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

http://www.medstar911.org/

Richmond Ambulance Authority

http://www.raaems.org/

Wake County EMS

http://www.wakegov.com/ems/Pages/default.aspx

King County Medic One

http://www.kingcounty.gov/healthservices/health/ems/MedicOne.aspx

Hidden Fire

Hidden Fire

Unseen threats to Emergency Services

By Alan Perry

February 11, 2015

Many a life and countless millions in losses can be attributed to the effects of hidden fire. These fires spread undetected, concealed in walls, floors and utility chases, destroying the structure and spreading to remote locations with catastrophic consequences. It is a threat every firefighter should know well and aggressively seek to identify, locate and extinguish before declaring a fire under control. This principal is an easy one to understand but also easy to overlook in the heat of battle. Many emergency services have similar threats to their ability to achieve their primary purpose and mission due to hidden threats within and outside the organization. Many appear well on the outside only to collapse under pressure when the underlying structure fails due to these “hidden fires”.

 The structural integrity of your organization can be compromised by inadequate training, poor morale, lack of public or political support, overextended resources, poor communication or any number of other threats and weaknesses you can name. The critical needs of the organization can be overlooked while distracted by ancillary programs, new services and trying to keep up with new trends. Some organizations seek out new responsibilities, programs and stature, enticed by State or Federal funding, setting up new services at the expense of those critical needs. I will argue that emergency services should do more to prepare for large scale events, integrate with more effective healthcare or cultivate needed specialized resources. These are all part of the public expectation and our mission just as the core services we provide are, there must be a balance between these “nice to haves” versus the “must haves”.

Identifying the threat or existence of the hidden damage is not difficult if you are in-tune with your organization. Objective quality control monitoring of your resources, human and physical, will give you the best and quantifiable evidence. Structural collapse rarely occurs without giving some evidence or clues to a developing problem, that’s why we sound floors and look for smoke and heat where it should not be. Similarly, problems within your organization will reveal themselves if we use common management tools to evaluate failures in our equipment, processes and personnel. Long standing problems will compound and accelerate the damage, like a hidden fire in a structure already weakened by termites.

To locate the source of this insidious damage we have to look at data, ask questions, and sincerely want to improve the situation without fear, or presumption, of what will be found. How effective are your firefighting operations? How reliable is your apparatus? How frequently do your providers deviate from operational or EMS protocols and SOP’s? Are there training issues? Funding issues? Do your personnel have the right tools and resources? Do they function well as a team? Are all concerns heard without reproach? These questions may reveal the symptoms; the cause may be well removed and must be located before it can be corrected and the damage stopped.

Stopping the destruction will require correction of the identified fault. It may also involve correcting other faults propagated elsewhere secondary to the origin. As with hidden fires, there will likely be extension to other parts of your organization. Your organizational culture can help you manage these shortcomings, or it may be decayed and damaged by the process itself. As with structures that are hopelessly corrupted by fire, the only solution may be demolishing it and rebuilding.  That would be an extreme outcome that will permanently alter the persona of the organization, but it would certainly give it the opportunity to rebuild the organization as it should be and on a solid foundation. An alternative that may be more appealing would be targeted restoration of affected components, like remodeling a kitchen, retaining the existing structure while upgrading the area in need, taking care to carefully examine other parts of the organization for weakness. So what kind of "house" do you want to inhabit? One with a solid structure, but perhaps without the fancy kitchen and showers, or a showplace that has cracked walls and creaking floors. Choose wisely.

Be Safe,

Alan

There's No Time

Don’t Re-invent Community Paramedicine, There’s no time!

By Alan Perry

September 25, 2013

It baffles me that the issues of community paramedicine, integrated healthcare and implementation of the EMS agenda for the future are still not resolved. Here we are, less than 30 days from major portions of the Patient Protection and Affordable Care Act (PPACA) being implemented, with most agencies having no clue how they will be affected and how/if they are going to make any changes. We have got to start thinking outside the box (pun intended). As we gather to meet and discuss these eventualities we need to stop trying to re-invent the whole process every time. There is a large body of work already completed working programs in place by nearly every variety of EMS system and free money to make it all happen. Duplication of effort is never a good idea, we must learn quickly to take the good work already done and apply it to what we are doing, or need to be doing.

Here’s the problem, the PPACA does not specify how medical care will be provided it only specifies the desired outcome and the penalties for not achieving the “triple aim”. So everyone involved in the process, especially those with the most to gain or lose, are moving aggressively to develop programs with little consideration on the effect on EMS services. The EMS community apparently does not feel threatened by this, much like our apathy about the recommendations of the EMS agenda for the future we think we have all the time in the world and that our federal or state officials will tell us how to proceed. I can tell you now that the Federal and State officials tasked with oversight of EMS don’t have a plan. The hour is growing very short; we are approaching a point where we will have to transition from being proactive to being reactive.

The best publication I have found so far is from the National Consensus Conference on Community Paramedicine, the meeting in October of 2012 produced an excellent summary of how a program should work that can be easily tailored and implemented incrementally by any EMS service. I am aware that the National EMS Advisory Council (NEMSAC), State offices of EMS, Local EMS councils and individuals are also working on their own plans, expending great amounts of time and effort to go through the same process already completed by acknowledged experts. Why? I suspect part of the problem is that it is not a priority. EMS still takes a back seat to other emergency services in many locales. Those tasked with this project may not have funding, and although grants may be available it may not be a priority for the senior administration.

Any program of this type must go through some necessary developmental steps that don’t necessarily need to occur in a chronological order. While you are obtaining the data to quantify the problem you can also be developing a general selection and training program for your providers, having dialog with the other stakeholders and creating your grant requests, and building the infrastructure to support it. This is possible because of the large body of work already completed and some known variables for your program. We must be seen by our healthcare partners, the public and policy makers to be taking positive steps to move our systems forward toward improving outcomes, reducing costs and improving the overall healthcare experience.

Acknowledge the quality of the work already done, use it, build upon it, and modify it. Build upon this foundation of what will be a new way of doing business, embracing the goals of the EMS agenda for the future and the PPACA. They are defining what we do and what the public needs and expects from us.

References:

Patterson DG, Skillman SM. National Consensus Conference on Community Paramedicine: Summary of a Expert Meeting. Seattle, WA: WWAMI Rural Health Research Center, University of Washington; Feb 2013.

DOT, HHS. Innovation Opportunities for Emergency Medical Services: A Draft White Paper. NEMSAC, July 2013.

Goodwin J, Finding a New Seat at the Healthcare Table, Best Pactices in Emergency Medical Services, Vol. 16, No. 7, July 2013