When putting together the EMS Compass Steering Committee, the initiative’s leaders knew it was important to include experts on performance measurement and quality improvement from outside of EMS. Those “outsiders” include a health economist, a patient advocate, a physician, and an expert in performance management in public organizations. Below is the first of four profiles of these experts who have helped put EMS Compass in the context of the broader healthcare continuum and performance management efforts.
The Performance Management Expert
Including researcher Patria de Lancer Julnes, PhD, on the EMS Compass Steering Committee was a clear effort to reach far outside the EMS community. De Lancer Julnes, the head of the school of public affairs at Penn State Harrisburg, isn’t an expert in healthcare or public safety. But she has dedicated her career to the use of performance measurement and management in government.
de Lancer Julnes
“I think [the EMS Compass leadership team] really wanted to have a very broad perspective. Sometimes when you just talk amongst yourselves you lose sight of the bigger picture,” de Lancer Julnes said.
The bigger picture includes how people, not just systems and organizations, respond to performance measures.
“[People] aren’t used to actually applying evidence to day-to-day operations,” she said, adding, “One, they feel like they are being judged. Also there’s the perception that trying to [use data and examine measures] is going to create more work.”
When employees feel performance measurement is being used to judge or punish them, rather than to improve service, it can have negative consequences.
“There is a risk, and unless we decide that the goal is really for learning and improvement and not for punishment, people are going to continue to be scared and they will continue to push back when it comes to performance measurement,” she explained. “Not just the people on the ground, but also the decision-makers.”
De Lancer Julnes also stressed the difference between establishing performance measures and establishing standards. In many cases, she said, organizations use good measures but establish meaningless or unrealistic standards.
“Politicians or bosses say we want to have a 99% [score on a measure]. You do have to be ambitious but you also have to be realistic,” she explained, adding that when unrealistic goals are set, “what happens when you don’t achieve those unrealistic goals is that you are blamed.”
Although his medical training included little time in an ambulance, EMS Compass Steering Committee member Kedar Mate, MD, knows a bit about improving healthcare. As a hospitalist and professor in New York, he treats patients and supervises new physicians. And as a senior vice president for the Institute for Healthcare Improvement (IHI), he travels the world helping to improve systems of care. Prior to joining IHI, he worked with Partners in Health and in the HIV/AIDS division at the World Health Organization. He has led efforts to raise rates of HIV treatment and to reduce childhood mortality in Africa.
“To make any system behave differently, you have to have some way of knowing what’s happening, to know whether your change is resulting in improvement,” he said. “Measurement is the bedrock of improvement.”
Too often measurement in healthcare is associated with accountability, Mate says. So-called “poor performers” are chastised or punished for not meeting certain standards.
“One way to make your system perform better is to find all the defective parts in the assembly line and just get rid of them,” he explained. “The problem with that theory is that it’s measurement for judgment–it’s measurement for discipline. You get a cycle of fear: ‘I don’t want to report my data because somebody’s going to fire me or kick me out of the system.’ Fear becomes the currency of that kind of system.”
People try to hide errors or bad outcomes, instead of examining why they occurred and fixing them.
“I think the opposite of that is continuous improvement. No matter where you fall on the bell curve, you can improve,” Mate said. “There’s no upper limit. Every year, we can [all] get a little better.”
Mate has seen how the development of performance measures can be a contentious and at times divisive process as the measures are dissected and debated. The solution, he argues, is not to aim for perfection, but rather to test measures and see whether they help improve processes and outcomes.
“We’re never going to get it exactly right-there’s no sense in even trying,” he said. “I’ve yet to see a situation in which the measures are, right out of the gate, completely nailed.”
The Patient Advocate
Martha Hayward has never held any healthcare provider credentials. Yet for the last five years, she’s been immersed in the nuances of healthcare improvement as the lead for public and patient engagement at the Institute for Healthcare Improvement (IHI).
Hayward brings the patient’s perspective to healthcare improvement: 10 years ago she was diagnosed with breast cancer. She remembers arriving at the hospital one morning for surgery and learning firsthand how improvement efforts can have an un-intended impact on patients. A hospital employee placed a band on her wrist and asked her why she was there-the first step in a safety procedure put in place to prevent performing surgery on the wrong patient or the wrong site.
“It took me about three minutes to say bilateral mastectomy,” Hayward recalled.
By the time she arrived in the operating room, she had been asked the same question about a dozen times. Her anxiety levels increased, and her husband’s frustration led him to shout, “Why does no one know what she’s here for today?”
A decade later, Hayward understands why they asked so many times, but also knows that there are ways to achieve the same result without increasing her fear. For example, hospital staff could have explained that the questions were a safety measure, making her feel like part of a team and reducing her anxiety.
“I would’ve felt confident with them, rather than completely freaked out,” she said.
Hayward later served on the Patient and Family Advisory Council at the Dana-Farber Cancer Institute before joining IHI, where she met Dave Williams, chair of the EMS Compass Measurement Design Group. She shared her experiences as both an EMS patient and a family member-her brother, an EMT, died in a line-of-duty helicopter crash.
Hayward says patient interaction with EMS is about more than just the care provided in the ambulance.
“When you’re meeting somebody in the midst of a crisis … prior to the activity at the hospital, that interaction can be so key to the patient’s safety,” she said, adding that EMS practitioners can help the patient “feel calm, feel focused on, feel safe. It’s going to change the way the patient presents at the hospital. It’s key to the entire patient experience.”
The Health Economist
University of Texas Associate Professor of Public Affairs Todd Olmstead, PhD, wasn’t an EMS expert when he began advising a group of public policy students who were studying how to better integrate Austin-Travis County EMS with local healthcare networks. But in some ways, he was the perfect person for the project.
While his current research focuses on health economics, Olmstead previously made his living as a transportation logistician and wrote his dissertation on highway safety. At the intersection of healthcare and transportation sits EMS.
“I knew enough to be dangerous, when this was starting,” he said of his students’ study, which was part of a requirement for master’s students to participate in a policy research project. “I was invited because I was a health economist. I spend a lot of time thinking about how much stuff costs, and who’s paying for it.”
Olmstead brings to EMS Compass the perspective of someone who has spent time analyzing complicated systems-whether in his job as an operations research analyst at Union Carbide early in his career, as a consultant with McKinsey & Company, or researching the cost-effectiveness of substance abuse programs. To Olmstead, measuring the effectiveness and efficiency of EMS systems isn’t only possible, it’s necessary.
“Otherwise you’re just wasting resources, or misallocating them,” he explained. “[EMS leaders] have a lot on their plates, to be sure. But I don’t know if they have the information or the analysts at their disposal to tell them how they’re doing. And maybe they’re afraid to find out. What if we find out we’re terrible?”
Olmstead, who also sits on the steering committee for the Promoting Innovations in EMS project (www.emsinnovations.org), recognizes that EMS agencies have limited resources and often lack the time or expertise to perform data analysis. He sees the potential of EMS Compass to help ease that burden and make data accessible to even the smallest agencies. He also sees it as a chance for EMS organizations to benchmark and share best practices in a professional environment that encourages open dialogue.
“One of the reasons for having EMS Compass is to try to develop measures that are pretty much apples to apples across agencies, so you can find the good performers and see what they’re doing right, and have them teach [other agencies],” he said.