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The Challenge of the “Project Management Triangle”

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There’s a story told of a man who wanted a house built. He was anxious to move in and didn’t want the builder wasting time—he wanted it erected right away. But to do the job quickly, the builder was going to need extra people. However, the man then told the builder he wanted to have the finest wood, bricks, wiring, drywall, appliances and plum-
bing available.

“I like to live in luxury and only surround myself with the finest things,” the client said. Finally, he told the builder, “I don’t want to pay that much for the house. Build it as cheaply as you can so I don’t spend all my money.”

The builder looked at him, confused and baffled. “So you want me to build your house fast, cheap and well.”

The man answered with an emphatic “yes.”

“Well, pick two,” responded the builder. “You can’t have all three.”

EMS systems are the same way—they can’t be fast, cheap and high-quality all at once. Of speed, cost and quality, you need to pick two.

For example, if you pick “speed” and “quality,” you’ll need a lot of first responders and ambulances, and a robust quality improvement and training program in place. But, if you have a lot of vehicles waiting for calls and a comprehensive quality improvement and training program, there will be nothing cheap about the system. You’ll have to give up “cost” since there’s nothing inexpensive about staffing positions and vehicles or quality improvement and training programs.

If you want your system to be fast and cheap, you need to forsake “quality” since the majority of your budget will be used for vehicles. But because you need so many vehicles, other functions in administration, training and quality improvement would need to be taken away. In order to keep the system low on cost, you’ll only have enough money to staff and maintain vehicles.

If you want a cheap quality system, you’ll need to give up “speed”—fast response times—since you won’t be able to afford an abundance of response vehicles and personnel. Thus, what money you do have will have to be dedicated to the administrative side, quality improvement programs and training.

All of this, in management terms, is called the “Project Management Triangle.” In some circles it’s called the “Triple Constraint” or “Iron Triangle.”

Although EMS systems are not technically a “project,” the same principles apply. Those principles state that the scope, cost and time of a project will equal its quality or how good it is. Thus, the Project Management Triangle can be applied in different ways to different situations outside of EMS.

For instance, if a software writer was developing software for a client, and the client suddenly said he or she needed the software by the end of the week instead of the end of the month, the software writer would be constrained to finish the project and would probably compromise the quality of the software.

Therefore, management educators attempt to explain that the Project Management Triangle needs to create a perfect balance between all three components of the Triangle.

In the case of EMS systems, there needs to be a balance between fast response times, how good the quality of care is, and the cost of the entire system.

If an EMS system runs 10,000 calls a year and can have a first responder meet the four-minute response time 90% of the time in the geographic region, there’s no sense in paying for extra personnel and vehicles in order to meet a four-minute first responder response time in 100% of the region—an acceptable response time has already been accomplished.

The same would apply to an ambulance transport of 10,000 runs a year. If you want your ambulances to average 3,000 runs a year (about 8.2 runs per day), assuming each run takes about 1.5 hours to complete or 12.3 hours out of each 24-hour day for about a 0.5 unit hour utlization ratio, you would need about three to four ambulances on duty 24 hours a day. Any additional ambulances would cost your system more and you would then compromise the cost of the system.

In order to create balance between cost, response times and quality, some services should be staggered. For example, the amount of vehicles on duty throughout the day can vary because EMS systems are traditionally busier during the times people are more active and moving about.

Private ambulance services usually employ this principle, but some fire-based EMS systems, such as Memphis (Tenn.) and Dallas, also increase the number of ambulances during the busier times while decreasing the number of ambulances during the overnight hours when the EMS calls are less frequent.

As an EMS manager, it’s imperative that you create a relatively close balance between speed, cost and quality when it comes to your EMS system. Because each EMS system is different, that careful balance is something only you can determine—by looking at the budget and geographic area/call volume—while delivering the quality and level of care your community expects.

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