Management Insights

     New leaders—and those wishing to become or remain more effective—largely have to figure things out as they go, drawing liberal helpings of wisdom and guidance from those around them who have traveled similar roads.

     There are, however, a growing number of resources dedicated to assisting them. Among these is the annual Pinnacle EMS Leadership and Management Conference, presented each year by Fitch & Associates. The 2008 show featured a variety of seminars and presentations over five days in San Diego. Three of these offerings—looking at novel ways to reduce response times, obstacles to making improvements in response times and quality, and technologies that will impact the future of healthcare delivery—receive follow-up treatments here, in hopes that their insights can benefit a wider audience. Next year's Pinnacle show will be August 3–7 in St. Petersburg, FL. For more, see www.pinnacle-ems.com.

     Many EMS providers work in systems that strive to get to calls in under nine minutes. The 8:59 response time standard, while not universal in EMS, is widely employed in urban systems and backed with the authority of NFPA standard 1710, which requires eight-minute ALS response to 90% of incidents. (The additional 59 seconds represents time for call processing.)

     The first problem with that, and with most response-time matters, is that not everyone measures things the same way. Do you start your clock from 9-1-1 pickup, from wheels rolling, or from some point in between? The NFPA excludes call-processing time from its standard, so the second problem is that if you're including it—i.e., starting the clock from call pickup—8:59 really may be leaving you just 4½ minutes of actual travel time. The rest, work done by veteran EMS author/consultant Jay Fitch illustrated, can be consumed by the call-taking and dispatch process.

     Each component of this process eats time virtually invisibly. It takes time for a PSAP to answer a call and transfer it to EMS, Fitch noted. An EMS answering point must pick up the call and gather pertinent facts. The call must be transferred to a dispatcher, along with location information, then assigned to a crew. Finally, responding personnel have to get on the road.

     Looking at this sequence, the question of how to reduce response times becomes much more interesting. Your best opportunities for time savings may, in fact, come during the dispatch process.

     "I'd say it's the single most controllable time element you have in your system," says Guillermo Fuentes, a consultant with Fitch & Associates and veteran of EMS systems in Montreal and Niagara Falls, Ontario. "Dispatch centers have evolved over time. Originally people had a notion that a call would come in and an ambulance would go out. Now things have evolved, and we want more from our dispatch centers. These new requirements are where you start seeing real lost time."

     Correspondingly, though, the industry is also beginning to see some fresh approaches for trimming those component intervals. One, being utilized in places like Niagara Falls, Ontario, and Pinellas County, Fla., involves separating dispatching by task instead of by zone.

     For these SSM systems, it works like this: One dispatcher essentially handles only deployment—having units positioned, based on past volumes, where they're likely to be needed. A second independently dispatches crews to calls, and a third manages destination decisions.

     Niagara's system is set up, as calls are triaged, to automatically identify the crew most likely to be dispatched to each and put them on alert. Once the initial call-taker forwards a call to the first, primary dispatcher, that dispatcher can either formally assign that preselected unit or override the computer's choice and send another.

     "That person should be able to dispatch an ambulance, from the moment it's finished triaging, in about eight seconds," says Fuentes, now chief administrator of the Niagara Regional Police Service. "Niagara EMS uses a 15-second/90th percentile evaluation for that, but they typically took around 8–9 seconds."

     Once the call is assigned, it switches to a follow-up dispatcher who supports the crew until they arrive on scene. The crew never interacts with the first dispatcher; additional details come through the second and over MDTs. At the scene, authority moves to the third dispatcher, who controls transport destinations.

     "One of the reasons hospitals get overwhelmed is because ambulance services don't manage destinations," Fuentes notes. "Dedicating a resource to making sure ambulances are going to their required destinations is crucial for the hospital system."

     Such a setup requires a robust technological foundation; paper-based systems wouldn't be able to manage it. Another recommendation, therefore, is for dispatch centers to embrace technology and its benefits—things like AVL/GPS-based tracking of units, automated collection and aggregation of run data, and measurement of various response metrics.

     Dispatch systems should also be integrated with first responders', lest dynamic units start making them second.

     "The way we do it today, first response makes very little sense," says Fuentes. "First response has to happen from a computer to a computer, without a human being who has to challenge himself, Do I call the fire department first, or do I dispatch my ambulance first?"

     In Niagara's regional system, where first response parameters differ among municipalities, location information and MPDS are used to determine whether fire-based first responders are alerted to calls. If so, information is automatically pushed into their CAD system.

     What this all enables is making sequential steps parallel. Niagara's likely responding crew can get ready while the primary dispatcher receives and assigns the call. Firefighters are already responding as that dispatcher sends EMS. The automation saves time—time that might be very valuable to certain emergency callers.

     "Because it's all done by a computer behind the scenes," Fuentes says, "there's no human being who has to remember to call the fire department or worry about holding units back in his [dispatch] zone. It eliminates all the politics, and it's the right thing to do for the patient."

     "We have met the enemy," cartoonist Walt Kelly famously said, "and he is us." Kelly wasn't talking about EMS, but he could have been. The biggest obstacles to improving EMS quality and response times, researcher Stephen Dean, PhD, found in examining a pair of major urban systems, came from those within the systems.

     "The No. 1 obstacle I found was internal stakeholders—people working inside the systems," says Dean, director of corporate training for Paramedics Plus in Oklahoma City, who did the work in 2004 as part of his doctoral studies. "Individual EMTs, medics, administrators, unions, management were the ones who created the most obstacles, and those obstacles basically trumped the economic ones."

     Dean conducted a qualitative review of a pair of big-city systems, one fire-based, the other a public utility model. The PUM performed better by a number of quality measures, not the least of which was response times. Its crews responded within 8:59 with 90% reliability; the fire-based system required 13:34. In addition, the fire-based system met the NFPA 1710 one-minute/90% of the time dispatch recommendation just 9% of the time, and the one-minute en route time benchmark just 43%. And its leaders spent more per-capita to do so.

     Several factors were found to contribute to the fire-based system's lackluster response time performance. For one, it conducted shift changes at peak demand hours. For another, its stations were distributed equally throughout the community, rather than being located to reflect demand. Conversely, the PUM was 20 years into using strategies like peak-load staffing and dynamic deployment to better match resources to times and places of greatest need.

     Surveying a range of people within each organization, Dean sought to identify obstacles to implementing these strategies. The top barriers to peak-load staffing, he discovered, were reported to be employee attitudes, union recalcitrance and skeptical management. Workers and their collective representation naturally preferred fixed schedules, and as one respondent noted, "Chiefs [would be opposed] because [it] would definitely create a lot more work for them, trying to cover positions and manage people who are going to be there for half of their shift and half of someone else's."

     Employee attitudes and intransigent management were also cited as the biggest impediments to dynamic deployment. Employees worried about things like access to facilities between calls and lengthy postings on the streets. "You get a workforce issue because it is increasing work load and taking them from their home base," one respondent explained. Similarly, managers face a constant need for fine-tuning their postings and an increased potential for accidents as units move about.

     In both cases, the various internal obstacles cited far outstripped the impact of external factors like funding, research and public opinion.

     None of these discoveries are especially earth-shattering, Dean says; it's just never all previously been chronicled.

     "It was one of these studies where everybody sort of already knows it, but it wasn't ever documented," he says. "Anybody who works in EMS knows of the infighting that goes on, and that what we call politics inside the system often stop things from improving. The significance of the study, to me, is that the feds put a lot of money into grants to try to improve EMS systems. But just throwing money at these problems won't necessarily solve them. You have to deal with the internal stakeholders."

     The primary difference between the systems, Dean found, came down to accountability. Accountability and competition, of course, are the defining ideas behind PUMs: If a community's contracted ambulance provider doesn't meet performance standards, it can be replaced with one who will. Conversely, as one survey subject succinctly observed, "You can't fire the fire department."

     How, then, to bring the benefits of competition and accountability to monopolistic municipal systems?

     "The one way you can," Dean says, "is by benchmarking monopoly systems against other systems. But still, you have to be willing to say, at some point, 'If you don't perform as well as the system you're benchmarked against, we're going to take it away from you.'"

     Replacing people on the back end isn't anyone's preferred answer. The best way to initiate improvement processes within EMS departments, therefore, is proactively.

     "The process is very important," Dean says. "You have to include those internal stakeholders in the process of designing and implementing improvements, so that you overcome their opposition."

     Competition has gotten a bad rap in EMS. When service is privatized and left to profit-driven entities, it's often driven down wages and diminished working conditions. But that's at what you might call the retail level.

     "What a lot of people don't recognize," Dean says, "is that wholesale competition, where you compete for the market, has an excellent record of success. Retail competition has failed; everybody in EMS knows that. But wholesale competition can result in accountability and improvements."

     In the emergency services, leaders are often "old school"—they've done time in the ranks, worked their way up, and now lead with attitudes and skill sets forged along the way.

     In these fast-changing times, that's not ideal. Like everything else in society, healthcare is evolving, and technology is profoundly affecting the way it's delivered. That will only accelerate. But what should EMS bosses know about these gadgets and gizmos and the changes they'll bring?

     "First, it's going to require having folks who actually understand what you can do with the technologies. And generally, folks working in healthcare IT have a ways to go to understand what we're really capable of in the IT world," says Don Jones, vice president of business development for wireless communications giant Qualcomm. "Healthcare as an industry hasn't really embraced the concept of a chief technology officer. A lot of times, when someone calls us and doesn't know how to do something, all they need to do is drive five miles down the road and buy things off the shelf."

     Jones spent many years in the prehospital arena, serving as COO of California's MedTrans and playing a key role in the birth of critical-care transportation. In 2000, he was named one of the 20 most influential people in EMS. He now leads Qualcomm's efforts to incorporate wireless technologies into the healthcare and medical device markets.

     That's a dynamic market that portends big changes for EMS. It will bridge many physical gaps with mobile services and telepresence, allowing remote monitoring, assessment and consultation through live streaming of data and video. Savvy EMS bosses must know what's out there and what's coming, how it's likely to impact what they do, and how to reshape and maintain their organizations as it does.

     Consider Wal-Mart. Beyond its well-known walk-in clinics, the retail behemoth is also deploying telemedicine links in some locations, letting patients visit remotely with docs. "When you combine that with $4 generic prescriptions and a desire to get people into your store to buy other stuff," Jones notes, "you're actually changing the face of how medicine's delivered."

     Going even farther are entities like Hello Health. This is an entire virtual medical practice located in New York City. The idea is basically to come in, meet your doctor and don't come back. Subsequent contact occurs by e-mail, text message, IM or video chat. Home and office visits are still available as needed, but a robust Myca technology platform allows routine matters to be handled quickly and remotely, saving time and expense.

     Now imagine delivery mechanisms like the RP-7 robot from InTouch Health. The RP-7 can be controlled remotely by a physician to interact with patients, family members and other caregivers. This can easily connect patients to distant expertise or even routine guidance.

     Vital signs will be constantly monitored and streamed. Pennsylvania-based CardioNet offers mobile cardiac outpatient telemetry that allows heartbeat-by-heartbeat ECG monitoring, analysis and response 24/7. Arrhythmias are detected automatically, expediting intervention. U.K. company BiancaMed's products enable contact-free sensing of heart rate and respiration for groups like babies and athletes. Triage Wireless of San Diego is working on "smart" bandages, basically peel-and-stick biosensors that can transmit seven signs, including blood pressure.

     These latter advances hold the potential to make EMS better warned and better armed. "You'd arrive at a scene," Jones says, "and if first responders have gotten there, they've already put something like this on the patient, and the vital signs are reading directly into your equipment."

     This is all very cool, but to truly maximize data efficiency requires end-to-end integration and interoperability within and without. To that end, major EMS players like Medtronic, Philips, Welch Allyn and Nonin are involved in the Continua Health Alliance, which is working toward an interoperability standard for personal health and medical devices. The alliance envisions a "rich ecosystem" of interoperable health and fitness devices that will ultimately provide people the data and feedback to better manage their health, let caregivers more accurately monitor and tailor care to patients, and let manufacturers develop products using accepted connectivity standards.

     Ultimately, this will all influence what EMS represents. Greater technological connectivity with physicians should prevent some transports. More data from more sources, moved around more easily, will better prepare crews to intervene quickly and appropriately. Ideally, information loops will let people better care for themselves and enjoy healthier lives.

     However it all shakes out, EMS must know the subjects and what's at stake.

     "I'd go out and speak with the customer base and understand what the customer really wants," Jones says. "EMS has lots of customers. What does a hospital need? We know they're not going to have enough beds, so how do you care for people at home? We have to get these conversations started and understand what it's going to mean to care for more folks at home and in alternative settings."