Administration and Leadership

The Evolution of MEDIC, Charlotte, N.C.’s High-Performing EMS Agency

Construction workers recently put the finishing touches on Medic’s new $48 million headquarters, a state-of-the-art facility that supports 600 employees, as well as an ever-expanding fleet of trucks, equipment and medical supplies.

Although the new headquarters is impressive, it really stands as a symbol of the hard work achieved by the organization’s people over the last two decades, says Joe Penner, executive director of Medic, whose teams serve all 544 square miles of Mecklenburg County, North Carolina, including the booming city of Charlotte.

Only after dedicating the entire organization to a patient-centered system of care and a culture of improvement did Medic establish itself as a premiere EMS organization—and one worthy of its new home.

For anyone who knows the history of the area’s EMS struggles, it may be hard to believe how far they’ve come.

Rewind 20 years: In the mid-1990s, the Mecklenburg County EMS system was failing in a very public way. Newspaper headlines reported long response times, firefighters complained about waiting on scene for ambulances to arrive, and residents—particularly those on the outskirts of the county—were noticing the poor service.

The system suffered from an aging infrastructure and had been ignored and underfunded for years. Political battles further complicated things, with the Charlotte Fire Department and two different hospital systems vying to take control of the county’s third-service EMS agency.

The situation in Charlotte drew national attention when JEMS published a cover story titled Battlefield Charlotte. In the midst of this crisis, county officials brought in Fitch & Associates, a leading EMS consulting firm, to manage the system and put in place a long-term plan for success.

After completely rebuilding the county’s EMS system, the firm recruited Penner as the new executive director—a position he still holds two decades later.

Earlier this year, Penner and Jay Fitch, PhD, the founding partner of Fitch & Associates, spoke at EMS Today: The JEMS Conference about Charlotte then and now, and how they helped lead the transformation of a failing EMS agency into one of the most respected systems in the country.

Medic’s personnel are essential in the effort to make Medic a better, stronger EMS agency. Photo courtesy Charles Eubanks
Medic’s personnel are essential in the effort to make Medic a better, stronger EMS agency.
Photo courtesy Charles Eubanks

Five Hallmarks

Joe Penner: I remember in March 1997, the big headline in JEMS was Battlefield Charlotte: The war over EMS. Set that stage for us.

Jay Fitch: This community was growing like crazy. What was interesting from an EMS perspective was that the volume was going up about 5% year upon year, and that happened for six or seven years prior to the system getting into crisis. There had been few additional resources during that time.

The service was an all-ALS service, but they had no new units and no new equipment, and they had major supply issues. EMS is like a balloon: If you push on it on one side, it’s going to bulge out on the other. So, response times really took a hit. They were managing at the 90th percentile at about 16 minutes.

Where that became the biggest problem was in the city of Charlotte, where the fire department’s first response was great—about four minutes to get on scene. And then they waited for a unit … and waited … and waited. That made the firefighters pretty angry. Being an election year, the politicians did what politicians do: set up a blue-ribbon commission to study the problem.

In some communities, cities and counties don’t always play nice together, right? When the city’s fire department began to say, “Hey, we can provide EMS,” the county was like, “Well, maybe not so much because we want to be concerned about the rural parts of the county, as well.”

There was a battle at the politician’s level. There was also infighting at the administrative level with the fire department. Then the hospitals offered to lead the system, and the county was skeptical about that, too.

So, the county asked us to put a transition plan and a transition team in place—to provide onsite management services in Charlotte. The county said, “We want you to write performance specifications for the system and we’re not quite sure yet who’s going to provide the service, so we want them to be tough. We want them to be painstakingly detailed.” To begin with, we told them they needed to do five things—follow five hallmarks.

First, regardless of how you design your system, you have to hold the emergency ambulance service accountable. We believe that you need to have an independent oversight agency; that somebody needs to be looking over the shoulder of the ambulance service to make sure they’re actually doing what they say they’re going to do.

Then you must account for all costs. That means first responder costs. That means all the ambulance service costs. That means the non-emergency services costs. Next, make it a requirement that all the features of the system ensure economic efficiency.

The last hallmark was, “Nobody should have the right to provide this service if they don’t do it well.” You should have a contractual relationship in such a way that there are penalties, and that you can fire the agency or the person if they don’t do what they’re supposed to do.

We started by putting a resident team on the ground: an executive director, an operations director and a part-time finance and reimbursement specialist. Because transitions aren’t easy, there was a 12-month window to make the performance targets. Trust was a big issue with the county and with the hospitals. We had to be able to move our resources where and when the calls came in.

Penner: There were a lot of concerns about things falling apart and people leaving to go to other agencies.

Fitch: Yes, and trust was also a big issue with the fire department. They had wanted to take over the system, and when county leadership went a different direction, that trust had to be redeveloped.

At the same time—on the street—firefighters and medics worked well together. One of the really outstanding things that built trust was that there were 1,200 firefighters who were trained that year in CPR and how to work closely with the medics. As part of its budget, the Medic agency purchased AEDs for every first responder in the county. They were all part of the system, and we had to make sure that the system equipped them to do what needed to be done. But what that really did was deliver on a promise to the fire department, so that improved the level of trust.

At the time, there were issues on all fronts. As a leader, when you find yourself facing that situation, you need to talk to caregivers about the vision, and to do that took time on the street.

It took being in stations at 10 or 11 o’clock at night and being back at 5 or 6 o’clock in the morning, and just showing people that there was a dream about how things were going to be different.

We also kept promises. Leaders need credibility to lead change. We made some big mistakes, but, when we screwed up, we admitted it, and we worked hard to treat people fairly.

We initiated weekly staff meetings that focused on performance and getting people involved. We really fostered teamwork. Last but not least, we involved the caregivers, in everything from the computer-aided dispatch (CAD) design to vehicle design.

Then we built a new building and began scouring the country for someone who could take on this magnificent mess that we created. We knew we had to have long-term leadership to make this work, and that’s where Joe comes in.

Medic ambulances drive a total of 2.8 million miles a year, responding to more than 146,000 calls for service. Photo courtesy Charles Eubanks
Medic ambulances drive a total of 2.8 million miles a year, responding to more than 146,000 calls for service.
Photo courtesy Charles Eubanks

Decades of Improvement

Today, Medic is independently operated by the Mecklenburg EMS Agency and receives its oversight from an Agency Board of Commissioners. The Board is comprised of members from Atrium Health (formerly Carolinas HealthCare System), Mecklenburg County, and Novant Health (formerly Presbyterian Healthcare). A Medical Control Board is responsible for establishing all emergency medical response protocols for Mecklenburg County.

Medic also collaborates with a network of first responders, comprised of 14 different fire departments, to provide EMS coverage throughout Mecklenburg County. Medic also manages a communication center that handles all 9-1-1 fire and medical calls for the county.

Penner: I’m a half-full kind of guy, so I like to think, how can we make things even better? Wherever we are, there’s always better.
Let’s talk about Medic today. I get to work with 600 of the best people in EMS. I believe everyone in EMS is special—but I really am privileged to be on the Medic team. Many are aware we just moved into a new building. We launch from that facility—take an ambulance, people, equipment and supplies. They go out and they serve the community. It’s a busy place. We drive about 2.8 million miles a year. In the past, it wasn’t anybody’s fleet. Today we know whose fleet it is, and they do an awesome job taking care of it.

There are close to a million residents in our service area and on a weekday, nearly one and a half million, so we have become good at system status management.

And here, management isn’t a noun, it’s a verb; you have to be active. How many ambulances do we need? Where should they be located? It’s not rocket science, and it is rocket science. We do quite well at it.

Fitch: When I look back over the 20 years, I realize you’ve done an amazing job at pulling things forward.

Penner: Again, I believe people come to EMS to make an impact with their career. It’s meaningful work! We want to do well, so we leverage all the perspectives in the business as often as we can—from the front line to support to managers—to come up with better choices, better decisions.

Even the hospitals help, they share with us resources we couldn’t afford to buy. We serve the same people and seek the best possible outcomes for them. And I believe most EMS organizations would benefit if you simply raised your hand and asked your local hospitals to join you in improving care because they really want to help. Your local cardiology group, for example, would love to talk with you about sharing information, and how to shorten STEMI times, or improve cardiac arrest outcomes.

Fitch: It’s really delightful to hear that Medic is now used as an example of collaboration and how that’s having an impact on other healthcare programs. As you think about it in your community, to achieve the “Triple Aim” in population health issues, requires collaboration.1 You, as EMS people, can’t do it by yourselves. It requires working together.

Penner: When we work together, it’s more fun. It’s better, it’s easier; we’re going to make better solutions, and all of us deserve rest here and there. The number one thing we do is we listen to our people. They’re engaged and are essential in the effort to make Medic better.

I think there was a transformation of Medic about 10 years ago. The first 10 years, those were the easy years because you just throw money at stuff, write checks. That’s the easy stuff. But when you want to change behaviors? You want to change culture? That’s much more difficult.

One example on improvement. Something we did was give the responsibility for performing CPR to first responders. Our team saw in the simulation lab that they were very effective at it—and it frees up the paramedic to watch and manage the other parts of the resuscitation process.

And because measurement matters, we were able to be very specific on how we could improve. We were very focused on what good, quality CPR is. We measured compression rate and depth, flow time (time on chest), and time to shock.

Getting Better

In 2017, Medic clinicians were recognized by the American Heart Association with a Mission: Lifeline Gold Plus award.

They also achieved an impressive 55.8% survival-to-discharge rate for patients meeting the Utstein criteria. The national average for all systems reporting to the Cardiac Arrest Registry to Enhance Survival (CARES) is 32%.

Fitch: That sounds like one of the real big accomplishments, then. You were training first responders using measurement—not just teaching CPR, but giving that feedback about it. The important part is measurement and how you integrated that into the improved outcomes.

You were also one of the early EMS systems to engage with the Institute for Healthcare Improvement (IHI).

Penner: IHI Improvement Advisor Training—I highly recommend it, and it pays for itself. While there, I learned of “Quality as a Business Strategy.” Now I call it our operating system. Imagine everyone in your business clear about their responsibilities, how work gets done, what their responsibilities and level of performance are.

There are six activities that every business must be intentional about to maximize success. The first is purpose. As part of this purpose activity, a group of employees developed our mission statement: “To save a life, hold a hand, and be prepared to respond in our community when and where our patients need us.”

Our purpose, collectively our mission, plus the vision of the Medic we’re building and our values—it all matters because now you have line of sight for everyone, from their activities to why they matter. It drives so many of our conversations, and when we pay attention to all of it, we’re so much clearer on what we’re doing.

The second activity is the organization—viewing your organization as a system. IHI taught me to understand our organization as a collection of processes; all work gets done in processes.

The third is measurement: How do you know that your business is working? How do you know the processes are stable and at a desired level?

The fourth is checking in with your customers. You can call it whatever you want to call it, but we have pre-service conversations with people who have never used an ambulance. We do focus groups every two years. We ask, “What are your expectations?” And ask point-of-care questions of the people who we serve right now, “How are we doing?”

Then there are post-service questions. So, we’re checking in pre-service, in the ambulance and post-service.

As part of planning—which is the fifth activity—we develop strategic objectives to move us toward our vision. Drucker’s quote, that the best way to predict the future is to create it, is so true. Here’s what we’re going to focus our efforts and resources on—spend money on—to move Medic to become that organization we want to be.

Finally, the last activity is improvement. And you can substitute LEAN, or other methods, but here we use IHI’s Model for Improvement. No longer do we simply dispatch theories to implement; people perform PDSA’s [plan-do-study-act] and the learning is tremendous. It’s a very useful and disciplined process, improves process performance, and most importantly, develops our people who become better at improving things. It is a very powerful set of tools that builds momentum.

Fitch: The message is we all have room for improvement in our systems, and the take-away is to get after it and make those improvements, and make a difference.

Reference

  1. Institute for Healthcare Improvement. (2015.) The triple aim. Retrieved May 16, 2018, from www.ihi.org/Engage/Initiatives/TripleAim/pages/default.aspx

Medic’s New Headquarters

Charlotte as well as the surrounding area, encompassing 546 square miles. In 2017, the agency—which employs 611 full-time employees—recorded 146,265 responses.

In 2018, Medic opened a new state-of-the-art facility. Here are some highlights:

  • Square footage: 181,073 spread over three buildings: the operations and administration building, a fleet maintenance facility and an automated vehicle wash
  • Fleet: 72 ambulances: 64 ALS units—most of which are built on a new 4-door Dodge 5500 chassis with a CAAS GVS certified patient care module built by AEV; 8 non-emergency transport vehicles built on a Type 2 Dodge sprinter chassis. Every day at the new facility, ambulances are cleaned and restocked 90 times.
  • Simulation center: A simulation center and two sound stages are used to create realistic scenarios using vehicles and high-fidelity patient simulators for training and continuing education.

 

Table 1: Medic’s mission, vision and values
MISSION
To save a life, hold a hand, and be prepared to respond in our community when our patients need us.
VISION

Medic will be an adaptable patient-centered system of care by:

• Continuously improving the patient experience of care
• Involving patients in decision-making regarding their healthcare
• Better aligning resources with patient needs
• Becoming more integrated into community and healthcare resources

Medic will be an an excellent place for people to work by:

• Demonstrating appreciation and value
• Seeking to understand and meet employee needs
• Providing opportunities to develop and use skills and talents
• Involving employees in improvement and decision-making

Medic will be fiscally sustainable by:

• Reducing per capita costs
• Exploring or pursuing alternative funding sources or models
• Adapting to future healthcare policies

VALUES
OUR PATIENTS OUR PEOPLE OUR STEWARDSHIP
Our patients are the reason for Medic’s existence. We serve our patients through a system of quality care focused on the patient experience with advocacy, respect, compassion and integrity. Our people are our most important resource. We invest in our people to create an engaged, accountable, safe and competent workforce (lead with competent). Our stewardship of resources allows us to fulfill our mission. We dedicate ourselves to financial awareness by practicing efficient and responsible allocation of resources.

 

Table 2: Five hallmarks of a good EMS agency

Hallmark 1

Hold the emergency ambulance service accountable.

Hallmark 2

Establish an independent oversight entity.

Hallmark 3

Account for all service costs.

Hallmark 4

Require system features that ensure economic efficiency.

Hallmark 5

Ensure long-term high-performance service.