Although many individuals, consultants, groups and committees have written on the subject of a “model EMS system,” few have been focused on what I call the “EMS triad of success.” This is the ability to successfully and continuously balance elements of patient care, employee well-being and long-term financial sustainability, which often compete with each other for attention.
I consider this to be the ideal EMS “system.” Few reach this goal, and those who do find it challenging to maintain this level of success because of the amount of continuous effort, manpower, training and resources that it requires.
Those who have achieved this goal find it brings agility and capabilities to the organization, empowering opportunities for innovation, creativity, research and best-practice development or refinement.
Could your EMS system get to this level? When evaluating your system’s evolution, consider employing Abraham Maslow’s hierarchy of needs, a psychological theory that’s typically represented by a pyramid with the basic essentials at the foundation of the pyramid.
In Maslow’s theory, individuals move between the five developmental stages—physiological, safety, love and belonging, esteem and self-actualization—in a hierarchy-like fashion, where the basics of one level must be met before moving upward.(1) However, Maslow also accounted for movement up and down the hierarchy. For example, human psychological development and maturity moves between these stages as these needs are met or lost.
Given that organizations are made up of people, they follow a similar pattern—moving up and down this continuum based on internal and external forces, as well as the ability and willingness to adapt and change. In addition, where your organization lies in this continuum drives your necessities and willingness to embrace or reject existing components necessary to make your EMS system a “model” of its components, as well as to develop new ones.
The most successful organizations, our model EMS systems, are at the top of the pyramid. They’re highly adaptive and willing to take risks, and they learn from their mistakes. They’re transparent and are values-based, and they can consistently balance the EMS triad of success. Those that stagnate at the middle or bottom of the continuum have the opposite traits. They could be steeped in tradition, unencumbered by progress, being imbalanced in the EMS success triad by focusing too much on one component.
A fundamental building block to becoming a model EMS system is what I call the “quality unit hour.” To better understand this concept, first you have to consider EMS as both a service industry and a production industry that creates an actual tangible product—a quality unit hour. The service we provide is the output from all the various components used to design this product.
Another way to think about it is to look at other products that provide services, such as a radio or an automobile. A radio is a product that provides the service of listening enjoyment. An automobile provides the service of transportation.
It’s important to understand that products can have several levels of distinctive quality associated with them. For example, you can go to your local big box store and buy a radio for $20, and it will provide you with one level of entertainment. You can also go to the Bose store and buy a radio for $200 that will provide you with what most would easïly recognize as a higher quality of sound. They’re similar products, but they yield substantially different quality outputs.
What separates the quality of the outputs of similar products is the quality of the components, manufacturing processes, people and engineering used to design the product. The same holds true for the EMS “product”—the quality unit hour. Poor component quality will yield poor service. The problem is, it’s not just the quality of one component that separates these two distinctions, but it’s also the sum of the all the parts working together in harmonious synchronization. Herein lies the essence of the quality unit hour concept.
A quality unit hour can be defined as an ambulance available for one hour with the following characteristics:
>> It responds to properly triaged calls;
>> It responds to properly prioritized call for service;
>> It’s produced within a continuous quality improvement environment;
>> It uses modern technology to collect and assess accurate data;
>> It’s fully staffed, trained, maintained and stocked;
>> It’s properly placed; and
>> It’s properly funded and safely operates within a consumer-educated patient population.
Each of these items is an individual component that makes up the product, and the level of quality of each will have a direct affect on the quality of service output from the product. Just like the sound will be affected if the Bose device has a poorly crafted component or one of the radio waves is missing, the same holds true for the quality of service of our product, the unit hour.
A Balancing Act
The various components used to build the quality unit hour are interrelated (see Figure 1). They also have a direct affect on the three elements of the EMS triad of success: Patient care, employee well-being and financial sustainability.
To better understand this concept, imagine you have a pie on a plate that’s balancing on a point. You need to cut the pie into three pieces while keeping it balanced. If one piece is much larger or smaller, or if you remove one of the slices, the balance of the disc would be disturbed. Now imagine those three slices are our three elements of EMS system success. Removing one, or making it larger or smaller than the other three by focusing more or less than the other two, affects patient care, employee well-being or financial stability. Disturbing the balance always affects one or more of the three success triad elements.
So for example, EMS agencies often tout their clinical quality, or the quality of their training programs, yet their ambulances may break down on the way to a call due to poor maintenance. You can have the best clinicians in the world, but you haven’t met the expectations necessary to deliver quality service if they fail to arrive at a scene in a timely fashion, or not at all.
In another example, an agency can possess some of the best equipment, training, employees and quality improvement systems around. But because of poorly designed supply and logistic processes, if its ambulances are missing or have a faulty piece of equipment or supplies, they will not be equipped to reliably and consistently perform every life-saving treatment. One way to avoid this is to consider implementing the best practice concepts of speed loading. (For more, read “The Need for Speed" in the March 2012 issue of JEMS.)
Other agencies focus a majority of their energy and effort on maintaining employee well-being practices to the (often unrealized) detrimental effects on an organization’s financial stability—or even patient care. This is often seen in urban systems that employ provider-focused deployment methodologies rather than having patient-focused deployment models.
In this case, employee comfort of sitting in a station waiting for the next call is adopted or accepted instead of positioning or dynamically moving ambulances to be able to respond to the next call in a manner that will better affect the patient’s potential clinical outcomes.
Think about it. You could have all the other components in place and have one of the best, clinically sophisticated EMS programs in the country. However, if you can’t get that care to the patient within enough time to positively affect their outcome, then why bother?
Another often-seen mismatch revolves around financially focused organizations. In these organizations, the focus on financial success and profitability can weigh heavily on employee well-being and attitude and, unfortunately, on patient care. We all know that reimbursement in this industry is low. To make up for this, some organizations push the limits of productivity and efficiency to reach profit goals.
These practices are what have given system status management a bad name over the years and are why many providers cringe when they hear those words, especially if they worked in one of these types of imbalanced systems. In extreme circumstances, patient care can be affected through service cuts or a lack of proper medical equipment or medical supplies. These types of financially imbalanced systems are often not looking for profitability. Rather, they’re in survival mode.
Find Your Sweet Spot
We’ve reviewed imbalanced system models, but you might have the question: How does an organization reach the nirvana of being a model EMS system? It comes down to ensuring that all component parts are in place and that each is of the highest possible level of quality. Many organizations achieve this balance by using best practices taken from peer EMS agencies as well as companies in other industries. They use what they’ve learned to develop their own best practices, often using such methodologies as lean manufacturing or Six Sigma process improvement strategies. (For an example, read “Doing More with Less” in the March issue of JEMS.)
To focus your organization on becoming a model EMS system, begin with understanding customers’ expectations of an ambulance service. Many of us believe patients want high-quality clinical services above all. However, when we’ve asked our patients what they want when we’re assessing customer satisfaction, they have often had different answers. Some of those answers include the following expectations:
>> Timeliness/on-time performance;
>> Professionalism of the EMS provider (includes professional look and customer service-oriented attitude);
>> Cleanliness and organization of the ambulance;
>> Comfort during the ride in the back of the ambulance;
>> Coordination of care and transportation with the rest of the continuum of healthcare (Note: This is a new emerging expectation.); and
>> Valuable service for the dollars spent. (Note: This is becoming more important as healthcare reform takes shape.)
Defining ‘Best Practices’
Before a system can employ respected—or best—practices, its leaders should define what makes a best practice. The best definition comes from Wikipedia, which defines a best practice as, “the belief that there is a technique, method, process, activity, incentive or reward that is more effective at delivering a particular outcome then any other technique, method, process, etc.”
It states that the desired outcome can be delivered with fewer problems & complications if proper processes, checks, & testing, are in place. “Best practices can also be defined as the most efficient (least amount of effort) & effective (best results) way of accomplishing a task, based on repeatable procedures that have proven themselves over time for large numbers of people.”
Given this approach, model EMS organizations have learned to apply best practices in every component of their quality unit hour production. This includes the following components:
>> Financial accountability
>> Quality assurance
>> Maintenance systems
>> Resupply systems
>> Deployment methodology
>> Command & control practices.(2)
Quality clinical services are assumed and are only put into question when we screw something up—or save a life. (And when we save a life, we don’t always hear about it because it is the expectation of EMS to save lives.)
Given these EMS customer-focused quality output expectations, how should you develop your product’s components? Each of the quality unit hour components affects any number of these quality output measures. To deny these customer-based expectations in the development of your model EMS system is akin to denying clinical treatment to a patient. It, therefore, must be an integral part of your EMS system’s recipe for success.
Is there a “model EMS system?” Yes, there is. These systems live the EMS triad of success every day. They do this while understanding that they don’t just run an EMS service, but rather operate a quality unit hour manufacturing plant that yields high-quality EMS service outputs derived from high-quality components, processes and people.
1. Wikipedia. (Nov. 6, 2012). “Maslow’s hierarchy of needs.” In Wikipedia. Retrieved Nov. 16, 2012, from http://en.wikipedia.org/wiki/Maslow%27s_hierarchy_of_needs.
1. Wikipedia. (Oct. 26, 2012). “Best practice.” In Wikipedia. Retrieved from http://en.wikipedia.org/wiki/Best_practice.