By: Dan Gerard
EMS is faced with an incredible challenge; we are at the forefront of fantastic change in healthcare. An aging population, technology (both sustaining and disruptive), diversity, adaptive challenges and the healthcare environment are all drivers that will need to be addressed in a meaningful way.
Our challenge is having the capability to adapt. For nimble organizations, this is an easy prospect. For others, due to internal (e.g., approval from city council) and external (voter initiatives) constraints, the ability to advance to the next level has hurdles that need to be overcome. The big elephant in the room is community paramedicine.
Costs associated with providing healthcare have skyrocketed approximately 150% over the past four decades. The share of the gross domestic product devoted to healthcare has increased from 7.2% in 1970 to 17.9% in 2009 and 2010.1 EMS (exclusive of ED care) accounts for only a fraction of 1%* of the total GDP spent on healthcare in the United States. We have increased demand for service and very little that is coming our way to increase capabilities and capacities.
Those managers who think small and wait for someone else to lead them down the path will have to accept whatever they are offered. The true leaders in EMS will embrace change and transform their services, staying ahead of the curve. Those leaders who go big, the early adopters, the ones who partner creatively and collaboratively, those services will achieve greatness. Now is the time to look within yourself and your agency, to reach deep down inside and transform our organizations in meaningful ways.
Change is scary for many of us but we need to remember that complacency is the bigger enemy. There are a few things we can do that can be transformative to our organization.
There are organizations that are struggling with how to make the transgenerational shift to community paramedicine. For some of them it may not happen. Our goal is to provide quality for our patients, both as a system provider and as part of the greater continuum of healthcare. How we provide it should not matter as much as making sure our patients receive what they need.
Advancing to the Next Level
We need to look at our organizations in the context of a much larger picture. If we can connect the dots, we will have a whole host of new opportunities. We can create new openings to leverage current capabilities and capacities within our services without creating new layers of care. These openings have the potential to catapult us to the next level of success, to truly transform our organizations.
Standardize what makes sense in your organization. Look at what successful services do to improve the ability to decrease turn- around times at change of shift, patient turn-over at the ED, even the completion of the electronic patient care report (ePCR). What are the biggest problems in your service, and what can you do to improve them through standardization and simplification? Many organizations have an ePCR, the truly successful ones have developed templates for every patient category and a style manual.
Customize the processes and services in your organization that will facilitate and enhance all phases of your operations: patient care, service delivery, logistics, dispatch, etc. Each organization has a certain uniqueness that is derived from management/labor work rules, contracts for service, organizational bureaucracy and, of course, culture. Make it work for you, but the end game is always providing the best in patient care and service.
When we speak about EMS in terms of the larger healthcare community, we tend to forget that we are one of the smallest sectors of the healthcare economy. Inefficiently delivered care wastes $130 billion dollars a year, with another $55 billion dollars wasted in missed opportunities for prevention.3 There is a tremendous opportunity for us to capitalize, to be innovative and to improve the quality of care and service delivered in your community with the resources we already have in place.
Many departments are looking to expand into a mobile integrated healthcare (MIH) platform by developing community paramedics. The idea of community paramedicine as a locally designed, community- based, collaborative model of care is progressive and has potential to elevate the profession to a new level in healthcare delivery.
The challenge for these organizations is that they are waiting for curriculums to be developed or for enabling legislation to run their programs. They are still asking how they will finance these programs and struggling with the metrics and benchmarks to quantify their value. In addition, no one is addressing competence or maintaining competency for these new providers. Failure to maintain competence will end up costing money rather than saving it.
Your service may not need community paramedics! We can improve care, increase our operational footprint, provide a more well-rounded scope of services and impact patients in a meaningful way by identifying potential partners who already exist in our communities.
If a community paramedic program is not in your near future, it is still vitally important to complete a needs assessment in order to work with these partners to address the needs of your patients. You would be remiss if you failed to perform this step. If you are looking at participating in a MIH program at some point, this is a critical first step to identify the gaps in care. Visiting nurse programs, mobile health clinics (pediatric and adult), homeless outreach, ethnic health groups, mobile psychiatric care, hospice, social services (public and private), veterans outreach, tribal medical programs, public health clinics, adult and child protective services are just a partial list of services that exist in your region.
My questions to you as EMTs and paramedics, or chiefs, managers and administrators:
Do you have a matrix of all the health providers, public and private, that are out in your community every day? Who provides medical, social and psychiatric services in my community? What are the services that they provide? Are they mobile? Are they providing the full breadth of services your community requires? Are you currently working with these services? Have you had discussions on how you can serve your overlapping patient populations better? What can you do to share information and serve your patient community in a new and meaningful way? How can you make a referral to them? Do they have a liaison with EMS? Who is it?
If you cannot answer those basic questions then your objective is clear: you need to reach out, find out what they do, how you can work together, and make them part of your team. Brand this new initiative with a name that is inclusive that recognizes your partnership.
Collaborate & Innovate
Once you have reached out to these other groups, leverage the complete skill set and talents of these organizations. This is a two-way street and should not occur in a vacuum. Ask yourself:
What services can EMS provide as a service that we currently don’t? An example could be public education and prevention awareness. Are you currently providing these services? What can these other potential partners provide that our current patient mix requires? They may already have a mechanism in place to provide vital functions such as complex assessments, referrals and admissions to healthcare facilities. Why reinvent the wheel if there is someone who already provides the service, has established relationships and does it well?
Is there a particular need that you have that these other groups may assist to creatively solve? Many times, visiting nurse services and hospice care providers have vendors that they work with who may be able to address a problem that plagues your service or patient population.
In the United States, 5% of the patients accounted for 50% of the total cost of providing healthcare, and 90% of the costs for healthcare were spent on the top 20% of the patients.
The Patient Protection and Affordable Care Act has increased the number of insured people in the U.S. Unfortunately, it has not increased the number of providers to keep pace with the increasing demand for care. High frequency users from populations that do not have access or ease of access to primary care, coupled with the increasing patient population reaching old age, is the challenge today. These patients are placing increasing demands and constraints on an already fragile and vulnerable system of emergency care.
A program out of Highland Hospital and Alta Bates Summit Medical Center in Oakland, Calif., Project RESPECT, utilized a multi-disciplinary case management approach to address the issues plaguing their hospital EDs. They utilized the skillsets of social workers, physicians, EMS, hospital administrators and even attorneys to address the needs of patients, to reduce ED over-crowding and demand for service.
One of the critical issues identified and solved by Project RESPECT was housing. While housing in and of itself was not the silver bullet to solve all of their problems, it was one critical piece that involved addressing primary care and social service needs, and it was a need not traditionally addressed by EMS. Remember: If you want to be considered more than a transportation service in the eyes of Medicare, hospitals and physicians, the provision of EMS and healthcare must extend past our preconceived boundaries.
We are at the forefront of a revolution in healthcare. We are attempting to stake our claim as being more than transportation, that we are equal to other healthcare providers. Recently I told some friends that we think EMS is about saving lives. Truth be told, our profession is charity; we deal in kindness. Every day, out of view of people with cellphone cameras and a YouTube account, unknown to the world at large, we make a difference in unique ways. It is those acts of the heart that makes us distinct.
Our future, the future of our patients and the future of our profession lie at a point we cannot see, but that does not mean they are outside of our control. Our destiny is determined by what we shape with our own hands, not fate. We think with our minds and need to hold onto the principles of right and wrong in order to correct what is in front of us.
Changes in the healthcare system will have the potential to leave the most fragile and vulnerable segments of society behind. As an organization, what can you do or what are you currently doing to advocate for the elderly? Children? Abused women? The poor? Society has an expectation that we will have the courage to do what is morally and ethically correct. Stand up, do what is right.
Empower Your Staff
The best solutions for your problems come from inside your own organization. Let your staff lead work groups to find creative solutions to your biggest issues, then give them the tools and information they need to be successful.
PCR compliance, patient satisfaction, quality improvement, policy development, protocol development—these are all hotbeds of contention, with many land-mines. I was the EMS chief for an organization and worked with the local union to develop policies and procedures. Once we had something down on paper we rarely had an issue with compliance. Why? The union and its members had first crack in developing it. They had already thought through the problems and helped find a creative solution.
I would draw the starting line (for example, "We need a policy on getting signatures to verify patient transport"); then I wrote out the boundaries for the race ("We need to comply with this new regulation from CMS"); then I identified the finish: the final policy. We brought in the billing company to act as the "referee" and when the clock started, they had three weeks until the buzzer. I stood back and let them go to work. When all was said and done, we had a rock-solid policy and 100% compliance on getting signatures. It never would have happened if I stood in their way.
Foster a Positive Environment
A complex organization where individuals come together on a daily basis to make life-and-death decisions is the perfect situation for something to go terribly wrong. We are in the business of providing high quality patient care with a highly trained and educated staff. We take care of people, both inside our organization and out. Create happiness—a place where people want to come to work. It has been shown that a positive and supportive environment results in having staff who show up ready for work, support new initiatives, take fewer sick days, have fewer accidents and are engaged in a meaningful way.
Have you created opportunities within and outside your organization to relieve stress and foster social interaction? Bowling, picnics, night at the ball-park, barbecues and holiday parties are just a few examples. Don’t look for excuses, but create opportunities. You should also designate social activities to include outside organizations such as ED staff, police, fire and flight teams. Those non-stressful social situations help build bonds and reduce tensions between organizations during times of high stress and critical activity. If you spent a Saturday on a fishing trip with new friends from the police department, there is less likelihood for confrontation when they want you to move your ambulance on the scene of an MVC on the highway in the middle of the night.
Enhancing creativity within your organization is another way for staff members at all levels to participate in improving the service. But there are some myths to creativity that need to be dispelled:
Myth #1: Creativity resides in the artistic or, for lack of a better term, the crazy ones. Nothing could be further from the truth. Creativity resides inside all of us, for some it requires encouragement and a framework in order to access it.
Myth #2: Removing barriers is all that is needed to facilitate creativity. It isn’t that easy to just make the walls tumble down and all of a sudden the magic happens. Believe it or not, you can provide a structure to facilitate any employee to leverage their creative side.
Myth #3: You cannot teach creativity. This is another fallacy. You can create opportunities for employee participation and allow them to develop creative skills in a supportive environment.
Tools for stimulating creativity within an organization are taught at business schools across the country. An excellent one that I use frequently is called SCAMPER: Substitute, Combine, Adapt, Modify/Magnify, Put to other uses, Eliminate (or minimize), Rearrange. I hand out the words of the mnemonic on separate pieces of paper with the following questions for each heading underneath:
What can be substituted? Who else? What else? Other place? Other people? Other materials?
What ideas can be combined?
Can we combine purposes? Units? Talents? Materials? How about an assortment?
What else is this like?
What other idea does this suggest? What could I copy? Emulate? What else could be adapted?
How can this be altered for the better? What can be modified?
Is there a new twist?
What can be made larger or extended? What can be exaggerated or overstated?
What can be added? More time? Stronger? Higher? Longer? What can be duplicated?
Put to Other Uses
What else can this be used for? Are there new ways to use as is? Other uses if modified?
Other extensions? Other markets?
Eliminate or Minimize
What if this were smaller? What should I omit?
Should I divide it up? Split it up? Subtract? Delete?
What's not necessary?
What other arrangements might be better? Interchange components?
Other pattern? Layout?
Other sequence? Change the order? Change pace? Change schedule?
We apply the questions to a problem and everyone answers each one on their own. It gets interesting when we read the answers aloud and we begin the discussion. Frequently people will hear another person’s response, and you can see the moment on their face when they have a new realization. They re-imagine the problem and the solution in a new way and develop novel and unique solutions to the issue we face. It is a true "wow" moment when you see it happen.
This is an exciting time in healthcare, especially for EMS. Think about your service in the context of the healthcare continuum: It is an intricate tapestry with many rich and interesting fabrics. Everyone is looking for new ways to collaborate and partner to provide high quality patient care. Good leaders will capitalize on this opportunity for their community. Look inside and outside your organization to recognize what you are doing well and improve upon what you could do better.
Build teams within the context of the larger healthcare system. Empower your staff and improve the work environment. Leverage the incredible talent that you have and show them they are appreciated. Foster creativity by using tools that allow everyone to unleash their inner genius.
Centers for Medicare & Medicaid Services. (Dec. 3, 2015) National Health Expenditure Data. Retrieved June 10, 2016, from https://www.cms.gov/research-statistics-data-and-systems/statistics- trends-and- reports/nationalhealthexpenddata/nationalhealthaccountshistorical.html.
World Health Organization. (June 8, 2016) Global Health Expenditures Database. Retrieved on June 10, 2016, from http://apps.who.int/nha/database.
Institute of Medicine. Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. Washington, DC: The National Academies Press, 2013. doi:10.17226/13444.
Cohen S, Yu W. (Jan. 2012) Statistical Brief #354: The Concentration and Persistence in the Level of Health Expenditures over Time: Estimates for the U.S. Population, 2008–2009. Agency for Healthcare Research and Quality Medical Expenditure Panel Survey. Retrieved June 10, 2016, from http://meps.ahrq.gov/mepsweb/data_files/publications/st354/stat354.pdf.
Pan American Health Organization. (Dec. 2003) Emergency Medical Services Systems Development. Lessons Learned from the United States of America for Developing Countries. Retrieved June 10, 2016, from http://publications.paho.org/product.php?productid=738.
Centers for Disease Control and Prevention. (n.d.) Ambulatory Health Care Data. National Center for Health Statistics. Retrieved June 10, 2016, from http://www.cdc.gov/nchs/ahcd/index.htm.
* Note: There are no concrete numbers for utilization and cost relevant to the GDP in the United States regarding emergency medical services. The estimate of a fraction of a percentage is determined based on the current GDP for healthcare in the United States ($2.9 trillion dollars) and utilizing the CDC’s National Ambulatory Medical Care Survey (NAMCS) survey tool. There were 136,000,000 emergency department visits in the United States in 2014, 15% arrived via EMS. Using 20.4 million (15% of 136,000,000) as a baseline number and multiplying that via the CMS fee schedule for an ALS1 response yields $6.6 billion dollars in revenue. The ALS1 rate was chosen because while the overwhelming majority of patients are transported utilizing basic life support, this figure does not account for mileage or those patients treated at the higher ALS2 rate (using CMS data approximately 3.6%).
This figure does not take into account patients who were treated/examined and left at the scene, nor does it account for the confounding variable in cost for volunteer versus career (paid) services.