate Information
Officer
Bill Monks
Corporate Services
Director
Kim Hosking
Regional Director
(Country)
Colin Frick
Marketing Director
Chris Lemmer
Regional Director
(Metro)
Dr. Hugh Grantham
Medical Director
Exhibit 1
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-
Exhibit 2
SA. Ambulance Service – Strategic Plan 1996 to 2000
Vision
We will have an empowered and accountable
workforce (that is committed to achieving the
vision).
We will ensure our selection, placement,
competencies and personal development of
staff matches the challenges facing the
organisation.
Our aim is to provide the best Ambulance
Service in the Asia Pacific region and maintain
this position into the 21
st
century.
The SA Ambulance Service is committed to the
provision of total quality clinical care and
transportation of patients.
Mission
Implementation
The implementation of our plan depends on all
of us. Implementation is being carried forward
by seven project teams.
Workforce Information Technology
Structure Commercial
Volunteers Structured Communications
Key Objectives
We will have a cost effective service.
We will effectively manage our assets –
replace, maintain, upgrade.
We will have a well informed public and staff.
We will retain and expand existing revenue
generation.
- 16
-
Exhibit 2 (cont’d)
Major Strategies
Creating an understanding and commitment to the team concept which will include processes for staff awareness and staff development.
Identifying and implementing the most appropriate structure to support and enable teams and to define relevant roles and responsibilities.
Identifying the competencies and/or educational requirements of all positions within the structure identified in the empowerment review.
In cooperation with teams, overcome obstacles that restrict the development of team performance.
Reviewing selection and promotion procedures.
Implementing a staff development plan that incorporates succession planning, performance review, management towards objectives and
encourage and supports lateral and upward relief and external exchange programs.
Creating an awareness of the state-side Ambulance Service which incorporates career and volunteer staff.
Creating an awareness of the value of volunteers to the organisation.
Linking the Country Volunteer structure to the empowerment goal as part of our workforce objective.
Ensuring that all strategic objectives apply to country volunteer systems.
Marketing the value of the SA Ambulance Service volunteers to the community in order to promote recruitment of country volunteers.
Adequately resourcing the promotion of country volunteer recruitment initiatives.
Developing an asset management policy (cognisant of the SA Government Strategic Asset Management Plan).
Recommending to Government, asset strategies that support the best interest of the Service.
Optimising the location of our assets.
Establishing internal service level agreements.
Reviewing and improving our internal communication systems.
Obtaining commitment from the Executive and the Ambulance Board to continue to fund commercially justifiable marketing initiatives.
Developing product specific marketing.
Putting in place real time Information Systems.
Obtaining government funding commitment for 5 years.
Identifying specific areas in SAAS for the responsible allocation of cost savings in a timely manner.
Advising the Minister for Emergency Services and Ambulance Board of the most commercially viable fee rates.
Putting in place Information Systems to manage revenue and reserves.
- 17
-
Exhibit 3
SA. Ambulance Service – Strategic Plan 1996 to 2000
- 18
-
Exhibit 3 (Cont’d)
- 19
-
Exhibit 4
For the Year Ended 30 June 1996
Note 1996 1995
$ ' 000 $ ' 000
REVENUE
Ambulance transport 3
24,385
24,731
Subscriptions 6,052
5,699
Government contributions 4
10,502
9,371
Other revenue 5
1,918
1,962
42,857
41,763
