I have seen several great EMS organizations over the course of my career. These organizations were focused on medicine and had both medics who had great attitudes and physicians and EMS managers who were dynamic and respected. When I was new to EMS in the early 1980s, I heard legendary stories of the great medicine at Denver General, Seattle Medic One and Ada Country EMS in Boise, Idaho. These agencies had peer groups that insisted on quality and had strong physician medical directors. Those types of legendary EMS agencies are becoming harder and harder to find.

Mike Taigman, a respected colleague, longtime EMS provider and quality-improvement expert, used to say, “You're either getting better or getting worse; there is no equilibrium in EMS.” There is danger in resting on laurels, and the lack of desire to compete or strive to be the best is propagating more apathetic firefighter/paramedics and bringing more scrutiny on fire-based EMS.

Chiefs around the country are frustrated by the amount of energy it takes to excite people to embrace public service. This problem stems, in part, because some members want to be firefighters but not EMS providers. Potential recruits are going to paramedic school only to get themselves hired by a fire department. Two years later they are grumpy and burned out, claiming they are trapped in the indentured servitude of pay differentials and overtime.

Many new hires don't have an appreciation for how far fire-based EMS has come. Have these once can-do and community-first departments done a bad job at teaching history, failed at mentorship, or water-downed training and accountability to the point that expectations for quality care and public service are at an all-time low?

A young mind, hip to technology and out-numbered by more traditional thoughts in a new station or with a new crew, will become what the leadership allows. People will conform to decrease unpleasantness and look for social acceptance. Soon the sense of entitlement trumps the sense of duty, eventually eroding the quality of patient care.

The responsibility for spreading a positive attitude toward excellent fire-based EMS and patient care rests with the company officer. Company officers are the most important and influential people in the fire service, responsible for setting the tone and maintaining the level of care delivered from their stations and from the people they supervise. If a captain disrespects patients by using derogatory terms, the crew and the paramedics will depersonalize patients and spread that belief.

Bystanders often know who is in charge when a company officer is present. Paramedics' performances reflect the motivation, additional study and accountability provided by that company officer. Company officers who make their paramedics educate other team members, call back on patients, or seek outside EMS training send the correct message.

The movie The Guardian illustrates what fire-based EMS needs from new members. It's easy to identify the characters' roles, attitudes and behaviors, particularly the cocky new trainee played by Ashton Kutcher and the seasoned trainer played by Kevin Costner. But as viewers watch Kutcher's character develop, it's also easy to see the mentality and techniques necessary to inspire dedicated public service. Everyone knows someone who they wish would get the message or travel a certain path, and Costner and Kutcher's on-screen relationship provides a powerful look at good mentoring.

The first step in Kutcher's character's development comes when he allows one of his team members to fail in an endurance exercise. How many times do people make mistakes and no one speaks up, only to hear in the investigation they didn't speak up because it wasn't their problem or it wasn't their patient? Later that same trainee helps another member get past a critical exercise. By the end of the movie, Costner's instructor filters out those who showed they did not need to be there.

Fire-based EMS organizations need to recognize that if it takes tremendous effort to get someone over the hurdle of rookie school or EMT class, he or she might not need to be there. Can the organization afford to put the energy into such a recruit for the next 20 years? Will his or her continued presence result in litigation or a persistent bad attitude that poisons the well? Often fire and EMS chiefs don't measure or filter out the bad attitudes during the rookie or internship period.

Fire-based EMS leaders must paint a vision of service excellence, and that vision should include some competition — among internal teams, station to station, shift to shift, or battalion to battalion. A department could conduct an internal competition on vehicle extrication and promote the winning team to an external competition at the state or national level. There are several EMS competitions around the country, and fire-based EMS participation doesn't match their proportion of the market.

For broader competition, a department also should strive for accreditation from the Committee on Accreditation of Ambulance Services or the Center for Public Safety Excellence. Having a percentage of staff accredited as chief fire or EMS officer promotes service behavior.

After CPSE accreditation, a department can go for the gold standard that competes with other industries. No fire-based EMS organization has yet attained the Malcolm Baldridge National Quality Award from the National Institute of Standards and Technology. This award goes to businesses and education, health care and nonprofit organizations judged to be outstanding in seven areas: leadership; strategic planning; customer and market focus; measurement, analysis and knowledge management; human-resource focus; process management; and results.

Those fire/EMS problem-children are like the attention-deficit disorder children in today's high schools — who incidentally will be joining rookie schools or EMT classes soon. They have been labeled problems by a system that refuses to produce a challenge, vision or model behavior to rally around. They are starved for leadership in the classroom. They want to belong and will show up just to feel like part of a team that is moving toward a championship.

Pick a goal, rally the team, let members know what is expected and give them the facts on performance, and watch the behavior fall in place. Fire chiefs need to share their vision. Most people come to fire and EMS to serve, and getting them to excel depends on being inspired by the leadership.

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Bruce Evans is the EMS chief for the North Las Vegas (Nev.) Fire Department. He also is the fire science program coordinator at the Community College of Southern Nevada and an adjunct faculty member for the National Fire Academy's EMS and injury prevention courses. He has an associate's degree in fire management and a master's degree in public administration.