Most EMS organizations have a long list of things they’d like to do, from updating hiring practices and improving safety to patching that growing hole in the parking lot. But the way items move from the “to-do” list to the “completed” list often has more to do with how urgent something is than how important it is.
“Unimportant but urgent” has a way of trumping “important but not urgent.” The result is a lot of items in the important category that don’t get addressed, and an environment that feels like all the priorities are upside-down.
Allina Health EMS, a hospital-owned nonprofit EMS system that serves approximately 1 million people in Minnesota, is a great example of how to turn things right-side up again.
Allina’s president, Brian LaCroix, is fond of pointing out that there are only two roles at Allina Health EMS: direct caregivers and those who support direct caregivers. “Everyone has what we call “˜line-of-sight’ to patient care, and everyone understands how important their roles are to patient care,” LaCroix says of the organization’s nearly 600 employees.
In that philosophy, the role of the organization is clear–to support direct caregivers. At Allina Health EMS, that translates not only to doing the obvious, such as scheduling, training, vehicle maintenance, billing and the like, but also the not-so-obvious.
I’ve spent time with and observed the operations, innovations and resuscitation success at Allina EMS. More importantly, I’ve ridden with crews, supervisors and medical direction physicians in the Allina system, so I have a firsthand perspective on the people of Allina EMS. They’re the fuel that drives this progressive healthcare system and allows them to be successful.
Following are 10 things Allina does, and that I believe every EMS system should strive to do, to support and enhance patient care.
1. DETERMINE YOUR “˜WHY’
Allina Health EMS President Brian LaCroix leads an agency where staff embrace the organization’s mission of serving their communities with exceptional care. Photo Jeff Lucia
In 2013, as part of a two-day planning retreat, the leadership team at Allina Health EMS thought outside the box and brought in a facilitator to identify the organization’s “why”– the deep-held beliefs that cause people to act the way they do.
What they discovered surprised them. “Our mission statement begins with the words, “˜We serve our communities with exceptional care,'” says LaCroix, “but we hadn’t realized how deeply the idea of caring runs through our whole organization. As cliché as it sounds, we really do care–about our communities, our patients and each other.”
Finding your organization’s “why” is important because it gives an organization the power to attract and retain people who share beliefs, inspire others to support the agency’s mission, persevere when the going gets tough, and much more.
For an organization providing a critical service like EMS, where there are always emergencies and system demands competing for attention with all the other things an organization needs to do to be healthy, knowing your “why” can be a powerful tool for making decisions, setting priorities, and even helping people whose values don’t align with the organization’s to realize they need to look elsewhere.
Find your organization’s “why” and you’ll discover a whole new way to motivate and inspire others.
2. INVEST IN SAFETY
Allina redesigned the back of their ambulance with both patient care and crew safety in mind. Note the adjustable seats on both sides of the stretcher. Photos Jeff Lucia (interior) and courtesy Crestline Coach Ltd.
Ambulances and other vehicles at Allina Health EMS travel more than 4 million miles annually. In recent years, Allina has implemented comprehensive safety initiatives to educate staff, limited the number of miles driven with lights and sirens, and leveraged technology to improve safety.
Three important technology solutions are now being used to accumulate and communicate vehicle operating data and location information via a system often referred to as telematics or informatics, which monitors driver behavior and provides feedback to staff.
Allina has also taken on the issue of violence against EMS providers. Kevin Miller, operations director and deputy chief at Allina Health EMS, notes, “It has been demonstrated that 8.5% of EMS calls involve some sort of violence, and in 4.5% of those cases the violence is aimed at the EMS provider.” This important fact should alert other systems to an area that may have fallen off their radar screen.
Allina Health EMS has also advanced the work of reporting medical errors as a charter partner and member of the Emergency Medical Error Reduction Group (EMERG). Through information sharing and lessons learned, EMERG enables providers, industry partners and all stakeholders to work together to find, implement and sustain improvements that make patient care and delivery safer, more effective and, ultimately, without preventable error. The organization also supports the national EVENT near-miss database.
If your organization needs a wake-up call about the impact a serious ambulance crash can have, there’s much you can learn from Allina Health EMS. After a horrific ambulance crash in 2014 that left two Allina Health EMS crew members seriously injured (but, thankfully, on the mend and back to work), the organization decided to invest the time, effort and finances to improve the safety of its ambulances.
“Our main priority was to redesign the back of the ambulance so that our clinicians no longer need to stand [or move around] to deliver patient care or reach supplies,” says Jeff Czyson, operations director at Allina Health EMS.
In a true innovative approach, representatives from Allina Health EMS worked with three ambulance manufacturers who each submitted prototypes for in-service testing in an effort to meet the needs, demands and design requirement presented by Allina. After careful review of the three prototypes, the model built by Crestline was selected for a fleet purchase.
“The bench seat has been replaced with a standard seat with a four-point harness instead of a lap belt, and all cabinets are also padded and angled,” Czyson says. “We’ll make some revisions to the best design and hope to start rolling out our new ambulances in mid-2016,” he adds.
Allina has also installed a fleet management and vehicle tracking system on all of its ambulances. The Fleetmatics/GeoTab system and Road Safety monitors driving and provides instant feedback to the driver on G-force, speed, acceleration/deceleration and other measurements.
In addition to protecting its own employees through the knowledge gained from the 2014 crash, Allina Health EMS has made a commitment to reach out and help other agencies via presentations at national conferences as well in comprehensive articles.
3. MAKE FOCUSED CLINICAL IMPROVEMENTS
Allina’s focused clinical improvement efforts resulted in cardiac arrest survival rates that are now among the highest in the nation. Photo Jeff Lucia
Beginning in 2007 and in every year since, Allina Health EMS has identified “care goals”–a clinical area where they felt their system had room for improvement. The process is worth emulating.
Susan Long, director of Allina Health EMS Clinical Services, says, “First, we establish our baseline performance, then we create a system-wide education program. Once the education program has been rolled out, we regularly measure outcomes and offer feedback to our clinicians.”
Planning and development for each care goal starts months before the official launch by researching what’s happening inside the EMS profession as well as other healthcare quality measures from groups like The Joint Commission. They then brainstorm with physician leaders, members of the quality improvement (QI) team and representative clinicians who provide direct patient care.
Past care goals have focused on congestive heart failure (CHF), ST segment elevation myocardial infarction (STEMI), respiratory distress, high-risk non-transports, stroke, cardiac arrest, treat-and-release patients, pain management and sepsis recognition.
Does it work? In a word, yes. For cardiac arrest, survival rates (measured as hospital discharge with a cerebral performance score of 1 or 2) are now among the highest in the nation, increasing Utstein survival rates that were in the 30%-range in 2007 to 50% and higher during the most recent three-year period.
Compliance with stroke recognition protocols improved more than 29%; treatment of shortness of breath due to CHF, asthma, chronic obstructive pulmonary disease (COPD) or acute heart attack improved more than 13%; and STEMI care improved more than 19%, with 99% of STEMI patients now receiving “best practice” care as defined by the latest treatment guidelines and standards.
In fact, for the past seven years, Long says Allina Health EMS has achieved each of its target clinical outcomes. “One of the biggest benefits is that by the end of the year, we’ve hard-wired these practices into our system going forward, so it’s an improvement that endures.”
4. BECOME AN EARLY ADOPTER
EMS Medical Director Charles Lick, MD (center), works closely with the crews and guides the agency in their efforts to become early adopters of emerging clinical practices, which are often part of clinical trials and the subject of research presented in journals and at conferences. Photo Jeff Lucia
When new clinical, operational, technological or business practices emerge, Allina Health EMS has consistently been an early adopter. With an approach using the business philosophies of PDSA (plan, do, study, act) and Rapid Test of Change, Allina Health EMS has implemented numerous practices in a nimble fashion that belies the size of the organization.
Being an early adopter means that sometimes Allina takes calculated risks, and not all approaches meet their expectations. This approach parallels that of successful nonmedical corporations and is an acceptable approach in the business world because you have to continually try new processes and products to improve performance.
This willingness to try new things has for a majority of the time paid dividends for Allina’s patients and the communities it serves.
In 2007, under the visionary leadership of respected EMS Medical Director Charles Lick, MD, Allina became the first EMS agency in the country to fully adopt the LUCAS chest compression system as its mechanical CPR device. As the organization with the most field uses of LUCAS in the country, the manufacturer sought early feedback from Allina Health EMS about how the LUCAS was packaged and operationalized, resulting in enhancements that are still in place.
Allina has also consistently followed up its programs and enhancements with research to show its effectiveness and ability to impact patient care. Multiple clinical trials have been implemented across the wide geographic region Allina serves, including leading-edge study of technologies such as temporal thermometers, lactate meters, the specially designed cardiac arrest ArrestPAC, the impedance threshold device and video laryngoscopy. Several of these efforts have resulted in published papers in Prehospital Emergency Care, Prehospital Disaster Medicine, Circulation and JEMS. The organization has also presented research posters at national and international conferences.
Another achievement Allina Health EMS is proud of is its dispatch center’s highly coveted accreditation as an Accredited Center of Excellence (ACE) by the International Academies of Emergency Dispatch.
“We are honored to be recognized as one of the top dispatch centers in the United States, where only 4% of centers have achieved this distinction,” says Communications Director Chuck Kaufman. “This is an important achievement for our teams who have been working hard to raise the bar on the level of care we provide our communities.”
5. CONNECT WITH THE COMMUNITY
The primary role of Allina’s community paramedics is prevention and coaching, but they also help patients navigate the healthcare system. Photo Jeff Lucia
The best EMS systems forge strong connections, on many levels, with the communities they serve. This is an incredibly valuable asset, especially in light of what’s occurring throughout the U.S. with police departments being criticized for having lost the connections they once enjoyed with their communities.
To provide the best patient care, EMS needs the trust, cooperation and support of the public, civic officials and the media. But many EMS systems, struggling just to keep up with day-to-day operations and tight finances, find it difficult to make community programs and relationship-building a priority. However, tough times are exactly when agencies most need support from their community, so LaCroix recommends making community involvement central to your organization’s mission–and budgeting for it.
“Our organization is highly involved in community outreach projects, participating in events ranging from helping to make resuscitation equipment widely available in our communities to raising money for cystic fibrosis,” he says. “We also participate in numerous prevention programs, including safety fairs, bike helmet programs and car seat clinics, as well as CPR, AED and first aid classes. And like a lot of EMS systems, we provide coverage at special events throughout the communities we serve–more than 500 events in 2015 alone, in fact.”
“One of our favorite things is community health fairs held in conjunction with the fire departments we serve,” LaCroix adds. “That’s our chance to teach community members about what we do–we want people, especially children, to see what the back of the ambulance looks like and understand its purpose in the event they need to use our services at some point in the future,” he says.
One special program Allina is involved with is Freedom House Station 51. Founded by the city of St. Paul, its fire department and Inver Hills Community College, Freedom House Station 51 is fashioned after the historic Pittsburg paramedic program of the 1960s. They’ve trained dozens of young men and women as EMTs. Recruitment is targeted toward youth of diverse ethnicities, linguistic abilities and cultural experiences, with the goal of building an EMS workforce reflective of the community. Allina provides financial support and employees regularly volunteer to teach EMT classes.
“Most importantly, we have hired approximately 20 graduates from the program,” says LaCroix. “We’ve been able to hire some really bright EMTs who have helped us as an organization be more representative of our community. Just a few years ago, only 2% of our employees identified themselves as minorities; now it’s closer to 16%.”
As a show of their commitment to the Freedom House purpose and benefit, in October 2015, Allina launched its own version of Freedom House with 10 EMT students enrolled.
Finally, the organization invests in a comprehensive annual community report, summarizing not just its statistics, clinical achievements, finances and community involvement activities, but also reminding stakeholders of the shared beliefs and values that characterize Allina Health EMS. “The community report is a powerful way for us to share our story,” says LaCroix. “It’s incredibly important.”
6. CONNECT WITH THE REST OF THE EMS PROFESSION
Allina EMTs and paramedics routinely provide training to the firefighters and law enforcement personnel they routinely interface with. Photo Jeff Lucia
When your organization has its hands full just keeping up, it’s a lot to ask to take time (not to mention money) to attend regional meetings, conduct research, write papers or participate in national conferences. But progressive EMS systems make staying connected to the rest of the EMS profession a priority.
At Allina Health EMS, that philosophy is baked in. The organization’s president and EMS chief serves on the board of the National EMS Management Association and has chaired both a local community college EMS advisory committee and a county EMS council. Its director of clinical services is currently president of the North Central EMS Institute. Other members of Allina’s leadership team serve on the board of the Minnesota Ambulance Association and the state’s EMS regulatory board.
Allina officials have also made it a priority not just to learn from colleagues, but to share what they’ve learned with the rest of the profession. The organization has supplied presenters to numerous state and national conferences, leading education sessions on both clinical and operational topics, and it encourages its team members to write for journals, websites and conferences.
7. INTEGRATE YOUR SYSTEM INTO THE OVERALL HEALTHCARE SYSTEM
“Being hospital-based brings many benefits, not the least of which is our connection to physicians,” says Lick. “For example, we recently worked closely with several Allina Health neurologists to identify and quickly treat a specific type of stroke, transporting these patients directly to a specialty stroke care hospital and saving valuable time–and, often, lives.”
Allina Health EMS has also embraced mobile integrated healthcare, employing its own team of community paramedics. Having undergone an additional 300-plus hours of specialized training, the Allina community paramedics are credentialed by the state of Minnesota and take on a preventive role. They visit patients in their homes to teach them about proper nutrition, check for objects that increase the risk of falling, instruct them how to access the healthcare system in the most effective way and more.
“Our primary role is prevention and coaching, as well as patient navigation,” says program manager Cory Kissling. “It makes sense to prevent illness, and it’s working.”
In 2013, Allina also launched an education and prevention project to reduce the number of readmissions and ED visits for patients with a history of repeated ED visits, mental health issues, or frequent hospital readmissions for CHF, COPD or heart attack.
The results have been extremely positive. Among the hundreds of patients seen by Allina’s 12 community paramedics in 2014 and 2015, the 30-day readmission rate was just 5%, significantly lower than the national average all-cause 30-day readmission rate of 18.4%.1 Among patients who were identified as high-frequency ED users (i.e., those who visited the ED at least 10 times in three months), 78% didn’t have a revisit within 30 days.
None of these achievements would’ve been possible without close collaboration with other healthcare professions–and professionals.
8. STAY CLOSE TO THE PUBLIC SAFETY FAMILY
Allina places high expectations on their caregivers, ensuring that high-quality patient care is delivered to the community they serve. Photo A.J. Heightman
The past couple years have brought unprecedented opportunities for EMS to come into its own as a respected member of the healthcare community via expanded patient care roles, innovative collaborations, data sharing and other initiatives. But it’s also critically important for EMS agencies to protect the special place EMS has in the public safety and emergency response community.
“As a hospital-based system, Allina Health EMS has a unique opportunity, as well as the responsibility, to form and maintain a solid connection between the worlds of healthcare and public safety,” notes Czyson. “These are the people we’re working alongside, not just in the clinical setting but in the streets, and we need to be able to count on each other.”
To help keep that relationship strong, Allina EMTs and paramedics often provide CPR and first aid instruction, as well as EMT classes, to firefighters and law enforcement personnel throughout the Allina service area. And the agency’s annual Pulse Check education conference draws attendees from all three branches of emergency services.
The organization also supports public safety traditions such as parades and honor guard programs. In fact, the funeral of a recently retired longtime Allina Health EMS clinician was attended by uniformed personnel and vehicles representing emergency response agencies from across Minnesota and western Wisconsin. “They came to pay their respects to the family of a respected member of the public safety community, but they also came to honor the traditions we all stand for,” says Czyson.
9. COMMIT TO LEARNING
Allina Health EMS supports its clinicians through a full-time clinical services department that oversees education and QI programs. Clinical providers in the Allina system have more than 100 hours of continuing education available to them during their twoyear recertification cycle. The department provides twice-per-year classroom sessions focused on the timely and topical subjects lead by a physician medical director, system physicians and other clinical leaders from across the Allina Health system.
Additionally, mortality and morbidity conferences are held every month. What began as a classroom lecture has expanded to an interactive experience that dozens of staff join via webcam. This approach parallels what hospitals do and further enhances the EMS profession by offering a similar review for prehospital cases.
The organization also provides traditional offerings to clinical staff such as CPR, ACLS, PALS, etc., along with regular education for emergency medical dispatchers. However Allina goes one step further, also offering access to focused education for vehicle mechanics specializing in emergency vehicle operations. They appreciate that their crews can’t use their skills and equipment without safe, reliable response and transport units.
New employees are also mentored by field training officers, all of whom have received extensive training in the development of new talent, including the National EMS Management Association’s Field Training and Evaluation Program.
For its network of more than 50 first responder groups–emergency response teams, police and fire departments–Allina Health EMS provides education on caring for patients while the ambulance is en route. It also operates an onsite television studio with a green screen, which allows just-in-time training via the Web and has facilitated one truly unique education offering.
Medical Monday is a weekly production that involves an approximately four-minute video, where a medical director or member of the clinical services team reviews a protocol and/or procedure for the benefit of field crews.
With a strong belief in education and commitment to advance the paramedicine profession, Allina Health EMS raised its minimum qualification for all paramedic candidates to include a minimum of an associate’s degree in January. Allina employees are also encouraged to take advantage of educational opportunities, with tuition reimbursement funding available for undergraduate, postgraduate and continuing education.
10. HAVE HIGH EXPECTATIONS OF YOUR PERSONNEL
At Allina Health EMS, people know there are high expectations of them. “Caregivers are expected to know their protocols without question, to be nice to a patient who just threw up on them, and to be supportive of their colleagues no matter what,” says the organization’s chaplain, Russ Myers. “Dispatchers, mechanics and everyone else know that quality work with a positive attitude is the norm. But in return, we have their back–it’s high expectations coupled with high support.”
Think about organizations you’ve known or been a part of in which endemic low expectations drove away the best people and dragged the organization down. That works both ways: The success that inevitably comes from a culture of high expectations–particularly when coupled with high support–has a way of attracting people who want to be a part of such an organization, which leads to further success.
CONCLUSION
Allina Health EMS is humble and doesn’t promote itself as the best EMS service in the country, but it does promote to its employees that it wants to be the best EMS service it can be for the residents and visitors of its designated service area.
ALLINA HEALTH EMS: BY THE NUMBERS
In 2015, Allina Health EMS experienced more than 125,538 patient contacts–an increase of nearly 8% over the previous year. Of those, the majority (approximately 80%) were ambulance responses, including 9-1-1 calls; 19,449 were interfacility, critical care and special transportation requests, such as wheelchair transports.
Allina Health EMS community paramedics have been involved in the care of more than approximately 1,000 patients since the program’s inception in 2013.
Allina Health EMS fleet vehicles drive more than 4 million miles each year, with an exceptional safety and maintenance record. They have a critical vehicle failure rate (i.e., an interruption in service responding to a patient or with a patient on-board) of 0.4 per 100,000 miles driven.
One million Minnesotans (20% of the state) receive an Allina Health EMS ambulance when they call 9-1-1.
Allina Health EMS is a division within the Allina Health system, one of the Midwest’s largest providers of healthcare services. Working with a team of more than 26,000 people in Minnesota and Wisconsin, Allina Health is a collection of 13 hospitals, more than 100 clinics and a group of specialty operations such as pharmacies, home care and hospice agencies, durable medical equipment providers and, of course, EMS.
“Our community outreach activities are a huge part of who we are–in fact, the number of people who benefit from our community programs rivals the number of EMS patients we transport every year,” he adds.
Learn more from A.J. Heightman at the EMS Today Conference & Expo, Feb. 25—27, in Baltimore, Md. EMSToday.com
REFERENCE
1. Gerhardt G, Yemane A, Hickman P, et al. Medicare readmission rates showed meaningful decline in 2012. Medicare Medicaid Res Rev. 2013;3(2).
