Tag Archives: EMS deployment

Toward a Better Understanding of Dynamic Deployment

I recently had two articles published by EMS1 as a couple of “mythbusting primers” on the topic of dynamic deployment. The articles were Dynamic deployment: 5 persistent myths busted and Dynamic deployment: 5 more persistent myths busted. My intention was not to convince anyone of a position that opposes their current EMS world view pertaining to deployment models, but I had hoped to extend the work Dave Konig began in The EMS Leader defining the terms of EMS resource deployment in 2013 and to have an open discussion about it. My hopes of engaging in dialog fell somewhat short of my expectations. But after watching the presidential debate last night, I understand that the idea of a robust “give and take” may be more difficult to achieve in public interaction than simply setting a stage with opposing actors.

One comment I received the first week after publication of my articles was a posting that basically just left a link for an article by Dr Bryan Bledsoe from 2003 entitled “EMS Myth #7: System Status Management Lowers Response Times and Enhances Patient Care.” The assumption being that the topic was settled long ago. While I have great respect for the man who calls himself “The EMS Contrarian” and his robust body of writings (including by first EMS textbook), I respectfully disagree with the finality of some of his assertions. A great deal has changed in the past 13 years. Some readers may actually recall that MySpace debuted the same year that his opinion was written. For those who do not recall that social media phenomenon, MySpace was a precursor to Facebook that was once the largest social networking site in the world – even surpassing Google as the most visited website in the US. This was also a time when almost every patient was administered high-flow O2 because it was considered safe, even if not always effective. Fortunately, the evidence-based movement in EMS has caused many practices to be re-evaluated both for inclusion as well as exclusion. And computer technology has also made great developmental strides from the 2003 introduction of the first wristwatch cellphone named the Wristomo. At that time, engineers were still thinking of wearable technology as a cross between the 2-way wrist radio device that became iconic for Dick Tracy in the 1940’s comic strip and the modern flip phone of the day. Naturally, the device was designed to be easily unclipped in order to hold it to the ear like a traditional cell phone. It even offered an optional cable allowing it to exchange data with a computer. The development of Bluetooth freed designers to reconsider how a smartwatch could interact in an entirely different way with a user’s smartphone. The evolution of dynamic deployment has followed a similar trajectory.

Gartner_Hype_Cycle.svgThe Gartner Hype Cycle is a graphical and conceptual presentation that describes the maturity of emerging technologies through five common phases. Each year, the organization follows several technologies through this consistent cyclical journey. While EMS deployment was not one of these tracked technologies, I would submit that the initial technology trigger in the case of dynamic deployment would have certainly been the work of Jack Stout on System Status Management in the 1980s. His publications in the Journal of Emergency Medical Services (JEMS) throughout the decade inflated the expectations for performance returns. Implementation issues however, contributed to it sliding down into the trough where many disillusioned system providers left it for dead around Y2K. But the story doesn’t end there. The combination of his economic theory with Geographic Information Systems (GIS) provided a new operational view of both demand as well as current positions of available vehicles reported in near real-time with growing bandwidth. The advancement of computer processing has allowed some of these same Stoutian concepts to now be performed in real-time. With practice in modifying the parameters, the concept of Dynamic Deployment has become, as one comment to the article stated, effectively SSM 2.0. The benefits are no longer theoretical or even limited to Public Utility Model services, but are being realized by both public and private EMS providers climbing the slope of enlightenment or who are content with the productivity gains they have already reached.

JCMCresponsetimevROSCOne of Stout’s assumptions that has changed since the Bledsoe article is the “20 week” rolling window for analysis. This is too broad of a query that effectively combines different seasonal impacts throwing off focused projections not improving them. Experience shows that just a few weeks backward or forward from the current date for only a few previous years gives the best demand  forecast. Tests conducted at BCS show that MARVLIS correctly forecasts 80-85% of calls in the next hour by identifying hotspots that are limited to approximately 10% of the overall geography. Going back too many years, as Bledsoe was led by a consulting statistician, can actually unfairly weight more established neighborhoods while undervaluing newer communities. The clinical significance of shorter response times is not always in the “37 seconds” that are saved or even in meeting an arbitrary response goal, but in reducing response to a meaningful 4-minute mark. Achieving this milestone has had a proven impact on ROSC in New Jersey for instance. And beyond clinical significance is contractual obligation. Like it or not, EMS is often judged (and even purchased) similar to fire protection – by compliance to a time standard. Software makes a difference in meeting those goals. Running a system so that it performs well in most cases means it is more likely to perform well in the cases where it really does matter to the long term health of the patient.sedgwick_compliance

The increase in maintenance costs of 46% as claimed by Bledsoe has also been disproven with services showing a reduction in the number of unloaded (non-reimbursed) miles driven and even a reduction in the number of post-to-post moves in favor of post-to-call dispatches. By reducing fines for late calls, some services have found significant cost savings compared to previous operations.

In trading station lounges for the cramped cab of an ambulance, there has been a genuine cost to the paramedics and EMTs. However, the argument they make is not about fixing the plan, but rather it becomes an attempt discredit the foundation of that plan completely. Consider the fact that most field providers in a closest vehicle dispatch operation describe a “vortex” that traps them in an endless cycle of calls if they do not escape it in time. They find ways to try to beat the system rather than suggest that recommendations account for the unit hour utilization by vehicle and allow busier units to leave the high call volume area and move to less call prone posts to complete paperwork and recuperate. It is not that the strategy is inherently evil or wrong, but is designed to support a business philosophy that is not properly balanced, so the outcome becomes skewed. It is time to stop challenging the core notion and focus on specific concerns of the implementation that will make the system work better for all participants. As long as we demonize the idea, we will not be able to impact how it works.

Much like the polarization of the presidential debates, I have learned from experience that when we perceive only bits and pieces of the world around us, our minds fill in the blanks to create the illusion of a complete, seamless experience, or knowledge of a system in this case. Sometimes that interpolated information is no longer correct and it can keep us from participating in the crafting of a solution that truly works for everyone.

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11 of the Top 10 Tips for High Performing EMS

Rob Lawrence, the Chief Operating Officer of Richmond Ambulance Authority, offered these tips as an article for publication in this blog, but we decided they would make good initial discussion points in an ongoing dialog with our readers and contributors. Consequently, each of these points is made as a separate page under the EMS Deployment Community of Practice link. For ease in reading the entire list, we have presented the original article here. I do ask, however, that any discussion of the specific points not be made in this general comment section, but directed to the comments of the appropriate section within the Community of Practice. Each heading is linked to take you straight there.

11 of the Top 10 Tips for High Performing EMS

1. Economic Efficiency
From an economic sense, the mission of EMS, or any other healthcare organization for that matter, is to “convert the amount of available budget money into high quality healthcare in order to produce excellent clinical outcomes.” Money is too tight to mention right now and the days of well-padded budgets are a thing of the past. Municipal coffers are shrinking for the public sector, collection rates and reimbursements are down for private EMS, and charitable giving and the donation of free time is fast disappearing in the volunteer sector. In other words, no matter the type or style of your organization, it must be run as a business, with an eye on the bottom line and a realization that EVERYTHING costs something.

2. Data is our Favorite Four Letter Word
In this day and age it’s difficult to believe that some EMS organizations think they have little or no management information. The actual situation is quite the contrary and individual data mines are bottomless. Information is freely available from call volume to patient condition to mean times between failures of vehicle components. When collected, collated and analyzed this information becomes a valuable intelligence product that can be acted upon to improve the next cycle of response, care and administration.

3. System Status Management (SSM)
System Status Management (SSM) is the science of being in the right place with the right resource at the right time to meet the patient’s need. Some say it is the practice of placing ambulances on street corners, but the crucial thing we must remember is that the patient is the one having the emergency so we must be poised to respond with minimal delay and maximum impact. SSM takes the intelligence products of demand analysis for both time and space and matches manpower and availability to deploy a responder as close to the patient as possible. This achieves a minimal response time for the patient and reduces time spent running under emergency conditions for the crew (and distracted pedestrians!).

4. Clinical Excellence
So far all the planning and data crunching has been devoted to the first 10 minutes or approximately 1/6th of the patient response episode. It is ironic that some organizations set their store in, and are judged on, their response times alone. It’s not “high performing” if you are good at racing to the scene only to be incapable of delivering the clinical goods on arrival. A well-trained workforce that has sufficient preception, mentoring and training, and is clinically current is an absolute requisite for success. To achieve this, the involvement and active engagement of the Operational Medical Director (OMD) must occur (often).

5. Lean Systems
EMS is not only response, treatment and transport – the back office and support functions are the “power behind the punch” of service delivery. The creation of lean, efficient and measurable systems is the key to success. An example of this is a high functioning fleet service. If your vehicles fail on the way to calls, then so does the mission. Keeping your organization well serviced and maintained is an arterial function and performance could hemorrhage if you can’t get to where you need to go. The swift conversion of treatment – to bill – to income is also an essential function. Remembering the economic requirement that we turn the amount of available funds into quality healthcare requires the generation of said funds to keep the EMS circle of life turning. While those in support functions are not delivering lifesaving and patient care, they keep the organization alive and healthy.

6. Culture of Safety
The Culture of Safety is perhaps surprisingly a new concept to some quarters of U.S. EMS. This is nationally apparent by a stream of Line of Duty Deaths (LODD) and devastating vehicle accidents that result in well publicized photos of ambulances splayed like bananas after impacts with both moving and static objects. An environment of cultured safety seeks to establish the root cause of these issues then put techniques, practices, procedures and philosophy in place to create a safe environment for all.

7. We Are Public Health As Well
When I go out and speak, I often ask the audience if they know who their Public Health Director is. Many do not, which is shameful. EMS enjoys its role in public safety and recognizes its place in the house of medicine, but fails to realize it is an essential member of the public health camp. Prevention is better than cure every time so understanding the aims and objectives of the public health system is essential. The current Ebola crisis has reinforced the point that we are joined solidly to public health and we must interact often and well.

8. Innovation and Research
To continue to push the boundaries of the EMS world, we require evidence-based practice, outcomes and data to trump industry anecdote and tradition. To progress, we can’t simply hide behind the mantra that “We have always done it that way.” Organizations should consider researching, collaborating, capturing and presenting studies and good practices. It doesn’t have to be major projects or massive patient studies, but perhaps a series of “small cycle testing” that relies on a “Plan, Do, Study, Act” (PDSA) cycle. Large change can occur from small tests. Writing these up, complete with supporting evidence, can effect change not only in the researchers’ organizations, but in the wider industry.

9. Community-Based Programs
The evolution of community-based programs here is almost anthropological in nature. Community paramedicine, or mobile integrated healthcare, is evolving and forming according to local environmental and political conditions. No two programs are the same, which is technically good, as they are shaped to meet the needs of the population for which they are intended to serve. The bottom line for many of these programs to be successful and attain longevity is to be actuarially sound and generate income to be self sustaining.

Sadly many programs to date have operated on a loss leading footing and, unless sustainable income is forthcoming via legislative changes, some could fade as quickly as they initially shone. That said, some community-based activity is already part of normal daily EMS practice and could rightly be classed as “paramedic in the community” activity.

Understanding who your “frequent service users” are and managing their whole system use and creating case conferences is a great community activity. Fostering relationships with other local care organizations such as behavioral health, social services, faith-based groups and both the primary and secondary care sectors may lead to the creation of cost-effective and sustainable programs. This level of liaison also assists in the breaking of barriers and removal of care silos.

10. Communicate, Communicate, Communicate
Internally, “If no one is following, then you are not leading.” Externally, if you don’t broadcast your message, then no one will hear it! A key communication strategy should be a major corporate activity. Some say that it takes 10 good news stories to trump the one bad one. Having an active communication plan that involves providing your local media with positive stories (to get your 10 good ones in the bank) is a good investment in time. Good news stories inform the public as to the quality of your agency and instills a sense of pride within the service. In the social media age, it is now relatively easy to place news. A photograph and a descriptive paragraph can quickly be crafted and posted on your organization’s social media sites or sent to the editor of a national trade magazine for both national and international coverage.

11. A Bonus 11th Point: The Four Words That Count Most
EMS organizations are usually only separated by a single degree from the world of politics. Public sector organizations are governed by Councils or Boards of Supervisors, private sector companies have shareholders and executive boards. If those who lead our EMS organizations are not politically aware and astute at navigating the rocky waters of achievement and funding then no matter how good or efficient an organization, they can be overturned by four political words: “All Those In Favor.” If you have an inability to influence those who govern, then be prepared to be out-voted or worse, voted off the island.

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Static v. Dynamic: A Continuum of Cost

In our recently published book, “Dynamic Deployment: A Primer for EMS“, John Brophy and I established a dichotomy between the standards of static deployment and dynamic deployment in the very first chapter.  Fortunately, that strong polar perspective has spurred some interesting discussions for me. While the check-out lane analogy was effective in distinguishing some of the differences of static and dynamic deployments, its simplicity only recognized the extreme ends of the spectrum and failed to acknowledge what I would describe as a “Continuum of Cost” between them.

Few systems (at least those with more than just a few ambulances) probably function exclusively at either extreme. The static model will necessitate some flexibility to provide “move-ups” to fill holes, just as dynamic systems will have reasons to keep specific posts filled as long as enough ambulances are available in the system. The reasons for moving, or even fixing locations, may have something to do with demand necessity or even the political expedience of meeting community perceptions.

While there are many differences between static and dynamic deployments that we could discuss, there are also some elementary misconceptions. For instance, dynamic deployment does not mean vehicles are constantly in motion. The term dynamic refers to the nature of their post assignments which can vary between, and even within, shifts. As alluded to in the book, proper post assignments also reduce, not increase, operational expenses. In at least one example we stated, the dynamic deployment strategy was shown to significantly reduce the number of unloaded miles actually driven, which in turn increases the percentage of overall miles that can be billed. This situation not only increases revenue while simultaneously reducing expenses, it also reduces fuel costs and wear on the vehicles (and crews) too which potentially extends their useful life. All this is still in addition to reducing response time and improving crew safety by positioning ambulances closer to their next call so that fewer miles need to be driven under lights and sirens.  The inherent efficiency of this management strategy allows a system to achieve response compliance at the 90th percentile with the smallest possible fleet.  To achieve the same compliance level with a static deployment of crews and posts, the fleet must grow significantly larger. Another recent sample calculation showed that both staff and fleet size would need to grow by well over double in order to reach the same goal. The resulting cost continuum, therefore, clearly shows that a static fleet has operational and capital expenses multiple times the costs of the dynamic deployment model without burning crews out with excessive and unhealthy UHU figures.

For the sake of validating my argument, it is unfortunate that these examples are from private ambulances companies who do not wish to openly share details of their calculations at this time for competitive reasons. It would be safe, however, to assume from these competitive reservations that these results are not automatic, but dependent on proper management and the use of good tools. There are certainly numerous examples of poorly managed systems or ineffective operational tools. To achieve similar positive results in your own system requires certain knowledge, an underlying reason for having written the book in the first place, and an assurance that the deployment tools are proven to be effective.  Just as managers should have references checked during the hiring process, vendors of operational deployment tools should be able to provide ample references for successful implementations of their technology in comparable systems to your own. It is also important that any solution be able to address a continuum that includes your specific objectives to find a balance between geographic coverage with anticipated demand coverage at an acceptable workload and schedule for your staff.

There is no “magic bullet” to achieving operational nirvana, but the combination of effective management with operationally proven tools has shown that cutting costs while improving performance is an achievable goal in most any size system. It is also fair to say that performance can be enhanced with less skill through the application of significant sums of money; but honestly, who can afford that sort of strategy in the competitive arena of modern mobile integrated healthcare.

It is our desire to produce yet another, even more extensive, volume on the topic of dynamic deployment to make the achievement of efficient and effective high performance EMS a reality for more systems. Stay tuned for future details!

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"No Available EMS"

No one really wants to read a bad story about some other EMS agency, but it is even worse to read a similar story about your own. The purpose of this post is not to make Detroit into some “failed EMS poster child? but intended to shed some light on similar problems that may be all too common at other locations as well. For instance, I am sure that the Detroit EMS is not alone in being accused of having their service underfunded and their resources understaffed. I also know there are many other agencies out there paying penalties for “exceptions? (calls outside the expected response time), but holding a call for an hour before dispatch as claimed by EMS workers in a Detroit Examier story is certainly not a common trait of a High Performance EMS. Actions like this are certainly worthy of examination, however, the thing that has really set Detroit apart right now is the realignment of its fleet effective January 3rd in response to the death of Gordon Mickey shortly before Christmas of 2010.

According to Detroit Free Press reporters in an article published in EMS World just today, the plan is to reallocate eight ALS (Advanced Life Support) ambulances to Basic Life Support (BLS) units by reorganizing the Paramedic/EMT teams. Jerald James, Detroit EMS Chief, said that the model “will help better address non-emergency runs? which can make up about 65% of the roughly 130,000 dispatches each year. But in the same article, a “city paramedic? was said to have expressed concern that the wrong ambulances will end up at the wrong calls identifying dispatch’s difficulty with properly prioritizing EMS response. Interestingly, Detroit had already reorganized its EMS service back in 2004 by adding Echo units (paramedic equipped vehicles without transport capabilities) to its formerly all-ALS ambulance fleet but concern was expressed even back then that “tiering? the system to add Echo units and converting certain ALS units to BLS years ago was not an answer to increasing service.

While the specific case in Detroit may have many unique conditions or particular circumstances leading to their current status, the idea I want to spotlight is the not-so-unique idea of reallocation of staff and resources just to improve the emergency response statistics rather than looking more broadly to improve overall EMS response. As David Konig (The Social Medic) describes the situation in his recent blog, downgrading certain 911 calls from ALS emergencies to BLS status is just “shuffling the deck? to improve response time stats in one category over another. I believe he correctly deduces a major part of the answer by saying that “systems improve service and response through intelligent deployment.?

It is exactly that type of “intelligent deployment? that is the driving motivation behind the Mobile Area Routing and Vehicle Location Information System (MARVLIS) suite of products. Using an agency’s own historical data, MARVLIS forecasts future demand by geographically highlighting the “most likely demand areas” with a confidence of approximately 80%. It is also the only system to dynamically predict vehicle response zones to calulate up-to-the-minute demand and geographic coverage based on vehicle status and location – even when units are moving!  This proven system has reduced response times, held growth in future spending, and improved the clinical outcome while working with EMS staff to improve operating conditions not squeezing productivity.

We would love to hear your comments or experiences on this topic, so please add a comment below and check back often for future discussions.

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