James A. Romagnoli became a New York City police officer in September 1980. He came from a family of emergency services workers; the men in his family were either police officers or firefighters. After years as a patrol officer, Romagnoli was promoted in 1993 to the Police Department's Emergency Services Unit (ESU), which did urban search and rescue, and special weapons and tactics (SWAT). Romagnoli became the ESU’s Urban Search and Rescue administrative coordinator, which made him liaison to the New York City Office of Emergency Management (OEM). OEM planned for emergencies, coordinated emergency preparedness drills and exercises, and coordinated emergency response to major events to ensure that the city's emergency services functioned together. ^[11]

In the new job, Romagnoli received extensive emergency management training. He graduated from the Emergency Management Institute at the National Emergency Training Center in Emmitsburg, Maryland, which also housed the National Fire Academy. He took courses on hazardous materials, weapons of mass destruction and incident command during hurricanes. During the hurricane training, "you actually work through an approaching hurricane and the recovery phase over the course of five days," says Romagnoli. ^[12] He also volunteered as a firefighter in Nassau County on Long Island and, like many New York City police officers, worked a second job, moonlighting as a paramedic. In June 1999, North Shore-Long Island Jewish Hospitals hired Romagnoli as a paramedic on a per diem basis.

North Shore-LIJ . North Shore-LIJ was a nonprofit chain of hospitals and healthcare facilities that spanned New York City and western Long Island, headquartered in Manhasset, New York. In 2012, the system had 16 hospitals: five tertiary (meaning full-service), seven community, three specialty and one affiliate. It also included three skilled-nursing facilities, 34 affiliated nursing homes and senior-living facilities, and nearly 400 physician practices. It also included the Feinstein Institute for Medical Research and North Shore-LIJ Hofstra Medical School.

In 2011, North Shore-LIJ registered four million patient contacts, 640,065 emergency visits, 503,646 home-care visits, 133,411 ambulatory surgeries, 91,400 ambulance transports and 25,609 births. It had over 43,000 employees, including more than 10,000 nurses, 9,430 physicians and more than 1,500 medical residents and fellows. That year, North Shore-LIJ recorded more than $6.3 billion in revenue. It was the third largest nonprofit, secular healthcare system in the country.

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Romagnoli had just retired from the police force and started full-time as a paramedic at North Shore-LIJ when the terrorist attack struck New York City on September 11, 2001. "The 14 members of the NYPD Emergency Services Unit that were killed, that was my work squad," says Romagnoli.

I trained in the Trade Center. I rappelled down the Trade Center. I worked with the people that were trapped there. I think it’s fortunate for me that I did retire. I certainly would have been there. I told my bosses—I had just started working—‘Hey, listen, my friends are in that pile. I have to go.’ My boss, Michael Dowling, the CEO of the health system, said, ‘I’m going with you.’ I said, ‘You can’t go with me. This is way too dangerous.’ He goes, ‘I’m a pretty tough guy.’

After digging through the rubble of the World Trade Center for a few days, Romagnoli and North Shore-LIJ CEO Michael Dowling organized a drive at the company to collect supplies. They took several truckloads of needed materials to the workers at the 9/11 site.

In the wake of 9/11, Dowling tapped Romagnoli to form a central emergency management unit for the hospital system. Over the next five years, Romagnoli created an emergency operations center, taught crisis decision making skills to physicians and other employees, and instituted emergency management best practices developed over decades by municipal, emergency services and hospital planners. After decades of work in New York City's emergency management structure, Romagnoli made it his mission to introduce a different way of thinking in a corporate environment. "That was my challenge," he says.

The decision-making process in an emergency, explains Romagnoli, was entirely different from the usual decision-making. For most purposes, North Shore-LIJ had instituted a committee-oriented approach to decision-making because a committee was inherently safer, simply because more people were involved. Committees ensured a checks-and-balances process to matters of treatment and medical protocol. But says Romagnoli, it does not work in emergencies, "Unfortunately, time is not on our side in an emergency, so the [emergency] decision-making process has to have a more vertical structure," he notes.

In 2010, Romagnoli was appointed vice president of Protective Services at North Shore-LIJ.