Managing for Clinical Excellence

     The Wake County EMS system has gained national recognition for delivering clinically excellent emergency medical care to its patients. The system has been profiled in numerous articles, and its medical director was the NAEMT's Medical Director of the Year in 2006. It has received thousands of requests for advice on the implementation of its ICE (Induced Cooling by EMS) post-resuscitation hypothermia protocol. But when I was asked how the system's infrastructure supports and encourages clinical excellence, I had to pause for some time and consult with colleagues inside and outside the system. What do we do, if anything, that is different than what happens in every other EMS organization? After a while, a few common elements emerged. There's really no magic—just focus on a consistent purpose.

     As senior EMS officers, we are charged to lead, manage and administer. We lead people, we manage processes, and we administer in accordance with the kinds of rules and processes that are present in any large organization. Although Wake County EMS is a good-sized EMS organization (132 line staff, seven officers, two clerical support staff), we are a small part of Wake County government, which has more than 5,000 employees. The county's EMS Division handles 38,000 calls a year, while the entire system (the EMS Division plus six contract agencies) exceeds 60,000.

     One of the unique aspects of the Wake County EMS system is that service delivery levels are set by policy, given clinical and budgetary guidance. While the revenue from transport billing is an important element of the financial management process, the operating budget has been effectively decoupled from the revenue stream. What that means is that county commissioners and the county manager set the service level expectations and provide funding to support the delivery of service. Revenue from ambulance transport billing does not establish the service level any more than it does for law enforcement, the libraries or other essential public services. That's a big positive: There's no expectation that EMS transports pay for the cost of daily EMS operations. The county's finance department is expected to maximize the revenue stream through effective billing and collections. While we've not faced budget cuts in recent years, we must present a strong business case, driven by sound data, for any increase to our annual budget. Like everyone else, we've had to learn to do more with less. Evidence of this is seen when comparing our requests for additional resources to cope with growth in the county (we add more than 30,000 new residents a year) to what we've actually received: We've been granted about half of what we've sought. Accordingly, our system-wide unit-hour utilization has been steadily rising over the last four years.

     As senior EMS officers, we are expected to deliver good operational and clinical performance, maximize unit-hour utilization and be good stewards of the taxpayer dollar through safety programs, accident prevention and other measures. This does not mean the EMS system gets whatever it wants to try to make things better. A rigorous process involving operations analysis, peer review and painful prioritization of budget requests takes place within the system even before our requests are submitted to the county's budget office. We are then well prepared to demonstrate the impact of the resources we've requested on operational and clinical performance. In this do-more-with-less era, we have to show, with data, that what we ask for will actually improve care. To support our business case, we utilize data from our CAD system, our electronic PCR system and current medical literature.

     Where necessary, we undertake special studies or surveys when a particular subject is not addressed in the literature. For example, for the last several years we have felt a need to increase the number of first-line supervisors in our system. We have been unable to make the business case for these additional resources, because there is no consistent standard for supervision in EMS. We've surveyed the industry using the National EMS Management Association's and EMS chiefs' list servers, so we had data from many organizations. However, there was no consistency—the numbers of deployed units per field supervisor ranged from three to 25! So we still have three system supervisors overseeing the actions of 18 county EMS Division field units spread over 860 square miles—the same number as when there were 11 units.

     Early in his tenure, our medical director, Dr. Brent Myers, set a direction. We recognize the patient doesn't care about agency politics or other factors inside the system. We serve the patients and their families, who want (and deserve) prompt, competent, compassionate care. It is our obligation to deliver what our community wants—we must be patient-centered. Our senior managers embrace that direction, and we encourage the whole organization to do likewise. We remind ourselves and our staff that we are committed to delivering prompt, effective, compassionate care to all who need it. We tolerate no notion that anyone is entitled to less, regardless of socioeconomic status or our perception of the criticality of their complaint. Like most EMS systems, we have our share of folks who call for things that don't neatly fit into a medical priority dispatch system; however, we understand that those folks are having very bad days when they call us, and we exist to help mitigate their difficulties.

     An organization's culture and behavior are shaped in large part by the expectations established by its leaders. Communicating and reinforcing expectations is an ongoing process, which we generally accomplish through our monthly continuing education program. Each Wake County paramedic is expected (and paid) to attend one full day of continuing education each month. Although the schedule varies somewhat to accommodate multiday classes like ACLS and BTLS, generally speaking, the first four hours cover clinical CME, while the afternoon is devoted to operational and administrative topics such as impending changes in policy or operations, reviews of performance data, incident management strategies and tactics, and critiques of noteworthy incidents. Clinical topics are selected on a "just in time" basis, focusing on issues raised through ongoing quality management activities, incident reports and clinical innovations. This way, potential problems can be addressed early, on a systematic basis.

     A recent innovation has been the incorporation of TurningPoint interactive software, which allows for immediate tallying of audience responses to scenarios and questions. This allows the presenter to spend more time on areas of greater need, and move quickly past topics where additional instruction is not needed. "Chief's Corner" is held during lunch hour, with a meal provided by the organization. During these sessions, which may include formal presentations on topics of interest, personnel are free to ask questions or offer opinions. All of these sessions incorporate the opportunity to reinforce ethical and service-delivery issues.

     Similar sessions are held quarterly for both field training officers and chief officers. These sessions represent not only a substantial financial commitment, but also involve a strong commitment from our instructors. Each session must be delivered five times a month, with the same message each time, to accommodate staff working both 24-hour and 12-hour shifts. We could not do what we do clinically if we relied on a do-it-yourself approach where individual personnel attended whatever CE courses they wished to meet state licensing minimums.

     Bringing new employees into the organization is a substantial challenge. Like many EMS agencies, Wake County EMS has to deal with significant turnover and experiences recruiting challenges. Our salaries are set using a norming process, so they are not greater than surrounding agencies'—we all pay pretty much the same. However, our system workload is higher than many of our neighbors', and performance expectations are high. Our skilled paramedics are also valued by other organizations, some of which have greater flexibility in setting salaries or arranging schedules, and some of which are experiencing growth that creates advancement opportunities for skilled, experienced paramedics. As well, hospitals and medical groups around the community, faced with nursing shortages, are offering significant salary increases to paramedics for work in EDs, cardiac cath labs and diagnostic imaging facilities. Unlike some agencies, we are unable to provide hiring bonuses, relocation expenses or other incentives.

     We believe it is important to bring new employees aboard in a manner that provides sufficient orientation, training and support during the first months of employment. We devote substantial resources to making that happen. New employees participate in an 80-hour orientation program, starting with a welcome and discussion of organizational values by the EMS chief, followed by a comprehensive medical director-led introduction to the protocol manual and foundations of practice, and ending with a formal "pinning" ceremony, where the oath of office is administered and the new member is presented with his or her badge and epaulets. Then, a minimum of 10 24-hour shifts are spent aboard an EMS unit as a third person, under the guidance of a trained field training officer. We use an adapted Field Training Evaluation Program (FTEP) derived from the respected law enforcement program of the same name. Using standardized evaluation guidelines to assure consistency, the new employee receives a daily written evaluation (called a daily observation report, or DOR) and feedback recorded for future use.

     Part of the FTEP process is preparing for and obtaining medical credentials to practice in the system. By the fifth month, the new paramedic is expected to have completed a menu of procedures, demonstrated proficiency and gone before the medical director for examination. Once medically cleared, they gain additional scheduling flexibility. For the balance of the first year, DORs are completed on a daily basis.

     EMS professionals do great things every day. Often those achievements go unrecognized, leading to a sense that efforts are not appreciated. At Wake County EMS, we take great pains to recognize the achievements of our personnel. A comprehensive awards program is in place, and we encourage individuals to wear the decorations that commemorate their achievements.

     Every year during EMS Week, the system holds a cardiac arrest save recognition ceremony, where the professionals who participate in successful resuscitations (telecommunicators, first responders and EMS medics) are honored. Those successfully resuscitated, along with their families and friends, are invited to attend. This ceremony is held in Raleigh's Fletcher Opera Theater, and pins and certificates are presented to everyone involved, from call-taking to arrival at the emergency department door. The event begins with an outdoor social, followed by a presentation of colors accompanied by pipes and drums, after which the group moves inside. The speaker has always been a survivor or a family member. This ceremony is also where we celebrate promotions and other noteworthy achievements.

     Data is starting to emerge suggesting that having too many paramedics in an EMS system can have a negative impact on patient outcomes. Yet that same data suggests that having experienced paramedics on critical calls improves patient outcomes. Like many EMS systems, we have experienced increasing loss of paramedics to other health professions. Overall, the experience level of our workforce has declined. In support of our primary focus on patient care, we take two measures to assure that experienced paramedics are present on critical calls. First, a district chief (all of whom are paramedics with eight-plus years of experience) is dispatched to each critical call. Second, EMS units are encouraged to voluntarily "check in" as additional units on serious calls. Occasionally this results in brief, localized depletion of system resources, but we believe what's most important is the critical patient in immediate need of our services. Our budget request, pending before the county commission at the time of this writing, is to implement an "advanced practice paramedic" program which would further ensure that an experienced clinician is assigned to every critical call.

     Since this was written, the county commission has funded our Advanced Practice Paramedic program initiative, and 19 experienced paramedics are currently participating in a six-week academy designed to prepare them for this new role, which will encompass both enhanced clinical capabilities, as well as public health interventions designed to prevent unncessary EMS calls.

     If a medic's perception of career opportunity is that there are two options (the back of the truck and the front of the truck), burnout and dissatisfaction are not far off. At Wake County EMS, we struggle to provide our medics with opportunities to expand their horizons. Our special operations teams include a tactical EMS unit, a hazardous-materials/urban search and rescue unit (HAMMER), an EMS cycle team and an honor guard. Each team is managed by a chief officer, assisted by assistant team leaders and team instructors.

     The responsibilities of our field training officers extend beyond coaching and evaluation of new employees. Our FTOs are designated as "lead medics" for the units to which they're assigned. In addition, they assist training officers and the medical director with skills teaching, periodic scope of practice evaluations and orientation and in-service programs. After completing a qualification program, FTOs are eligible to work as relief District Chiefs.

     Independent professional development is encouraged and supported. Members regularly participate in local and regional continuing education events and attend programs at the National Fire Academy. The medical director's office supports the attendance of staff medics to national conferences of significance.

     Every organization has a responsibility to ensure it delivers quality service to its customers. Sometimes this involves delving into difficult areas.

     To keep us on track, our medical director has developed a quality management philosophy that starts with believing that our medics want to provide excellent clinical service. When issues arise, we expect members to report them immediately, regardless of the hour. This lets clinical misadventures be dealt with nonpunitively. If necessary, additional education or practical skills experience can be provided. This atmosphere of openness, integrity and mutual trust allows honest mistakes to be addressed separately from administrative disciplinary processes. These matters only become disciplinary if those involved are less than honest.

     Administrative disciplinary actions are few and far between. Complaints about customer service, driving practices and attendance are handled by first-line supervisors, usually through nondisciplinary coaching. Formal discipline is conducted in accordance with county policy, but always on the foundation that our people are important to us and are here because they want to be part of this organization.

     Certain aspects of our clinical success would not be possible without the strong, positive commitment of our emergency response partners. Throughout Wake County, our 23 municipal and private nonprofit fire service agencies are committed to delivering excellent basic life support medical first response. We have no doubt that the prompt response of defibrillator-equipped medical responders and EMT firefighters is a major factor in our EMS system's achieving a 39% cardiac arrest survival-to-discharge rate. In the past year, many of those fire departments have begun carrying long backboards aboard engine companies to help us further reduce times at scenes involving traumatic injury. We value these partnerships, work to enhance them and include them in our celebrations of success.

     As the county's EMS agency, Wake County EMS is responsible for the continuing education and credentialing of all EMS providers in the county, regardless of agency. We facilitate, document and in some cases deliver continuing medical education for first response personnel (principally firefighters), EMTs, paramedics and EMS dispatchers. Since state law provides for single medical directors for county EMS systems, our medical director is tightly integrated with all agencies in the system.

     Chief officers from the major public safety agencies meet in a variety of venues. The county EMS chiefs association provides a neutral forum for the discussion of issues between the county and the chiefs of our contract agencies. I meet every month or two with Chief John McGrath of the Raleigh Fire Department and senior officers of the Raleigh Police Department. We share building space with the Wake County Sheriff's Office, so interaction with Sheriff Donnie Harrison and his staff is frequent. We have bimonthly meetings with the staff and user agencies of the Raleigh-Wake Emergency Communications Center. And where major policy issues require formal presentation, we attend meetings of the Wake County Fire Commission, where we can address all the county chiefs together.

     Within the last 30 days, in the face of the national economic crisis and declining growth in revenue from property and sales taxes, Wake County has implemented cost-cutting measures that have impacted the EMS system. Hiring has been frozen (with exceptions available for essential service delivery personnel), travel has been restricted, and the purchase of food for meetings and classes has been curtailed.

     Skip Kirkwood, MS, JD, EMT-P, EFO, CMO, is chief of the Wake County (NC) EMS Division. He has been involved in EMS since 1973 as an EMT, paramedic, supervisor, educator, manager, consultant, state EMS director and chief EMS officer. Contact him at skip.kirkwood@co.wake.nc.us.

     Throughout the budget year, we try to remain flexible. Where clinical science or operational need dictates, we will reprioritize within our existing budget to make room for something we believe to be important. For example, when the opportunity arose to begin our post-cardiac arrest ICE program, there was no funding in the budget. We sought a simple, low-cost approach that would work, and postponed some other purchases to make funds available. We purchased freezers designed for recreational vehicles at about $500 per vehicle, put them on the floor of the backseat of the supervisors' vehicles, plugged them in to the cigarette lighters and went to work.

     Wake County's 30-plus EMS units are spread over some 860 square miles and operate from 15 fixed stations. Maintaining personal contact with employees requires there be adequate numbers of supervisors in the field such that employees are supported when necessary, and have chances to ask questions, solve problems and receive feedback. Five EMS district chiefs (first-line system supervisors) are assigned to each shift. Operating from large SUVs outfitted as first response vehicles, DCs are expected to visit each station and each crew during each shift. These visits include the usual administrative routine (e.g., equipment and narcotics checks), but provide the supervisor a chance to interact with crews, review patient care reports and troubleshoot.

     Nothing will discourage EMS professionals as much as fighting with their vehicles and equipment that seems determined to obstruct patient care. We work diligently to make sure tools and equipment and vehicles support, rather than hinder, our medics. We replace ambulances as they approach 100,000 miles, our fleet manager having determined that this is where the costs of breakdowns and repairs begin to seriously increase, while resale value begins to decrease. Similarly, physiologic monitors are replaced on a five-year cycle.

     Personal equipment is no less important. Protection, comfort, functionality and image are all considered. Each member receives complete winter and summer uniforms, cold-weather coat, raincoat and ANSI-standard boots. In addition, each receives a gear bag containing a turnout ensemble compliant with NFPA 1951 (governing protective ensembles for technical rescue incidents) and NFPA 1999 (protective clothing for emergency medical operations), helmet, fire boots, level C hazmat coverall, mask, chemical protective boots, extrication gloves and appropriate mask cartridges.