Wednesday, February 26, 2014

Effects of "Obamacare" on Public Safety

Effects of "Obamacare" on Public Safety

By Alan Perry01/15/2014

The public is slowly coming to grips with the still evolving effects of the Patient Protection and Affordability Act affectionately known as “Obamacare”. There are many new provisions that the public, local and State governments are already working on that the general public has little or no knowledge of. It’s not because of any conspiracy or deception, it’s just that all of the reallocations of resources are for the most part still being worked out here in Virginia. One of the stated goals of the legislation is the improvement of patient outcomes and a reduction in overall healthcare cost which are incentivized without defining who specifically is responsible for the outcome, or who will receive the incentives. The legislation has prompted the emergence of Accountable Care Organizations (ACO’s) which can be a hospital(s), private organization or collaborative. This fundamental change in the delivery of healthcare will affect every healthcare provider, emergency services,  fire departments, nurses, physicians, clinics, hospital systems, insurance providers, and of course patients.

Beyond the known and much discussed facts and conjecture on Obamacare, most citizens are probably unaware of the pending effects on Emergency Medical Services (EMS). Regardless of the basis of the service as EMS, Fire, volunteer or paid all services will be forced to adapt to changes in the reimbursement  by Medicare/Medicaid and the likely necessity of providing additional services that do not involve taking the patient to the hospital. My concern is that further erosion of the core emergency services function within these public safety organizations will have a deleterious effect on the quality and availability of these resources when true emergencies occur. EMS in Virginia is already facing legislation which will reduce the required training for these positions under the guise of making EMT certification more obtainable, to what end? Our resources are already stretched too thin to even maintain quality training programs for those requiring continuing education to maintain their current certification.


I know most who read this will have little care for the plight of EMS services locally until they have to make that call for themselves or a loved one. I hope that if you have read this far you will look into what is going on with your local EMS system and voice your concerns at the State and Local level to keep it a viable and effective emergency service. Is your service using modern methods, evidence based practices and providing its staff with the best training possible? How will they sustain these practices in face of the changes facing them now?

Think about it,

Alan

Friday, February 21, 2014

ALS Precepting Program

EMS Preceptor Program

by Alan Perry
10/02/2006

I. Program purpose:

       Emergency Medical Service is a demanding profession requiring extensive study and training to obtain the required knowledge and skills needed to successfully treat a wide variety of illnesses and injuries in the field safely and competently. The most dynamic part of the training process is the clinical phase where all of the knowledge gained is put into practice in real situations with real patients. The need exists for a structured program within this department to properly and consistently provide training to EMS providers during field clinicals required for certification and as required to enable them to function as AIC within this Fire Department. The purpose of this program is to provide a clear and consistent method for implementing this program, making all aspects of it clear to all parties involved. The primary participants in the program will be new EMS providers (Interns) and Veteran EMS providers who are qualified and trained specifically for the task of supervising and training these new providers (Preceptors). Preceptors and Interns will work together to obtain the required field training objectives, which will result in State certification and release of the Intern as a well trained and competent EMS provider who can function independently as an AIC.

II. Goals and Objectives:

     The goal of this program is to develop within the Fire Department an effective and consistent program which will produce functional and competent EMS providers, and meet state and regional requirements. This will be accomplished by the selection of a core group of providers with the demonstrated skills, knowledge, and experience desired for the task of Precepting EMS Interns. These candidates will receive additional training in the administrative and instructional requirements associated with the program, and further qualify them as EMS Preceptors. As new EMS providers are trained and enter the clinical and field phases of their education and certification process, they shall be assigned a Preceptor. It shall be the responsibility of the Preceptor to observe, coach and educate the Intern as needed so that he/she can function confidently and competently as an AIC.


            Overview of process:

1.      Develop core group of ALS/BLS providers with desired personal, professional and technical skills to act as Preceptors.
2.      Train selected providers in requirements and expectations of field clinical program.
3.      Assign Intern a primary Preceptor upon entering clinical phase of training
4.      Preceptor reviews materials, requirements, and expectations with Intern
5.      Preceptor observes, coaches, and educates Intern in EMS  and Operational skills
6.      Intern acts upon direction of Preceptor by reviewing materials and skills as needed for successful completion of program
7.      Preceptor reviews operational issues with Intern; equipment, maps, hospital locations, chain of command, etc.
8.      Preceptor completes objective evaluation of Interns technical skills, knowledge, and 12 core behavioral competence areas for each shift.
9.      Preceptor completes monthly evaluation of Intern’s progress, reviews evaluation with Intern, makes suggestions for improvement and facilitates same as needed.
10.  Preceptor acts upon any weaknesses or deficiencies of the Intern and provides, or arranges for, intern remediation to include involvement of FMO if required.
11.  Upon satisfaction of field internship requirements, Preceptor completes final evaluation and forwards to FMO/FTS


III. Roles, Responsibilities and Definitions of program participants:

  1. Definitions:

1.      Preceptor:
a.       Veteran EMS provider currently functioning at or above level of Intern being precepted with at least three years field experience.
b.      Desires to keep learning, seeks out new training opportunities, and continually seeks to improve skills and knowledge base.
c.       Recommended by FMO with approval of Battalion Chief and EMS Chief.
d.      Fire or EMS instructor credentials.
e.       Supervisory experience or training.
f.        Has completed Department Preceptor program.

2.      Intern:
a.       New or advancing EMS provider currently enrolled in a state approved EMS course requiring clinical evaluations.
b.      Completed approved OSHA course.
c.       Current CPR certification.
d.      If advancing, currently valid Virginia EMS certification.


  1. Roles & Responsibilities:

1.      Preceptor:
a.       Provide a positive learning environment with clear and obtainable objectives.
b.      Responsible for patient care
c.       Require the Intern to take control of patient and incident to the greatest extent possible commensurate with the knowledge and skills of the Intern.
d.       Fairly and objectively evaluate the Interns performance with feedback given following each contact, each shift, and monthly.
e.       Provide guidance, instruction and coaching as needed to facilitate Intern’s success.
f.        Demonstrate superior patient care, leadership and scene management, thereby teaching by example.
g.       Adhere to The Fire Dept. policy & protocol.
h.       Adhere to TEMS protocol.
i.         Complete all required written evaluations and paperwork associated with clinicals, review with intern, and submit completed forms to appropriate individual coordinating clinicals.
j.        Provide additional training opportunities as required to remediate or reinforce skills and knowledge of Intern to include scenarios and practical evolutions.

2.      Intern:
a.       Maintain a positive attitude and be willing to learn and adapt to any situation presented.
b.      Be prepared, study course materials, protocols, SOP’s, and any other material related to the job, or recommended by your Preceptor.
c.       Take charge of patient care and maintain scene control to the fullest extent of your abilities and level of training or certification, communicate with preceptor if the situation is beyond your abilities or comfort level.
d.      Maintain a professional demeanor, follow instructions of preceptor, other released providers and Officers.
e.       Adhere to EMS and Fire dept. protocols and policies at all times.
f.        Complete required paperwork and make records available to your Preceptor as needed

g.       Verbalize concerns, needs, questions



Preceptor Development Process

I. Process description:

       The Fire Department Preceptor development Process will address a long standing and recognized need by the department to properly train a core set of EMS providers for the specific task of precepting EMS Interns within this Department. The first step in this process is recognition of a problem; that problem is inconsistency and lack of education and understanding by the EMS providers on our apparatus about the requirements and objectives of the clinical phase of EMS education, It is also the mismatching of Providers and Interns; frequently Interns are paired with excellent Providers who are not trained to, or do not have the inclination or personality to teach and mentor. The second step is identification and training of qualified and motivated EMS providers with superior skills, knowledge, and experience. The final step would be the formalization and implementation of the program with periodic review and feedback for each Preceptor. With this program in place a more consistent, reliable, and practical method will be available for EMS Interns and Preceptors.

II. Selection Process

       The responsibility of the EMS preceptor is great; it will require the utmost attention to patient care and scene control given the added responsibility of monitoring the actions and safety of an EMS Intern. The task requires an individual with superior technical skill, leadership, knowledge, and experience to adequately teach by example. One must possess the gift of teaching and the ability to work with a wide variety of personality types and recognize which learning style will work best with each Intern. With this in mind some minimum requirements must be present; however it will be the responsibility of the Field Medical Officer to make the recommendation that a provider be placed in the role of Preceptor. The FMO has the most insight as to the providers technical abilities, knowledge and interpersonal style, and in conjunction with the approval of the provider’s Battalion Chief and Chief Medical officer, will make the recommendation that the individual be placed in this role.

Individuals seeking this appointment should be prepared for the additional responsibility and scheduling difficulties that will be required of them, They may be required to spend additional hours on Medic units to facilitate the training of their Interns, and may be required to ride on Medics/shifts other than their own.


Minimum Requirements:
  1. Currently certified by the state of Virginia at or above level being precepted
  2. Minimum three years experience (Senior Paramedic)
  3. Fire or EMS instructor certification
  4. Superior Knowledge, Technical, and interpersonal skills.
  5. Supervisory experience or training

III. Training:

          Once selected, the provider will be given a hard copy of the The Fire Department Preceptor Manual, and a training date will be selected. Training will consist of a review of the expectations and responsibilities’ of the preceptor, familiarization with all associated forms, a practical workshop with a mock Intern, State, Regional, and Local Regulations, Standard Operating procedures, and Policies. If necessary this training can be performed at the monthly preceptor’s meeting. All preceptors will receive periodic evaluations based on Interns and FMO feedback. If additional training or review is required it must be done to the satisfaction of the Providers FMO prior to being assigned any additional Interns.

Core Training Topics:
  1. The Fire Dept. Preceptor Manual
  2. The Fire Dept. Policies & SOP’s
  3. Regional Clinical & Field requirements
  4. Forms and Documents
  5. Conflict resolution
  6. Adult education

IV. Implementation:
        After training has been completed the Preceptor will be assigned an Intern. Every effort will be made to assure that the Intern and Preceptor will be assigned to the same Medic/Shift, this may require that the preceptor be assigned several medic shifts in succession, be assigned to a Medic/Shift other than their own, or split their shift. The ultimate goal is that the Intern be permitted to develop and practice their skills in a consistent, predictable environment that mirrors the expectations placed on them in the field as an AIC. Upon successful completion of internship, Preceptor will meet with FMO and present recommendation that their Intern be given AIC status with documentation supporting their recommendation.


V. Re-assignment

        It is expected that not all personality types will be compatible in the learning environment, and other situations may present themselves that require reassignment of the Preceptor and Intern. If any unresolved conflict arises such as schedule conflicts, illness, injury, failure to progress, etc. The Intern or Preceptor may be reassigned after meeting with their FMO and attempting to resolve the issue. In all cases it will be the responsibility of the Preceptor to pass on all pertinent information and paperwork to the Interns new Preceptor or the FMO whichever is appropriate.

Saturday, February 15, 2014

Flexible Facts

Flexible Facts, it’s in the data
By Alan Perry
February 15, 2014

Data has become increasingly more important both in the practice of Fire & EMS as well as the management of these vital public safety institutions. Data should never be subjective, yet frequently the way in which it is vetted, gathered, analyzed and used is just that, and in some cases downright deceitful. It is incumbent on anyone trying to make a good decision based on data to do their homework; making certain that the data is accurate, relevant and free from bias and other influences that may corrupt it. Good decisions also require the good judgment of the evaluator and his/her ability to recognize their own biases in the process. It is not uncommon for poor or incomplete data to be used and/or manipulated to make some predetermined point. Don’t let the numbers fool you, especially if you know an agenda already exist, the numbers don’t always tell the whole story and at best are only a small part of the information needed to make a good objective decision.

If I were a Fire Chief trying to justify the number of engine companies in light of declining call volumes I might simply move my ALS personnel to the engines, requiring the engine companies to respond to more EMS calls and increase their call volumes. If that resulting statistic is looked at by itself the point will have been made, however looking at the total circumstance I might discover that it was a simple card trick. This also compounds the problem because of the additional expense involved with running full engine companies on EMS calls that they are not needed on and takes resources away from the agency that could be applied elsewhere in the taxpayer’s interest.

An EMS Chief can play this game too; when faced with the possibility of losing a medic company he/she might “voluntarily” take the busiest medic company out of service, the resulting increase in response times across the whole system could be used to suggest that losing that company has produced catastrophic results and that staffing must be restored if not increased. By looking only at the response times as an indicator of system staffing needs one could be misled by the data. Playing games with people’s lives is a certain way to lose credibility and the confidence of the public.

An EMS system with poor data discipline might deduce from data acquired with poor documentation practices that its mid-level EMS providers are not performing their skills and recommend doing away with that skill level to save the department money on their training and recertification. Looking a little deeper one would discover that these providers are the backbone of the organization extending their skills on both BLS & ALS calls. The source of the data error is that only one provider writes the report and frequently does not give other providers credit for those skills because it is simply too difficult to keep track of them in the reporting system. It is likely this reporting error was known and the data simply used as an excuse to reduce training expenses at a time when expanding EMS education is even more necessary.

Data always deserves investigation; know its source, its accuracy and the bias of the parties involved. Do not view it in isolation; if it seems questionable assume there might be a problem with it and look for the flaw(s). Do not build research around data and do not build data around research, if you focus your efforts on a specific outcome you will probably find it while excluding the important facts. Data should be viewed in a scientific light, in science things must be proven and able to be duplicated before they are considered fact. The same standard should apply to data, for data to be sound it should be free of defect and produce the same results consistently without external manipulation. If your data cannot hold up to this standard it should not be used, especially when the lives and careers of others are at stake.

Be Diligent,

Alan