1. Improving Operational Performance Presented By: Jonathan D. Washko, BS-EMSA Director of Deployment – REMSA President – Washko & Associates, LLC HPEMS & Public Safety Consulting Partner – Stout Solutions, LLC & FirstWatch

2. Some Food for Thought… Late 9-1-1 Wears The Late Crown

3. Notice in this video –The media focused on problems created for 9-1-1 center from this video –They are actually talking about EMS only –They are talking mostly about RESPONSE TIMES –They are talking about customer service and clinical care Improving Operational Performance

4. Discussion Topics Successful Performance Defined Defining Operational Performance Measuring Operational Performance Improving Operational Performance

5. Successful Performance Defined The EMS Success Triad –A Balancing of… Patient Care Employee Wellbeing Financial Stability Patient Care Employee Wellbeing Economic Stability Success Triad

6. EMS Success Triad Patient Care –Response Times –Clinical Performance –Customer Service

7. EMS Success Triad Employee Wellbeing –Retention –Health / Safety / Welfare –Satisfaction –Compensation –Recruitment

8. EMS Success Triad Financial Stability –A/R & Billing Practices –EMS Delivery Model / System Design –Operational Efficiency & Effectiveness –Employee Compensation –Safety & Risk Management –Systems Engineering

9. The Balancing Act… A Quality Unit Hour The Quality Unit Hour Human Resources Public Education Control Center Training & Edu Operations Finance Supply / Logistics Data Analytics QI / CQI / PI Fleet Maint. Safety & Risk IT / Technology PR/Marketing

10. Defining / Measuring & Improving Operational Performance Limiting our Discussion to… –Response Times –Key Operational Efficiency & Effectiveness Measures

11. Defining Response Time Performance Typically System Specific National Standards Measured Via –Clock Start –Clock Stop Measurement Methodologies –Average Response Times –Fractile Response Times

12. Defining Response Time Performance Clock Start….a controversial topic (Smoke & Mirrors) –Time First Received at 9-1-1 PSAP –Time First Received by Responding Agency (Secondary PSAP) –Time Certain Info Obtained –Time Dispatched –Time Unit En Route Clock Stop (Pretty Definitive) –Unit Staged –Unit on Scene –Crew at Patient

13. Measuring Response Time Performance Typically two types of measurement –Average –Fractile (or frequency distribution)

14. Measuring Response Time Performance Average –Total Response Times for Sample divided by Total Sample Size –Yields roughly the 50th percentile, or ½ of your responses are above and ½ of your responses are below the average number…or 5 out of 10 patients are receiving this level of response –Old standard of measurement when we didn’t care about this stuff as an industry

15. Measuring Response Time Performance Fractile –Frequency distribution of time that shows reliability percentage of responses based on specific time bins –Many systems (and standards) are going to 90 th percentile reliability standards (e.g. a response time standard of 00:08:00 at 90% reliability)…or 9 out of 10 patients receive this level of response –Best measurement approach for Patient Care and/or Customer Service –Ability to achieve depends heavily on deployment methodology (demand vs. geographic based) and size of your pocketbook.

16. Measuring Response Time Performance Response Time Measurements Fractile Measurement Example

17. Measuring Response Time Performance Fractile Measurement Continued Response Time Exemptions –Calls that are exempted from response time calculations due to uncontrollable factors that would require significant financial and human resources to overcome… Examples: –Severe Weather –Significant Hospital Diversions / Delays –MCI –Second Unit to Same Incident –Others based on financial needs »System Overload »Un-notified Construction

18. Improving Response Time Performance Emergency Calls –Function of Volumetric and Geospatial Supply and Demand of Resources, Call Segment Efficiency and Effectiveness and Responding Unit Travel Time and Impedance Non-Emergency (Inter-facility Transport) Calls –Function of Mostly Volumetric and Some Geospatial Supply and Demand of Resources, Effective Call Scheduling and Responding Unit Travel Time and Impedance

19. Improving Response Time Performance Performance Variables –Call Segment Processing –Matching or Mismatching of Supply and Demand Curves –Deployment Methodology –Other System Issues Support Systems GIS / Mapping Systems Employee Performance

20. Improving Response Time Performance Call Segment Processing –A significant number of agencies can improve response time performance just by measuring and fixing two variables (based on how you measure Clock Start): Call Processing Times (Received to Assign) Unit Chute Times (Assign to En Route) This Increases Available Travel Time which Improves a Responding Unit’s Effectiveness and Coverage Area

21. Improving Response Time Performance The net effect of a 2 minute improvement in call processing / chute times on geospatial coverage isochrones

22. Improving Response Time Performance Matching Supply and Demand Curves –EMS Demand curves are Predictable (see next session) Volumetric Basis (Temporal Demand Analysis) Geospatial Basis (Geographic Demand Analysis) –Analysis of Existing Resource Supply to Demand curves will show if a mismatch of resources exists which definitely has a LARGE effect on response times –Stoutian Theory (Prediction of Demand on EMS)

23. EMS Temporal Demand & Static Supply Improving Response Time Performance

24. EMS Temporal Demand & Static Supply

25. Lost Revenue Opportunities EMS Temporal Demand & Static Supply Improving Response Time Performance

26. EMS Temporal Demand & Temporal Supply Improving Response Time Performance

27. Deployment Methodology –Another Significant Variable in Emergency Response Time Performance is your Agency’s Geospatial Deployment Methodology: Fixed (Static) Geographic Based Dynamic (Temporal) Demand Based Hybrid (Static & Temporal) Demand / Geographic Based –Effects How Response Ready You Are To Respond To The Next Call

28. Improving Response Time Performance EMS Temporal Demand & Static Supply

29. EMS Temporal Demand & Temporal Supply Improving Response Time Performance

30. EMS Temporal Demand & Temporal Supply Improving Response Time Performance

31. EMS Temporal Demand & Temporal Supply Improving Response Time Performance

32. Other Variables –Support Systems Fleet Maintenance CAD AVL Dispatch –GIS / Mapping GIS Data ACCURACY! Reading a Map Book –Employee Performance Culture Unions Management Style and Approach

33. Improving Response Time Performance –Overall Improvement Strategies Use Effective and Efficient Deployment Methodologies Root Cause Analysis on Each and Every Late Call Will Show a Pattern and Focus your Improvement Efforts Reliability, Accountability and Measuring are Key Systems Engineering that allows for Minute to Minute System Adjustments Based on Real-Time Performance Data is Vital for Success Daily After Action Review Processes (from the military) will improve situational awareness, identify trends, allow the organization to communicate and will eventually lead to improved performance (on all fronts)

34. Improving Financial Performance –Financial Performance Definitions Measurements Improvements

35. Defining Financial Performance –System Specific For Profit / Not For Profit / Non Profit Publicly Traded / Privately Held / Government Performance Based / Level of Effort Based –Self Imposed / Contractually Imposed –Performance Profitability Survival Growth

36. Successful Performance Defined The EMS Success Triad –A Balancing of… Patient Care Employee Wellbeing Financial Stability Patient Care Employee Wellbeing Economic Stability Success Triad

37. The Balancing Act… A Quality Unit Hour The Quality Unit Hour Human Resources Public Education Control Center Training & Edu Operations Finance Supply / Logistics Data Analytics QI / CQI / PI Fleet Maint. Safety & Risk IT / Technology PR/Marketing

38. Defining Operational Efficiency & Effectiveness A Majority of Most EMS budgets Consist of Labor Costs (typically 60% to 80%) Revenue Availability is a direct result of EMS system design and reimbursement methodologies (subsidy / billing insurance) Cost Structure is a direct result of EMS system design, efficiency and reimbursement methodologies (subsidy / billing insurance) Reimbursement rates are diminishing, tax dollars are tightening and public expectations are rising Because of this, only the most efficient and effective properly designed EMS systems will be successful in balancing the Triad…if not something will have to give eventually (Patient Care, Employee Well Being or Financial Stability / Survival)

39. Defining Operational Efficiency & Effectiveness Given that EMS budgets are mostly labor based, focusing on this area when attempting to improve financial performance typically gives you some kind of return Equally important is revenue and collections, but for this discussion we will focus on operational improvements Other areas of significant budgetary allocations are also likely candidates

40. Measuring Operational Efficiency & Effectiveness Service Model versus Production Model EMS Strategy Measuring Key Performance Indicators (KPI’s) –Quality Unit Hours & Unit Hour Utilization (UHU) –Controlling Lost Unit Hours –Managing Call Task Times –Managing Pay Roll Leakage (or payroll UHU) –Manage Headcount to Control Overtime –Managing Response Errors –Benchmarking and Trending Statistics –Many Others

41. Measuring Operational Efficiency & Effectiveness Quality Unit Hour Definition A “Quality Unit Hour” is an ambulance that is available to the EMS System for one hour that responds to properly triaged calls for service, is produced within a CQI environment that uses modern technology to collect and assess accurate data, is fully staffed, fully trained, fully maintained, fully stocked, properly placed in location and time, properly funded and safely operates within an educated population

42. The Balancing Act… A Quality Unit Hour The Quality Unit Hour Human Resources Public Education Control Center Training & Edu Operations Finance Supply / Logistics Data Analytics QI / CQI / PI Fleet Maint. Safety & Risk IT / Technology PR/Marketing

43. Improving Operational Efficiency & Effectiveness Control your Unit Hours and UHU –Function of EMS System Design –Properly Allocate Supply with Demand –Geographic Deployment Methodology is HUGE in terms of efficiency and Demand Based Systems are usually the most cost efficient and effective

44. Improving Operational Efficiency & Effectiveness Controlling Lost Unit Hours –A Lost Unit Hour is one that is not otherwise available to the deployment plan if not on a call –Many causes Start / End of Shift Procedures Critical Failures Hospital Diversions / Off Load Delays Employee Problems Poor Management Practices Lowered lost hours means more available hours to the system More available hours may allow you to reduce scheduled hours

45. Improving Operational Efficiency & Effectiveness

46. Managing Call Task Times (somewhat controversial) –Highly efficient systems can run a call in less then an hour –Less time to run a call means less hours that are needed to meet the same response time performance standard –Less hours needed results in financial savings (but may unbalance the triad on employee well- being or patient care…be careful!)

47. Improving Operational Efficiency & Effectiveness Managing Payroll Leakage –Payroll leakage are unproductive dollars spent for various reasons –Measuring Payroll UHU against Actual UHU defines leakage –If a variance if found between these two numbers, then leakage is occurring or you’re measuring wrong –If these numbers match or are very close, then leakage is more then likely minimal –Minimizing leakage helps to lower costs

48. Improving Operational Efficiency & Effectiveness Managing Headcount –Manage your Headcount - Don’t let it manage you! –Perform bi-weekly headcount meetings as a means to anticipate attrition and therefore drive hiring practices –Ensure you allocate your employee thru put times into the equation –Also ensure you allocate proper FTEs to cover PTO, Sick, Vacation, LOA, FMLA, etc to avoid backfilling with overtime

49. Improving Operational Efficiency & Effectiveness Managing Response Errors –Systems engineering flaws –Unit Hour production problems –Deployment Plan issues –System support problems –Human Error

50. Improving Operational Efficiency & Effectiveness Trending and Benchmarking Statistics –Allows you to see where you have come from and where you are going –Can be used to adjust your system dynamically in a real-time fashion thus keeping costs down –Can be used to help predict the future –Can be used to help find special cause variations that may be effecting financial performance

51. Improving Operational Performance Closing Remarks REMEMBER the EMS Success Triad –Patient Care –Employee Well Being –Financial Stability Questions