Sometimes you have to step outside a problem to see the solution. Many EMS systems fail to do this when implementing their quality improvement (QI) programs. Often, these programs simply ensure everybody is doing what they_re supposed to. There_s no attempt to make system improvements or help employees become better at what they do. We need to look at the bigger picture.
POP & SARA
We can borrow two important models from law enforcement to help us work toward these larger goals. The first is derived from the concept of problem-oriented policing (POP). The idea, introduced by University of Wisconsin-Madison Professor Herman Goldstein, was based on a proactive response to crime. He believed law enforcement should examine and analyze recurring crimes in a community to potentially prevent or deter them in the future.
POP applies the SARA model: scanning, analysis, response and assessment. In the first phase, "scanning," a recurring problem in the organization and the consequences of that problem must be identified. In the "analysis" stage, the problem_s causes, scope and effects are identified. These should be data and conditions that preceded the problem or are linked to it. "Response" is acting to mitigate or eliminate the issue. This step requires brainstorming for new interventions and creating an outline of how the change would be implemented. Finally, "assessment" is determining whether the response actually worked. This fourth component consists of obtaining pre- and post-response data and analyzing it to determine if the objectives were reached.
A great way to illustrate SARA is to apply it to a dilemma seen in many EMS systems todayƒlong wait times in the emergency department (ED). When EMS crews have to wait around before they can hand over patients to ED staff, stress is placed on the system because ambulances aren_t available for other calls. So, the situation must be analyzed: On average, how long do ambulances sit at EDs? What causes ambulances to wait at EDs? The analysis that would follow might reveal that a single ambulance is losing two or more hours of unit-hour utilization (UHU) per 24 hours. Basically, the crews are providing free labor to the hospital by watching their patients.
The "response" could include an array of solutions. The EMS officials could first try asking the hospital administrators if they want to work as a team to reduce the wait times because the issue affects both organizations. Other options might be to divert ambulances when they_re backed up at a particular hospital, to have supervisory personnel respond to a backed-up hospital to help move ambulances out,to have the supervisor watch multiple patients while the ambulances return to service, or to place extra ambulance stretchers at the hospital so patients can be left there.
These solutions may or may not work. That_s why the last component of SARA is needed. The data collected after the new processes are in place indicates if theobjectives were reached.
The other law enforcement philosophy that EMS could benefit from is community-oriented policing (COP). This mindset encourages law officers to venture outside theirpolice vehicles and connect with the community. Police officers who walk the beat know the community and the people in it. Local residents open up to them about community issues that need to be addressed. They aren_t afraid to approach police officers for help since they have a relationship with them.
EMS QI personnel should also get out of the office, develop relationships with colleagues, and look at problems at the field level to understand how things can improve. The answers aren_t always found by crunching numbers and reading trip sheets. Connecting with the field provider is another QI toolthat can lead to solutions that impact individuals or a whole EMS system.
As an example, paramedics might not be compliant on administering morphine to a patient to control their pain. When the QI ventures into the field and asks, "Why don_t you administer morphine more?," the answer might reveal that it_s difficult to replace, so they don_t administer it. Once this is revealed, changes in the system can be made to makeit easier to administer morphine.
You initially wouldn_t consider applying law enforcement practices to EMS. But we should look across the street to our brothers and sisters in law enforcement, take what they_re doing to prevent crime, and apply it to EMS to make us more efficient.JEMS
Gary Ludwig,MS, EMT-P, is a deputy fire chief with the Memphis (Tenn.) Fire Department. He has 30 years of fire and rescue experience. He_s chair of the EMS Section for the International Association of Fire Chiefs and can be reached atwww.garyludwig.com.
Learn more from Gary Ludwig at the EMS Today Conference & Expo, March 2Ï6 in Baltimore.
For more on COPs, go tolawofficer.com