Identifying the stakeholders and what they need from us
In the immortal words of Astronaut James Lovell during the Apollo 13 mission, “Houston, we have a problem.”
For the past three decades, EMS leaders and public policymakers have educated the community that generally a “fast” EMS system equates to a “quality” EMS system. We have no one to blame for this but ourselves. We promoted time as the most valuable component of EMS system design and have invested millions of dollars across our nation to achieve an eight-minute ambulance response time goal.
The problem lies in the growing body of research indicating that any response time greater than five minutes for the most critical of our EMS response requests–cardiac arrest–has a minimal, if any impact on patient outcome. Before you shoot the messenger, I acknowledge that although current research indicates that response times don’t clinically matter for the vast majority of our medical calls, there is a customer service aspect to this part of our service delivery that needs to be balanced.
The larger issue is that, as the healthcare landscape continues to dramatically change, it will be increasingly difficult to prove our value to stakeholders based solely on how fast we get to the patient.
So, our mission, should we choose to accept it, is to begin focusing on “What Matters” to our internal and external stakeholders. In some cases, this will include the need to educate them on the “What Matters” concept. What matters will be different based on the specific view and role of stakeholder involved, but there are some general concepts we, as EMS leaders, should begin to be prepared to discuss with our customers.
What matters from an employee perspective?
Arguably, our success or failure is primarily dependent on the way our employees interact with our customers. Keeping them happy, or at least satisfied, is crucial. The things we hear most often from our employees about what matters to them are:
Will I get off shift on time?
Of course, EMS is EMS and there will be times when employees must stay late, but are we, as managers, doing all we can to help minimize the frequency our employees are assigned calls that will result in their late departure? Do we have processes in place that provide post/station coverage for them to help them avoid being assigned a call close to the end of their shift? Does our schedule and payroll process provide enough overlap of shift start and end times to afford street resources to prevent low resource call assignments?
Is my equipment safe and reliable?
For our field employees, the ambulance and equipment in the ambulance is their office for 12 hours. They want to know that everything the ambulance works, it’s comfortable (seats, armrests and cooling systems count!), and looks nice to the public. The same is true for the equipment.
Does anyone care about me?
The motivation of most EMS workers is that they want to make a difference. An aspect of making a difference is that employees want to be heard and be recognized for the value they bring to the organization. Do we have an environment that embraces and encourages employee input and recommendations? Are members of the management team available when it’s convenient for the employee, or do they need to schedule an appointment to talk to a manager? Do members of the management team go to see the employee in their environment instead of them always having to go to the “second floor”?
Most importantly, when employees communicate with their manager or supervisor, is the manager “present”–meaning, are they focused on the employee or distracted by other things during the conversation? It may be as simple as whether we respond quickly when an employee sends an e-mail or text. Nothing kills morale faster than not responding to an employee who has taken the time to reach out and communicate with you.
What matters from a patient perspective?
Patients rarely know if the clinical care we provided them was consistent with sound medical protocol and guidelines, but they do know if we were not nice to them. The compliant calls managers receive from patients typically are not, “Ya know, your paramedic treated me for a third-degree heart block, but I’m pretty sure my rhythm was seconddegree Mobitz Type II.” More often, we hear calls like, “I was really scared and all I wanted was the paramedic to hold my hand on the way to the hospital. I asked her and she said, “˜I don’t have time to do that ma’am, I have to complete my patient care report.'”
What matters to the patient is, were we nice to them? Did we put a blanket on them? Did we explain everything that was happening? Did we seem concerned about them and their anxiety? Did we refer to them by name at the hospital instead of, “Where are we putting the arm lac?”
What matters from a clinical perspective?
How do we identify, track and report to the community what makes a difference in patient outcomes? EMS is healthcare, but we have not done a good job of demonstrating that there is a difference in patient outcomes when they go to the hospital by ambulance. Does endotracheal intubation proficiency matter? Does IV proficiency matter? Does protocol compliance matter if the patient outcome was positive? Defining measures of clinical quality can be a daunting task, but here are some things we should all reliably measure and report:
- Percentage of ST-elevation myocardial infarction (STEMI) or stroke patients correctly diagnosed as STEMI or stroke. How good are we at identifying STEMI and stroke patients? How many do we miss? What is our under and over triage rate?
- Percentage of patients with STEMI or stroke transported to a STEMI or stroke center. Of the patients we correctly diagnosed with STEMI or stroke, did we take them to the right place?
- Symptom onset to PCI time. Hospitals for years have focused on door-to-balloon (D2B) times, but that is not good enough. It makes no sense to have a 28-minute D2B time when the patient sat at home for three hours with ischemic chest pain or stroke symptoms (and affected cardiac tissue is now impervious to reperfusion). What are we doing in our community to educate people to seek help when chest pain starts–and the reasons to not wait?
- Percentage of cardiac arrest cases with neuro intact at discharge (good or moderate cognition). All the metrics we currently measure and report really point to this final metric. How well do we, as a system (all components, out-of-hospital and in-hospital), work together to return a patient back to productive function? All the rest of the measures (call processing time, response time, automated external defibrillator (AED) time, etc.) only outline a process that we need to continually improve to impact this measure.
- Number of people trained in CPR. One of the most important predictors of survival from cardiac arrest is bystander CPR, or more importantly, bystander cardio-cerebral resuscitation (CCR). Tracking how many people you train in CCR is a great predictor of improving bystander CCR rates and therefore survival rates for out-of-hospital cardiac arrest.
What matters from a hospital perspective?
In the past, hospitals cared most about on-time performance and the ease of requesting ambulance transport. However, their expectations are drastically changing. Yes, on-time arrival is still important, but so is patient satisfaction, since it could reflect on their Press Ganey scores and subsequent reimbursement in the new health care reimbursement scheme.
Hospitals also have major issues with readmissions. What are we doing to prevent readmissions? Are we providing data on most frequent patients or facilities sending patients? Are we working with them on taskforces to reduce unnecessary admissions? Should we be working collaboratively on programs to take the right patient to the right facility–which in some cases is not the emergency department? What is the impact of those processes on the hospital’s economics? These are things we should determine with our hospital partners.
What matters from a payer perspective?
The payers of our services today will most likely not be our payers in the near future. This is already changing with accountable care organizations and bundled payment schemes being pushed in the Patient Protection and Accountable Care Act. Payers care a lot about how we can impact their cost stream. Are we a navigator of patients through the health-care system–getting the right patient to the right facility at the right time–or are we a transportation commodity to be auctioned to the lowest bidder?
How are we partnering with payers to demonstrate the value of our services (and expanded services) to patient health and payer health? If we keep chasing the same payment model for our services (using the most expensive mode of transportation–ALS ambulance in less than nine minutes 90% of the time–to take the patient to the most expensive setting for primary care–the emergency department), we are going to die a slow death. We need to make value proposals to the payers–get outside of our sandbox and find a new service delivery model that matters to the patient and the payer.
What doesn’t matter?
The flip side of all this is to stop focusing on what doesn’t matter. This includes punitive policies that don’t make a difference, sending the entire cavalry to calls that don’t need it, having a drug box full of drugs that get restocked only due to expiration, and creating clinical standards, procedures and barriers that make no difference in patient outcome.
Stop “busying” your schedule with things that don’t matter to the detriment of being able to invest time with your employees in their environment.
Finally, the only way to truly know what matters to these stakeholders is to ask them! When was the last time you sat down face-to-face with your internal and external stakeholders, looked them in the eye and asked, “What can we do to help you with something that matters to you?”