Soon after I became the medical director for Dallas Fire-Rescue (DFR) in 2006, it became clear that many believed DFR provided high-quality prehospital care. After observing DFR operations in action, three things were apparent to me: 1) DFR paramedics, firefighters and officers are extremely talented, hardworking and committed; 2) Other than short response times, there was little data toproveDFR's service was excellent and that its members were extremely talented, hardworking and committed; 3) DFR paramedics appeared to have an extremely high workload and utilization rate.
That fall, DFR EMS Assistant Chief Joseph Vasquez, former EMS Deputy Chief Joe Kay, DFR Executive Officer Leanne Siri and I recommended that DFR develop and implement an EMS "Vision Process" to take a fresh look at Dallas's EMS resources and, as needed, restructure or enhance them to better serve our personnel and patients. Paul Pepe, MD, MPH, Dallas's City Manager Mary Suhm and Fire Chief Eddie Burns Sr. supported the undertaking of this project. We had three simple goals: 1) To improve the working conditions and morale of DFR's members; 2) To improve the quality of emergency medical care provided to the citizens of Dallas; and 3) To work with our partner agencies in and around Dallas to improve the overall function of the EMS system.
The DFR Vision Process involved holding a series of meetings to develop a draft "EMS Vision Position Paper." This paper would outline the recommendations for meeting these three goals.
Workgroups & Workhorses
We wanted to provide a unique opportunity for the members of DFR, as well as doctors, nurses and administrators from DFR's partner agencies, to chart a proactive course for the continued improvement of prehospital care in Dallas. All members of DFR were invited to submit an e-mail indicating their desire to serve on one of six workgroups: 1) Training; 2) Call-taking and dispatch; 3) Response and operations; 4) Policies and protocols; 5) Quality improvement, research and system issues; and 6) PCR/documentation.
Each workgroup had two co-chairs: DFR's EMS deputy chief and a subject-matter expert. Also, two experienced and talented paramedic lieutenants served as full-time "workhorses." In addition to attending and preparing materials for the meetings, they contacted many large urban EMS agencies throughout the U.S. to collect data in our attempt to determine best practices.
Each workgroup met for two hours weekly over the course of six months.
Meeting 1: Orientation, ground rules, goals and requests for data. During this meeting, we explained to the more than 50 workgroup members what was expected of them during the process.
Meetings 2/5: Review data elements of the current system. These meetings focused on the review of available data specific to DFR.
Meetings 6/8: Review best practices of other EMS systems. During these meetings, data and program descriptions from other urban EMS agencies were presented and discussed.
Meetings 9/11: Develop recommendations.
Meetings 12/14: Vet recommendations.
Meetings 15Ï16: Narrow recommendations. These meetings were the "meat" of the process. Armed with the best possible data and understanding of the current state of DFR within a particular workgroup's area of expertise, as well as data and information regarding other EMS systems, workgroup members were encouraged to make recommendations. A recommendation could be discussed immediately or assigned to a workgroup member for vetting at the next meeting. They would be in charge of reporting to the group on the feasibility, advantages and disadvantages of that recommendation.
Members who wished to put forth recommendations had to abide by just two rules. First, recommendations couldn't simply "throw money" at a problem. For example, you couldn't recommend buying and staffing 10 more ambulances to address the high call volume. And second, recommendations had to satisfy at least one of the three goals of the Vision Process. Satisfying all three goals was the "holy grail" of the recommendation phase.
Meeting 17: Vote on recommendations. Once we reached a consensus to move a recommendation forward, a vote was held on that recommendation. All members had to vote in favor of, against or abstain on every recommendation. Members could include anonymous comments as well.
Meeting 18: Discuss draft EMS Vision Paper. During the final meeting, members discussed the preparation of the draft EMS Vision Paper.
Drafting Our Vision
After the co-chairs submitted their individual sections, we edited the sections, added the data and completed the draft. The paper was nearly 100 pages and included almost 50 recommendations.
We distributed 100 hard copies of the paper for review.We attempted to obtain the broadest possible input regarding the draft. A hard copy of the paper was distributed to Chief Burns and Dr. Pepe as well as to every DFR fire station. In addition, copies were given to the Dallas City Manager's Office, the mayor, city council members, every DFR chief officer, UTSW EMS faculty and fellows, every Dallas receiving hospital emergency department, the Dallas Office of Emergency Management, BioTel, the Dallas Police Department and other partner agencies.
The report was accompanied by instructions for providing feedback. Finally, the report was posted on an internal DFR Web site and on the public BioTel Web site.
The public comment period recently closed, and we're currently compiling the comments we received. The vast majority of the comments have been extremely favorable. We held meetings during the summer to review the comments and discuss moving forward with many of the recommendations.
There were several potential limitations to the Vision Process.
>> We didn't have a particular agenda before the process began. The workgroups determined the agenda and how to proceed with developing recommendations.
>> Because the process involved only local "players," we may have lacked a broad perspective. However, our members and partner agency staff have a wealth of experience from EMS systems and agencies throughout Texas and the U.S.
>> We did our best to review any published literature when important to the question at hand, but the process involved little clinical debate, and thus published medical literature wasn't particularly helpful. Defining best practices is a subjective discussion.
>> Obtaining objective data for comparisons of systems was limited by the cooperation of other agencies and available data. We can't vouch for the validity of this self-reported data. And because of the lack of standardized measures in EMS, it's difficult to make meaningful comparisons.
Each workgroup came up with several major recommendations:
>> Develop pre-employment testing to better identify candidates who will excel in the role of firefighter/paramedic.
>> Continue to partner with the UTSW School of Allied Health Sciences to train DFR paramedics and to provide continuing education (CE).
>> Require EMT field experience prior to commencement of training as a firefighter/paramedic.
>> Ensure members' time is "protected" during CE on duty.
Call-taking & dispatch
>> Evaluate, select and implement a medical priority dispatch system to ensure patients within the system receive the most timely and appropriate EMS response.
>> Develop a new dispatch protocol and quality improvement program to address the rise of "cellular Samaritan" calls for "person down on the street" and "motor vehicle collisions without known injuries."
>> Conduct an analysis of workload and staffing to determine if current resources provide the most efficient and appropriate dispatch operations.
Response & operations
>> Ensure the department has the appropriate EMS resources to meet the emergency medical needs of the community.
>> Develop an ALS Engine Program with the goal of providing paramedic-level assessment and initial intervention for critically ill patients within six minutes.
>> Investigate and develop alternate methods of disposition or transport for patients with minor medical complaints.
>> Implement paramedic-staffed rapid response units.
Policies & protocols
>> Work with members and partner agencies to enhance the current transport policy to ensure we provide the best possible service to our patients.
>> Develop the role of EMS field supervisors to assist and mentor paramedics and firefighters when responding to critical patients or complex EMS incidents.
>> Develop a state-of-the-art pain management policy.
>> Re-examine and further develop the mass-casualty incident policy.
Quality improvement, research & system issues
>> Develop and implement a comprehensive quality improvement plan, which will include a standardized and fair method for investigating inquiries/complaints, customer-service surveys, a peer-review process and the formation of an EMS Quality Improvement Council.
>> Develop and institute a multi-tiered employee recognition program to ensure exemplary performance is recognized and supported on a regular basis.
>Continue to partner with UTSW and other health-care organizations to carry out high-quality prehospital research.
>Develop community-based EMS programs to improve the education and health of the Dallas community.
>> Research, develop and implement a new PCR software program. The new program will be user-friendly and more efficient. It'll also provide data for quality review and research, and ensure information is collected optimally to improve billing and reimbursement.
>> Work with UTSW to provide training to ensure the continual improvement of EMS documentation.
The DFR Vision Process presented a unique opportunity for DFR members and others within the Dallas community to evaluate the current state of their EMS programs and develop a blueprint for continued excellence. It's my hope that other EMS agencies, medical directors and EMS staff will take what they believe to be valuable from our system-evaluation experience and use it to enhance their own systems, medical care and quality of life for their EMS providers.