Tuesday, March 10, 2015

Debilitating Decision Delays

Deliberating Decision Delays
The performance pitfall perils of procrastinating for proof
By Alan Perry
3/8/15



In the era of evidence based best practices for the EMS and Fire services, we are beginning to accept that this ideal as the norm rather than the exception. Those holding the purse strings and writing policy are more often compelled to act based on evidence and proof of value before allocating resources. This is of course the most responsible and practical thing to do, but should this rule be applied to every decision we make? Is there still value in making decisions based on reasonable expectations? Does every project have to have some specific, measurable and obtainable outcome to have merit? If we are bound by this dictum we would all be hemmed up in a hopeless feedback loop of indecision every time we tried to do something new and unproven for which no “proof” exists. Someone actually has to do something before any proof or positive results can be found, and occasionally the outcome is not what we expect even if it is a positive one.

A perfect example is public education; fire prevention programs have a proven and documented history of success as declining fire events and related injuries can attest. Why then, do we have to prove that an injury/illness prevention program will work and establish a set of metrics to analyze it? The benefits of education and prevention programs go far beyond reducing injuries and illness, although those would be primary goals. The benefits generally translate into greater public support, better reactions to emergencies and participation in community health and safety, things that can be difficult to measure but can have a profound impact on the community’s resistance to emergencies of all types.

The same logic can be applied to integrating healthcare services and incorporating EMS systems into the patient care continuum. Start where you stand, do not be blinded by the wide array of possibilities. I assure you, that while you are doing your research and developing evaluation methods to measure your success, someone will be acting. EMS is not alone in this arena, hospitals, public health, health care systems and insurers are all looking for ways to improve their bottom lines while improving the quality of care for patients as mandated by the Affordable Care Act. Most traditional Fire and EMS systems are ill prepared to step into this fast paced arena using old management philosophies and insufficient resources compared to the other players.

In areas where diversity in delivery models is significant, consensus is the enemy. I’m not saying cooperation isn’t desirable or even preferred, I’m merely pointing out that while trying to mesh too many disparities it will be difficult if not impossible to reach a decision that will enable all parties to benefit and maximize the use of the resources they have. I have seen such attempts last for months if not years with no tangible results or even progress. Sometimes you have to take the tools you have, the resources you have, and use them to start pushing the ball forward.

The word I’m looking for is responsibility; as public safety professionals we have a responsibility to the citizen taxpayers to provide responsive and caring service, keep up with the state of EMS & Fire sciences, adopt and develop the most effective care and delivery practices, dedicate sufficient and appropriate resources to training and equiping our providers, and act with purpose when we know our system needs work. We can ill afford to attend another unproductive meeting or continue to conduct business as usual when that is not producing the change our services desperately need.

We have known for several years that routine back-boarding of patients is of no benefit, and can actually be harmful, why do we still do it? Narcan, in the hands of a first responders or bystanders saves lives, why don’t we permit it? Fire and EMS personnel are injured every week in vehicle accidents even though the evidence indicates priority responses have no proven relationship to patient outcomes, why do we run two, three or four vehicles lights and sirens to any EMS call? We know integration of healthcare and EMS benefits patients and the EMS systems involved, why have we not yet acted? These are just some examples of best practices that are delayed by our traditional decision making process. It is broken, it may be time to re-evaluate our command structures and seek a leaner more responsive model that is made possible by using modern communication tools.

As a test, try asking one of those questions of the person next in your chain of command. If you have a responsive and nimble organization that person should be able to answer the question directly and have the ability to effect an immediate change if needed. If you do not have a responsive nimble organization you will have to wait for an answer from the ivory tower, if you ever get a reply at all, it will likely not result in any change or further discussion of the matter. You can’t hold an individual responsible for that type of problem, it is cultural in nature, it is no wonder that when leaders of such organizations gather to address the need for change and new challenges facing them, they are hopelessly mired in the apparatus of consensus and “chain of command” decision making.

I don’t like putting stuff like this out there without trying to point us in the right direction for solving it, so here it goes;
·                       - Flatten the command structure.
·                        - Use the freed-up resources to allocate sufficient personnel to training and organization                          development.
·                        -Spread out authority and accountability for decision making.
·                        - Don’t be afraid to do the right thing.
·                         -Do it now

The Heart of High-Performance EMS

The Heart of High Performance EMS

By Alan Perry
3/10/2015

What makes a High Performance EMS system work? It’s not just the mechanics of the operations and program development, but also its culture –the people and attitudes that make it work. It is not new and innovative practices, advances in the field of mobile healthcare, a charismatic Chief Officer or a dedicated OMD. These are influential, however I doubt any system could effectively support that type of change and progression without the firm foundation of a strong and supportive organizational culture. If you examine the most proactive, progressive and respected organizations providing EMS in the nation; such as MedStar in Fort Worth, Texas, or The Richmond Ambulance Authority in Richmond, Virginia, you notice something very special right away. No one sitting in easy chairs watching TV, No sloppy facilities, everyone embraces, and can articulate the mission, goals and achievements of the organization, what is this? It is pride, empowerment and accountability, all things born out of a positive organizational climate. This is the foundation these organizations build upon to be leaders and innovators in Emergency Medical Services.


This is not an idea that can be mandated as a performance criteria on an evaluation, it must be supported throughout the organization by effective leadership, administration, training, logistical support, public relations, public education, medical direction and healthy relationships with allied professions in hospitals, public health and nursing. Several of the most effective systems sprang from collapse of failed delivery models, taking the opportunity to rebuild the EMS delivery system from the ground up to be focused on performance and delivery of quality care. Common features include an organization focused solely on delivery of EMS services and related health and public education programs, Dedicated dispatching facilities, training facilities on par with a good community college, a full-time OMD(s), In-house vehicle maintenance, supplies and logistical support, use of system status management and call prediction software, and a nearly flat organizational structure with liberal and frequent lateral communication. Such a design promotes rapid response to any threats or opportunities that present themselves, allowing the organization to be nimble and proactive in meeting the needs of the public and its providers.

These organizations value efficiency as their responsibility to patients and the general public. Efficiency improves patient care as much as it makes effective use of public funds, if they are used at all. Every aspect of EMS system design and delivery has been carefully thought through and implemented to maximize utilization, reduce waste, and maximize the use of precious resources. Providers are supported with adequate training, field support, and career progression. There is accountability and questions/problems are solved or addressed quickly. The cost of providing this type of service to traditional, Fire-based EMS or EMS-based Fire systems is not a monetary one; it may be the dismantling of existing command and management structures, and drastic changes to the organizational culture. This is the future of EMS, high-performance EMS is here to stay and is what the public and providers deserve.

Be Safe, AP

MedStar 911

Richmond Ambulance Authority

Wake County EMS

King County Medic One

Tuesday, March 3, 2015

My Visit to MedStar -The Phoenix in Fort Worth

The Phoenix in Fort Worth

What MedStar can teach us all.

By Alan Perry
3/1/2015


I chose to visit MedStar Emergency Medical services to examine what makes their system work, not just the mechanics of operations and program development, but also its culture –the people and attitudes that make it work. Some would suppose that I should be more interested in their high-performance EMS system or their advances in the field of mobile healthcare. These are compelling interest as well; however I doubt they would exist without a firm foundation.

My first impression came through a brief examination of their website and an email I sent to Matt Zavadsky, Public Affairs Director. I introduced myself and explained that I intended to visit their operations as part of another trip I was making to Dallas. I also requested some detailed information about their operations and how he thought a Fire-based EMS system might best proceed, as well as several other questions relevant to my regions unique EMS structure. I was pleasantly surprised to receive a reply within a day with detailed and unguarded answers to my questions. His very candid responses reinforced several things I already suspected and cleared up some misconceptions. This entire exchange set me off with high expectations.

MedStar EMS has a story that began with struggle, the Area Metropolitan Ambulance Authority was established in 1986, and was responsible for contracting ambulance services with vendors while maintaining infrastructure and communications assets. In 2005 after multiple months of poor performance from vendors, the authority cancelled the contracts and took on the responsibility of the daily operations. The rest is history; they took the opportunity to rise from the ashes, apply best practices for EMS delivery, refining and developing their system into the high-performance system that it is today -an ongoing process.

To make my visit official, I scheduled a ride-out with an EMS supervisor rather than an ambulance crew or the administrative tour, hoping to get into the nuts and bolts of the operation and have time to discuss the daily operations with mid-management. The MedStar facility is an impressive sight to behold, the afternoon I arrived was sunny and 60 with a light breeze, their beautiful facility on the top of a hill with the sun reflecting on the glass backlit the flagpoles on the front walkway.  I believe a figure of twelve million was mentioned in later discussion for the approximately 85,000 square foot facility. This facility houses the administrative offices, a training facility on par with a good community college, a state-of-the art dispatch center, an apparatus repair and maintenance shop, logistics & supply, break rooms, a quiet room, library, and a soon-to-be employee clinic. The facility also houses their supply vendor in a leased space. It’s hard to believe that this type of facility and operations require no taxpayer support. That’s high-performance the public can appreciate.

After a visitor pass was issued, I was escorted to the offices of the Shift Supervisors in the middle of the building, with the offices of the MIH medics and related support personnel. I rode with Brian White, a senior medic who worked his way up through the organization; he is well acquainted with the history and operations of the organization. In his position he manages scheduling of crews, filling holes, shepherding crews through their tours and responding to significant calls requiring additional personnel or equipment. I soon found that the location in the middle of the building was no accident and was representative of the organizations structure. The structure is nearly flat with frequent and liberal lateral communication; this seems to be what makes the organization so nimble at addressing new challenges and achieving such high efficiency. As Mr. White took me through the facility and introduced me to various staff members it became apparent the he was not the only one knowledgeable about the organization, everyone he introduced me to was eager to tell me about what they do and how the organization functions, the enthusiasm was truly contagious.

The administrative space houses the director’s offices, the billing staff, business development and the OMD’s offices in a very roomy and classy environment with lots of light and windows. The dispatch center is located in a separate space with multiple dispatch consoles, using Pro QA for medical call screening. Units are deployed using system status management and call prediction software that anticipates calls based on historical data. The number of units staffed is based on historical call volume and ranges from 22 units at night to 44+ during the day. Shifts are typically 12 hours with employees self-scheduling using E-pro net scheduler. Discipline is managed using the “just culture” model for serious events.

Logistics are housed on the ground floor and include supply and maintenance areas. A complete repair facility with full time technicians manages the repair and maintenance of the vehicles. A rigorous preventive maintenance program is in place that keeps the units productive and reduces maintenance cost through failure avoidance. A bin stocking system is used to uniformly stock each ambulance; the bins are inventoried, refilled and replaced at the end of every shift. A logistics vehicle is staffed to resupply units at the hospitals; it carries EMS supplies, oxygen, spare batteries and vehicle maintenance items. The supply room keeps two days of stock on hand; items are reordered and delivered via conveyor from the vendor housed on the second floor. As units return from their tours they are cleaned, washed and restocked by the logistics staff and placed back on the ready line. Units are garaged indoors when not in use.

Training facilities and training staff offices are in their own space away from operations, logistics and administration spaces. The spaces are comfortable and flexible for various types of instructional methods and classroom configurations. The AV equipment, computers, software and simulation aids are current or new reflecting the best technology available –on par with a good community college. The organization offers continuing education for providers in a classroom setting, certification programs for EMT through paramedic and MIH, and has its own AV production unit.  The training unit provides training to administrative and support staff as well.

It appears that efficiency is valued by the organization as its responsibility to its patients and the general public. Efficiency improves patient care as much as it makes effective use of public funds. Every aspect of EMS system design and delivery has been carefully thought through and implemented to maximize utilization, reduce waste, and maximize the use of precious resources. The cost of providing this type of service to traditional or Fire-based EMS systems is not a monetary one; it may be the dismantling of existing command and management structures, and drastic changes to the organizational culture. This is the future of EMS, high-performance EMS is here to stay and is what the public deserves from both a quality of care perspective as well as fiscal responsibility. I thank all the staff at MedStar for taking time to hear my questions, for caring and having the commitment to move the profession of EMS so far forward. Great job MedStar!


AP