Monthly Archives: July 2014

Could Busier be Better?

There is plenty of talk about “evidence-based procedures” in EMS lately. Well, today I read an interesting article that shows a link between being busier and better patient outcomes.

Okay…, now after reading that statement, what just happened to your heart rate? Was your automatic response to click the link in order find fault so you can dismiss the finding, or did it pique a genuine interest to read the article and find what might be of value to you personally in hopes of possibly achieving a better understanding of even one aspect in a very complex patient/care giver dynamic? It is interesting to see how we respond to “evidence” we don’t necessarily like, or evidence that contradicts with our own longstanding personal stereotypes.  I know that whenever I talk about Dynamic Deployment, or System Status Management, I immediately hear complaints from those who work in the field that it is all about the numbers and is often driven by greedy consultants forcing “snake oil” math on all too willing administrators who have forgotten their “street experience.” I usually try to combat the stereotype perception with facts about more progressive experiences with creating high performance systems, but I will admit right here that everyone is at least partially right – it really is about the numbers. However, it may not just be the same numbers you are thinking (but I will stick to my assertion that the logic is probably much less nefarious than suspected.)

Time is an easy thing to measure, but in itself, it is seldom very important. In fact, it can be much like a single vital statistic from a patient taken out of context. Still, time is a pretty fair proxy measure of performance on the aggregate.  And, like good base line vitals, it becomes especially useful when combined with other numbers.  Now, before writing your comment, please note that I never said anything about a 7:59 response standard, I was only talking about measuring time in the abstract.  I believe the argument over response time standards is very similar to arguing that everyone should have a BP of 120/80. Sometimes it is the right goal, but for others, or depending on the situation, the target may be higher or lower.

Each of us measures our work shift in terms of hours.  System Status Management extends that basic idea by measuring everyone’s time in a shift along with the work they accomplish and balance it against the public’s perception, reasonable risk, and the actual needs of individual patients and their providers.  There are plenty of bad examples out there and I refuse to justify them, but at the same time there are good examples of systems that are improving and taking the right measures into account.

The key is not UHU, TOT, response times, compliance, ROSC, patient outcomes, employee satisfaction or budgets – it is all of those things and much more. Those numbers are no more definitive in themselves than BP, pulse, O2 sats, capnography, skin condition, ECG, GCS or anything else we measure is a truly accurate indication of a person’s overall health. Similarly, it is no less fair to view SSM as a static group of measures than to believe the components of our patient assessment are unchanging. If some medic had overly emphasized, or even ignored, some measures in an assessment, that specific experience should not condemn a process that has been proven valuable in many other cases.

It may seem that I have ventured pretty far from the question with which I started this post about how busy we should be in order to be most effective. You may have even thought I was promoting an idea to maximize every minute.  As for the clinical interpretation of the answer, I will leave that to the authors of the particular study I referenced.  Instead, I will suggest that we all must be a little busier in understanding how our collective time and actions impact the performance of the systems in which we work. It doesn’t matter if your service is private, non-profit, fire-based or whatever; money and resources are always finite while demand and expectations are often increasing.  I would ask that you don’t simply rely on the assessment from “vitals? of SSM taken years ago, but reassess with an open mind and set aside the prejudices of previous assessments. After all, very little in our business is truly static. Like a “routine? interfacility transport, we can assume nothing has changed regarding the patient’s condition, or we can get busy and engage in our profession looking to have a positive impact on potential outcomes. Don’t leave leadership to the administrators, but take initiative to at least understand, if not improve, your corporate mission. You may be caring for patients, but the care of your career is part of your job too. Get even busier and improve that outcome for yourself.

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Is 'SSM' Still a 'Bad Idea'?

Ideas often take time to saturate a market. Even if the idea is generally recognized as a good one, complete with compelling evidence, change can still take time.  As a current example, how many agencies still have a protocol for complete spinal immobilization on a long spine board for “any fall” or “significant impact”?  On that very point, Dr. Ryan Jacobsen puts forth a lengthy argument in this recording of a  presentation at a NAEMSP conference.  The process of acceptance can be even worse yet if the idea has been controversial – as in the case of “System Status Management” introduced by Jack Stout in 1983. This distinction means it takes longer still in order for it to receive a “fair hearing” even if the evidence now shows a positive impact. In an ideal world, the best ideas would always be automatically and universally adopted, but that simply isn’t how the world works.  And for any professional industry it is a good thing that ideas are properly “vetted”over time to determine what is truly “best” before wholesale adoption or, in the case of “bad ideas”, that they are discarded only when a fair reading of the evidence discredits them.

CycleDynamicsGartner, Inc. of Stamford, Connecticut, has built both a reputation as an information technology research and advisory firm and a booming business of annually publishing their signature “hype cycle? graphs by industry segment.  For those unfamiliar with these charts, the basic structure starts with a technology trigger near the origin of time and is visibility followed by a quick rise to the “peak of inflated expectations” that is often driven by a combination of unrealistic claims by proponents and the hopes of users desperate to believe those claims.  The exaggerated peak of hype is inevitably followed by a crash of popularity into the so-called “trough of disillusionment.”  Many ideas just die here and drop off the curve, but for others, a more realistic set of expectations develop as ‘believers’ (the “early adopters” according to Everett Rogers’ “Diffusion of innovations”) begin to experience measurable benefits and serves to push the idea (sometimes with changes) up the “slope of enlightenment.” This gradual advance passes an important point of inflection on the performance “S” curve known as the “attitude confirmation” identified by Joon Shin.  The next landmark is crossing a social “chasm” identified by Geoffrey Moore at another critical inflection point called the “attitude plateau.”  Once an idea successfully crosses the chasm, it plateaus as a generally recognized productivity concept for that industry. Some ideas fly quickly along these curves passing other older ideas that seem to just plod along at a much slower pace.

So, is “SSM” still on the curve? And if so, where is it?  We must first realize that ideas evolve and sometimes morph into other names (just as “Emergency Medical Services” is known by some as “Mobile Integrated Healthcare” now.)  One apparent synonym for “SSM” is a broader idea of “dynamic deployment.”  If we look at the literature and practices of emergency ambulatory services, we find that the underlying concept is still quite popular despite attempts of detractors to further discredit or simply ignore it.  One such potentially damning article was written by Bryan Bledsoe back in 2003 after a crash of industry expectations for the idea.  This could easily be explained as the time that SSM passed its own pivot point where its value was questioned in the trough of disillusionment. (Some may also claim that hypothermia treatments for cardiac patients was also recently in this trough.)

Computing performance has increased dramatically since the 1980’s (or even the early 2000’s) and algorithms are discovering patterns in many human activities.  Demographic data show socioeconomic clustering that leads to similar health issues and traffic patterns with road designs that see more accidents than they should. These patterns are proving to be key in forecasting demand for EMS services. Automated Vehicle Location systems allow far better tracking than ever before and traffic patterns are being used to calculate more realistic routes. These are some of the advances that help explain the numerous agencies that are significantly improving response performance and making use of resources. Where field providers take an active part is developing strategies, there are also reductions in post moves, unloaded miles driven, and better disbursement of work loads.  The efficiency gained by its use in mainstream agencies beyond the initial public utility model organizations seem to vindicate Stout’s early vision and research as the concept moves up the slope of enlightenment toward the plateau of general acceptance.

Ideas are not static entities, so our understanding must continue to evolve and incorporate new thoughts.  As the iconic American social commentator, Will Rogers once said, “even if you’re on the right track, you’ll get run over if you just sit there.”  So, to honestly argue an idea, proponents of either side must continue to evolve their understanding and witness the current thought and evidence of an idea.  There is little point in continuing to attack past grievances which have been addressed while ignoring the mounting evidence out of sheer disbelief.  If “SSM” is not a “good idea’ yet, it is certainly moving in that direction all the while being shaped by those who are concerned over the future of EMS (or MIH.)

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