This month, we received a three-page letter from Austin-Travis County EMS (ATCEMS) responding to the September article “Trouble in Texas: Is the Austin-Travis County EMS system broken?” We are publishing much of ATCEMS’ letter and response by the article’s author David M. Williams, PhD, with only minor edits made for space.
This is a formal response to Mr. Williams’ article, published in the September 2013 Issue of JEMS. Austin-Travis County EMS requested that Mr. Williams meet with its executive team prior to the publication of his report, to have the opportunity to validate his information, given the fact he used only publicly available information in his research. Mr. Williams did meet with the executive team, however, prior to the meeting he indicated that his editor’s deadline had already passed and he no longer had the ability to make changes to his report. This made the meeting futile, since it would have no impact on the report.
Had ATCEMS been able to review Mr. Williams’ report facts prior to the editor’s deadline, we would have been able to help him correct the inaccuracies in his report. We believe the report does not reflect an objective point of view. In our opinion, Mr. Williams’ AAA assessment tool, primarily used for private ambulance providers, does not accurately assess the unique framework of a government-funded, unionized, civil service, stand-alone 3rd service agency such as ATCEMS. We find the following inaccuracies in Mr. Williams’ report, listed by section:
Internal issues: The department’s commanders (field supervisors) sued the department over disagreements regarding exempt vs. non-exempt status and overtime compensation. Decisions concerning employee wages, including overtime issues, are managed at the corporate level of our organization and are based on broad practices. When agencies such as ours transition into meet and confer or collective bargaining, it is not uncommon for lawsuits to arise. We do not believe that resolving an issue through a lawsuit indicates that an organization is “in distress.”
Financial distress: The EMS department overran its budget in FY 2012 for the first time ever, by $745,411.00, not the $910,000.00 reported by Mr. Williams. The article failed to mention that ATCEMS collected over $33 million in total revenue the same year, far exceeding its revenue target of $16.5 million. The additional funds were credited to the City of Austin’s General Fund operations and aided in offsetting any cost overruns that were experienced that year. The article does not mention that the overrun occurred after three significant budget cuts in response to the recession. Further, ATCEMS made changes to the structure of our budget to avoid future cost overruns.
Response times: Population growth in Travis County’s suburban areas has far outpaced City of Austin growth in recent years, creating an imbalance in “Demand vs. Availability.” The City of Austin and Travis County have been working together to resolve this by adding equipment and personnel. The article makes no mention of the fact that new equipment and personnel have already been approved to improve suburban response times.
Despite the challenges we face in funding and resources, our clinical performance remains stronger than ever. For example, the ATCEMS system boasts a Cardiac Arrest Survival Rate of 12.9%. The CARES national comparison is 9.6%. ATCEMS also measures its performance in several other evidence-based areas.
Because Mr. Williams used a calculation of per capita cost that is used for the private sector without adjusting it for the public sector, his calculations failed to take all of the correct factors into consideration. In the private sector, revenues translate into profit. Because ATCEMS is not a private, for-profit agency, our revenues are returned to the city and county general funds. This allows both governments to use that revenue to fund other taxpayer priorities. This allows for better use of tax dollars. Our revenues reduce our total cost; therefore, our per capita cost is also reduced.
Long-term High Performance
ATCEMS is committed to continuous improvement. All EMS leaders have completed the Institute for Healthcare Improvement’s Open School to develop a common understanding of patient safety and performance improvement. The department is maturing in its ability to operationalize the IHI Model for Improvement. A group of 18 ATCEMS personnel are Root Cause Advisors equipped with skills in root cause analysis based on TapRooT training. Team leaders are tying all these skills together through improvement projects and A3 reporting.
ATCEMS is also preparing to apply for the Malcolm Baldrige-based Quality Texas Award for Performance Excellence and has six in-house examiners.
Through the development and implementation of its Community Health Paramedic program, ATCEMS is setting goals to reach toward the elements of the Triple Aim Initiative; a framework developed by the Institute for Healthcare Improvement that describes an approach to optimizing health system performance.
ATCEMS is preparing for changes to healthcare that will require healthcare providers, including EMS, to adapt, change and develop ways to improve the per capita costs of all services. The three dimensions of “Triple Aim” as utilized by Austin-Travis County EMS are:
- Improving the patient experience, including quality of care and patient satisfaction, through the ATCEMS Customer Callback Program;
- Improving the health of “at risk” populations through the ATCEMS Community Health Paramedic Program; and
- Reducing the per capita cost of health care by developing qualitative, quantitative and financial measures to become a more effective and efficient system.
ATCEMS was awarded CAAS Accreditation in July 2013, was recently re-accredited by NAEMD for its Communication Center of Excellence and, as previously mentioned, is currently pursuing the Malcolm Baldrige based Quality Texas Award for Performance Excellence.
As a leader in our industry, we understand that many are watching how our system will transform itself as the demands of an ever-changing industry continue to evolve. We believe, however, that Mr. Williams omitted much of what he knows about our system and was not objective in doing so. It is our opinion that he used tools to measure our system that have not been validated or that were designed for other purposes.
EMS Community Relations
City of Austin EMS Department
Austin-Travis County EMS
Author David M. Williams, PhD, responds:
The Austin-Travis County EMS Department (ATCEMS) is under significant local scrutiny from city audits, media attention, and community leaders pushing for change. The perspective of subject matter experts or the use of objective, industry-specific criteria to look at the system has been absent.
This article intended to provide a systems view of the Department, in as objective a way as possible, in order to present a counter argument to the prevailing rhetoric that the system is broken and needs to be changed versus improved.
The leadership from the Travis County Department of Emergency Services, Austin-Travis County EMS, and the Office of the Medical Director were advised months in advance of the aim and the method of the article. The author spoke to each leader in the course of the research process and then met in person with each to review the final article. No facts were challenged following their reviews.
Several of the concerns raised by ATCEMS were addressed in the article, including discussion of the selection and limitations of the method used and the imposed constraint of only using public data.
There is no universal standard or validated method for evaluating EMS systems. The EMS Structured for Quality criteria, similar to the CAAS standards, which the EMS Department recently celebrated accreditation, are rooted in the work of the American Ambulance Association and developed by industry stakeholders from the for-profit and not-for-profit sectors.
The decision to only use publicly accessible data was a constraint self-imposed by the author and served several purposes. Publicly accessible data ensured all data was referenced for any reader to review. It also reduced potential bias of the findings because it was based on published reports from the Departments itself or local media sources.
All figures reported in the article were referenced directly to reports generated for the EMS Advisory Board, current City of Austin Budget reporting data, or published in the local media. The article contained 30 references with the majority including a link to the source material.
Cost per capita or cost per member is a standard calculation used by the Agency for Healthcare Research and Quality, the Centers for Medicare and Medicaid Services, and the City of Austin (see “Imagine Austin Comprehensive Plan Cost Report” for EMS). The calculation takes the total cost of the department and divides it by the population served. There are no modifications made for profit status or organizational affiliation.
The methodology used as the framework for the assessment included specific criteria. The analysis included the specific findings related to the scope of those criteria. Information that was not part of the scope of the methodology was not included.
ATCEMS missed the aim of the article and its conclusion. In a community where elected officials and community leaders are questioning the department’s sustainability, this article is a singular voice from a community leader and subject matter expert that took an objective, data-based look at the EMS Department and concluded it wasn’t broken.