When I started my EMS career at age 16, my first job was to wash and resupply ambulances. It was a rite of passage, with the local volunteer rescue squad. I was wide-eyed and wanted to prove my worth to my fellow volunteers. But the job progressed from being something I looked forward to and took pride in (literally counting every Band-Aid and alcohol prep; every time) to being something I came to loathe.
I began to embrace the “it looks full to me” technique of restocking and counting, and was even guilty of using the “washing below the line” method of vehicle cleaning, especially as I gained my clinical credentials and got to the paramedic level.
I, like many of my colleagues, worked hard to advance my clinical expertise and felt that washing and restocking vehicles, while
necessary, was an inefficient use of a clinical provider’s time. We felt it would be much more productive and beneficial for EMTs and paramedics to focus on delivering quality care, studying, training and being involved in clinical rotations to become more knowledgeable and proficient in our skills.
But this was my responsibility, and it was ingrained in us that if something was missing, we’d be held accountable. I also watched crews stock their vehicles “by sight and emotion,” often failing to count each item on each shift because the task became too routine.
Thus, problems began to surface, and this practice came back to bite me and others when we needed that use-once-in-a-career item, and it was missing or expired.
As my business acumen grew and I became exposed to other EMS systems, I started to realize that many EMS agencies suffered the same problems. So I knew there had to be a better EMS restocking method.
Addressing the Issue
In 1993, my senior year in college, I had the opportunity to work with Jack Stout (father of system status management, the public utility model EMS system and high-performance EMS). He arranged for me to participate in a six-month working college internship at Sunstar Paramedics in Pinellas County, Fla.
This was early in the consolidation of systems in the EMS industry, and LifeFleet LLC was still the parent contractor to Sunstar. They were gracious enough to offer me a voluntary management internship and a paid paramedic position.
During this time, I was introduced to Sunstar’s concepts of fleet standardization, assembly line-like speed-loading processes and intentional building workflow design. Their processes, like those you’ll find in most modern high-performance EMS systems today, featured standardization, reliability, efficiency and effectiveness in vehicle restocking and cleaning processes, as well as significant financial return on investment.
So what do these agencies do that makes them so successful and able to replace the time-honored tradition of provider-based vehicle restocking and washing? More importantly, how do they maximize the use of their skilled crews and avoid wasting time, crews and financial resources?
I’ve had the opportunity to see many different spins on this concept, with both best practices and subpar approaches in the largest high-performance EMS (HPEMS) systems in the world, to a mix of practices deployed in small and rural systems. The following themes tend to exist in successful programs:
>> Centralization: Whether it’s in a centralized supply warehouse, deployment center—or both—centralization is key because it becomes the hub for efficient and effective processing for all types of systems
>> Shift cycling: Many medium-to-larger HPEMS systems use centralization to enable shift cycling. Peak-load staffing schedules have units cycling on and off duty based on anticipated service demands. Centralizing means fewer vehicles are needed and less time is wasted because they don’t have to swap out one for one.
In centralized systems, oncoming crews use the “next vehicle up” model in which crews are assigned a vehicle based on preflight readiness; fleet hours and mileage load balancing; and vehicle service cycle needs. As a result, providers never get stuck waiting for a vehicle, getting a “back-up” vehicle or losing the effectiveness of deploying a waiting relief crew. Additionally, if your fleet services are located at the same facility, your vehicle servicing can become much more efficient because you no longer have to shuttle vehicles around. The only downside is that crews aren’t assigned the same vehicle every day.
>> Fleet & equipment standardization: Standardization does many things. First, it helps eliminate errors and wasted time by ensuring everything is laid out the same way in each vehicle. Also, by standardizing equipment, servicing becomes more efficient, education on use is streamlined, equipment error rates go down and you’re able to take maximum advantage of bulk purchasing discounts. Standardization also gives crews the peace of mind that they’ll know exactly where to get something in an “emergent” patient
>> Scientifically designed inventory PAR levels: Although most states regulate what supplies are required on an ambulance, many EMS agencies supplement these items based on the standards set by medical control and/or the agency’s medical director. Although this process sets the minimum inventory levels, EMS providers often supplement this list either based on restocking by “sight, look and feel” or allowing emotions (“the big one” mentality) to drive inventory levels.
Successful speed loading programs standardize through careful study of supply usage patterns based on clinical documentation of use, shift lengths, vehicle productivity quotients and margin for error. This approach acknowledges minimum level requirements, but it also addresses a maximum level, thus reducing waste, overstock and an excess of expired supplies.
>> Employee-designed vehicle, cabinet & medical supply layouts & packaging: Another common trait found in well-designed ambulance resupply systems are ambulances that have been designed by the end users—the field providers, mechanics and resupply technicians. All have important needs and stakes in the game. Field providers want good ergonomics, creature comforts, efficient cabinet placement and access, good equipment placement, ample room and safety. Mechanics are concerned about servicing capabilities, safety, fuel economy, weight, size and durability. Resupply technicians want easy access, cleaning and the ability to seal both internal and external cabinetry and compartments.
Another key component is the actual prepackaging of medical supplies into the “speed loader” system itself. The sky is the limit with the number of permutations that are possible, but the key elements include employee-designed grouping of medical supplies to treatment types (e.g., BLS, ALS, ECG and airway); use of color-coded bins for quick clinical identification; and use of bin numbering/labeling systems that allow providers to immediately recognize where the “speed loader” belongs within the ambulance. Some agencies have even gone so far as prepackaging treatments all into one easy-to-open package—anything that makes a clinician’s life easier and treatment more efficient while making restocking easier at the end of the shift.
>> Assembly line approach: Successful ambulance resupply processes take cues from automobile and other assembly line concepts when vehicles are being restocked. For example, the vehicle may be washed first, then sent to the restocking area for processing, where a step-by-step procedure ensures each vehicle is resupplied the same way every time.
>> Lean manufacturing processes eliminate waste: Some manufacturing concepts work to keep the number of steps, paces and physical movements to a minimum to improve task efficiency. When laying out the physical plant for an ambulance resupply system, many agencies take these things into consideration, keeping items placed close to where they’re needed in the assembly line. For example, every time a vehicle is queued up to be restocked, it’s placed in the same position in the restocking area so that external cabinet equipment is in alignment with restocking items, which are placed on nearby shelves that match the needs of the compartment. This way, as the supply tech makes their “once around the unit” pass, everything they need is right there. The “once around the unit” approach follows a by-the-numbers “service points” system, with inspection points numbered and sequenced so that, as the vehicle is serviced, each point is checked, inspected, restocked and resealed when items have been used.
>> Building design: Many agencies have to contend with placing processes into an existing building vs. having a custom building to match efficient processes. No matter what your situation is, the key is to establish an efficient workflow. Sunstar, Reno Nev.-based Regional Emergency Medical Services Authority (REMSA) and Emergency Medical Services Authority (Tulsa and Oklahoma City, Okla.) took proper workflow engineering into consideration and built their buildings around the processes. (See their facilities and processes at www.remsa-cf.com.)
>> Recycling: It’s also important to recycle unused or excess supplies. For example, unused IV tourniquets or Betadine skin preps are often thrown out unnecessarily. Having a bin for these items in an internal ambulance cabinet saves useful items that can be rechanneled during the restocking process.
>> Cabinet, package & equipment sealing: This is one of most important aspects of speed-loading programs. Sealing of interior cabinets, exterior cabinets and equipment provides a visual cue that something in a cabinet or bin has been used. It’s also important because sealed cabinets don’t have to be rechecked. This saves valuable time and resources. Typically, each seal is traceable back to the individual who sealed the cabinet or equipment, which allows for an audit trail in the event that something is missing. Sealing of bins is typically performed using shrink-wrap, super-thin, heat-sealed plastic bags or a packaging machine. Intact packaging can be easily recognized and opened, and it reminds crews and restockers that packaging integrity has been broken.
>> Audit trail: Many HPEMS-based resupply systems employ an audit trail system that allows for both packaged supplies and cabinets to be traced back to the original individual who sealed the cabinet or made the prepackaged supply pack. That way, if something is missing, the crew can initiate an accountability process to correct the problem. Additionally, processes that include identification of the most recent expiration date displayed in plain site allows for a quick check to ensure items are in date. Some agencies even record this information into a database along with a unique bin identification number or bar code. This way, if something expires or is recalled, the tracking system identifies which unit and bin the questionable materials were on, speeding up processing and improving accuracy.
>> Audits & quality assurance processes: The best speed loader programs have quality assurance process that can track performance and reliability down to the individual. This process measures performance and reliability with a scorecard that shows audit results, which is typically shared in a public fashion. For example, audits reveal 99% reliability for premade packages for this month, meaning that one in 100 had something wrong with it.
This is an important feature that helps clinicians feel confident in their team members. It also provides a mechanism to track performance and allows for feedback and remediation opportunities if continual problems arise or to root out individuals who may not be meeting performance metric standards.
>> Ergonomically designed warehouse environments: HPEMS systems have moved the tedious physical counting of items out of the back of the ambulance and into ergonomically designed, environmentally controlled and efficiently designed facilities. They also deploy anti-fatigue mats, waist-level shelf storage for high-use items to prevent constant bending and supply shelf grouping strategies to eliminate walking to retrieve items.
Benefits of Speed Loading
Although having unexpired items available to you when you need them has obvious benefits, there are many other less obvious benefits to using these types of strategies and processes.
>> Recycling & elimination of wasted supplies: You can achieve significant cost savings by putting unused items back into the supply chain for future use. Large systems (30-plus units) have reported saving of $15,000 –$25,000 of excess inventory annually by focusing on careful waste control and restocking of unused supplies. REMSA and EVAC Ambulance (Volusia County, Fla.) have recently converted to speed loading and have experienced these types of savings.
>> Resupply cost per hour: Think differently about restocking and washing. Put your bean counter hat on for a minute and consider this: The marginal cost per hour (the cost to put one additional hour on the road) for most EMS agencies runs between $80–120 per hour. This means that if a crew takes 30 minutes at the start of a shift and 30 minutes at end of a shift to restock and clean their unit, it costs between $80–$120 to perform this task.
In some EMS systems, especially those with centralized deployment hubs using dynamic posting methodologies, provider-based restocking and washing can cause other problems as well, especially with deployment availability and response times. (See “reduction of lost unit hours” section below.) The deployment impact has to do with how much out of service time is generated by the process and providers. Higher out-of-service time affects proper skilled man power availability and deployment that results in the loss of significant revenue and increased response times, which can affect patient care and overall system performance.
>> Reduction of lost unit hours: Lost unit hours are defined as a unit of ambulance time that’s being paid for but is unavailable to the deployment plan. In an HPEMS system, lost unit hours are like poison. Lost unit hours are generally controllable via process engineering and system reliability. Vehicle readiness and cleaning are areas that generate significant lost unit hours at the start and end of shifts. Resources not available due to lost hours have to be replaced. So in an HPEMS system, the actual cost of provider restocking is double that of other models. So in this case, the cost to perform provider-based vehicle servicing is a staggering $160–240 per hour.
>> Lower equipment & vehicle reserve needs: In station-based and fixed-server (those that mimic station based models without the station) EMS deployment models, hot racking occurs. Hot racking is a military term for the sharing of a bed (or rack) when space is limited and sleeping must occur in shifts. In this case, the rack is the ambulance, and one crew has to wait to start their shift until their ambulance is released from the prior shift.
This practice creates all sorts of inefficiencies and costs, especially in larger, high-volume EMS systems. The reasons for this are simple; if the ambulance that the crew needs isn’t available, then that crew must wait for the unit to return and therefore waste valuable service resources. If the agency combats this practice by having “backup” ambulances available, this too is inefficient and cost prohibitive. Agencies that use centralized deployment hubs require significantly lower reserves of vehicles and equipment, have substantially lower maintenance costs and generate much lower lost unit hours than their station-based counterparts.
>> Fewer man-hours required: Well-designed EMS systems find that speed loading also reduces the number of man-hours needed to run their business, thus lowering operating costs. This includes the hours needed to shuttle vehicles for maintenance, the number of ambulance unit hours needed to provide quality response times, and the number of vehicle supply technician hours needed.
>> Lower facilities costs: Centralized deployment schemes that use speed loading programs reduce the need for brick-and-mortar housing of vehicles and equipment, which also lowers operating costs.
>> Improved cleanliness: Because each ambulance is cleaned and restocked each shift, vehicles and equipment are typically cleaner and better maintained. Additionally, supplies kept in covered and protected speed loaded packages don’t exhibit the diesel soot that can be found on medical supplies that have been sitting in cabinets for years.
>> Lowered warehousing costs & just-in-time ordering: By centralizing stations and eliminating the number of distribution points necessary and lowering par levels, the volume of inventory on hand can be greatly reduced. This approach can also help to empower just-in-time ordering practices that minimize inventory carrying costs.
Many EMS systems successfully deploy speed-loading practices. We profile the Sunstar (Fla.) and Paramedics Plus (Calif.) systems here. We’re profiling others in an expanded version of this article online at jems.com/speedloading.
Sunstar Director of Operations John Peterson and Paramedics Plus Chief Operating Officer Jeff Taylor share the following on how speed loading has improved their systems.
Paramedics Plus [the contractor in both Pinellas County, Fla., and Alameda County, Calif.] uses a ‘speed loader system’ for asset tracking and management. This system uses bar coded bins, each containing a set inventory and assigned to uniform locations within each ambulance. Each bin is sealed in plastic, and each cabinet is then sealed with a tag. When an ambulance returns at the end of a shift, it can be determined easily if any cabinets/bins with broken seals and/or plastic have had product used from them. The speed loaders from the product that has been used are immediately replaced with fully stocked and sealed speed loaders.
The speed loaders with broken plastic are removed from ambulances and sent up to production to be replenished. The items missing or used from the speed loader are then recorded electronically using Web-based software and a bar code scanner, and the usage is credited to the ambulance to which the speed loader was last assigned. This provides for quick, accurate and detailed reconciliation of all field supply usage.
Once new supplies are placed into a speed loader, the speed loader is sealed and logged into the system, indicating it’s ready for reassignment to another ambulance. In addition to indicating that a speed loader is ready for reassignment to an ambulance, sealing the speed loader also serves to increment the supplies out of the inventory.
Every item stocked in the warehouse has preestablished maximum and minimum stock points. Once a minimum level is reached, the system automatically sends a requisition to the appropriate vendor providing for automatic replenishment of all disposable medical supplies and equipment.
Because Paramedics Plus is also responsible for the resupply of all of the county’s first responder agencies, it uses the speed loading system to track usage and the need for resupply of non-Paramedics Plus agencies. This aspect of the system works similarly to the general ordering of supplies by Paramedics Plus, except
the automatically generated requisition is sent to Paramedics Plus for fulfillment instead of directly to a vendor of disposable medical supplies.
The system eliminates the need to provide oncoming crews with the 15–30 minutes many other systems allow prior to going into service. This helps Paramedics Plus get crews and units into service almost immediately. This eliminates delays in the start of shift duties and eliminates approximately 7,300 lost unit hours for our system.
Using basic calculations, it’s feasible that Paramedics Plus’ speed loader system saves approximately 40 man-hours per day (this is based on approximately 80 shift changes per each 24 hour period, at a savings of 30 minutes per unit). This saves approximately 14,600 staff hours annually. With an average hourly rate of $22.56, this results in possible annual savings of over $329,000.
In addition to achieving an astronomical savings of upwards of 40 hours per day, an additional savings will result from the ability to tightly monitor and track supply usage and flow and accordingly, greatly eliminating loss and waste.
While unsealed bins are being replaced with newly stocked sealed bins, another support services assistant is circulating the outside of the unit, restocking equipment or supplies and cleaning the cab. Once these tasks are complete, the support services assistant begins cleaning the interior of the patient compartment.
Depending on the number and types of patients treated in the unit during the previous shift and how many support services assistants are available, it can sometimes take only a few minutes to ready the unit. A realistic average for resupply and cleaning a unit, not including washing the outside of the unit, is about 15–18 minutes. On occasion, depending on the types and numbers of calls a unit has been involved in, it can take up to an hour.
During downtime when there are no units arriving at end of shift, the support services assistants restock the unsealed bins and reseal them. About 500 bins are typically kept on shelves ready to resupply units. These bins are constantly rotated into the units so it’s rare that any one item sits on the shelf for an extended period of time or expires. Over the course of a typical week, fewer than 3,000 bins will be removed, replaced, restocked and resealed. It is a lot of work requiring a lot of organization, but the benefits for the system are great. The benefits of this type of system include:
>> An increase in the number of unit hours produced by having fully staffed units available for service at the beginning of each shift.
>> A measurable increase in the ability to track the overall system supply usage and inventory.
>> An increase in crew confidence in being able to move from one unit to another knowing the supplies and equipment are in the same location in each unit.
>> An increase in the consistency of cleanliness within individual units and supply quantities within each unit.
>> An increase in the consistency of supply availability within each unit.
>> Units not currently in service being ready for service—particularly important in case of a disaster.
>> A reduction in the amount of lost or missing equipment and supplies.
>> A reduction in liability from ‘critical failures’ because a critical piece of equipment or supply was not restocked.
>> A reduction in the number of crews off late because new crews are available sooner at the start of the shift. A reduction in errors in restocking of supplies and equipment.
>> A reduction in crew complaints about other crews not restocking or resupplying properly.
>> Units looking more professional and organized with the bins as opposed to miscellaneous boxes or items lying loose in the cabinets.
To present an example of cost savings that may be realized, let’s suppose the following:
>> Unit hour cost is $100.
>> Ten units are placed into service every day for 12-hour shifts.
>> Cost per day for each unit is $1,200.
>> Ten units at $1,200 each for one day would be $12,000.
If each unit spends the first 30 minutes of each day restocking the unit, it would cost $50 per unit (half of the unit hour cost) or $500 per day for all 10 units for a total of $182,500 for one year. This would be the amount of money spent on a unit and crew to be on duty but unavailable for calls. That is a large sum to throw away. It would represent 1,825 man-hours spent on restocking—1,825 man-hours paid that didn’t generate one penny in revenue.
What if you could reduce that amount by half? $182,500 divided by two, or $91,250 which would be the cost savings if you could get each unit on the streets in 15 minutes instead of 30 minutes. What if you could cut that 30-minute restocking time to 10 minutes? The savings would be even greater. Is this type of scenario achievable?
Let’s look at this from another point of view. If you use the 30 minute restock time, completed by your ambulance crew, and your crew cost per hour is $50, you will pay out $25 a unit multiplied by 10 units a day, multiplied by 365 days for restocking, which comes out to $91,250 a year to restock the units.
What if you could get the units restocked for $12.50 an hour? Let’s just suppose you hired one individual to work restocking the 10 units. Your cost per employee is $15 an hour or $180 a day. One employee could potentially clean and restock all 10 units in a 12-hour period. So instead of paying out $500 a day for your ambulance crew to restock the unit you only spend $180 a day for someone to restock. The cost difference is $320 a day, or $116,800 per year, in savings.
Note the numbers used in these examples are just random numbers and not really the point. Plug in your own numbers and see how much you can save. JEMS
Jonathan D. Washko, BS-EMSA, NREMT-P, AEMD, is assistant vice president of Operations for North Shore–LIJ Center for EMS located in NYC and Long Island, N.Y., and is president of Washko & Associates, LLC, a leading EMS consultancy group dedicated to improving EMS agency performance around the globe. He’s also a member of the JEMS Editorial Board. He may be contacted at [email protected] or [email protected]
This article originally appeared in March 2012 JEMS as “The Need for Speed: The effectiveness & financial benefits of rapid vehicle re-stocking and “turn-around.”