Minority Report or Moneyball

I have often heard comparisons on the automation of System Status Management to the 2002 Spielberg movie starring Tom Cruise called “Minority Report” loosely based on the 1956 short story by Philip K. Dick. This science fiction action thriller is set in the year 2054 when police utilize a psychic technology to arrest and convict murderers before they commit their crime. The obvious comparison there is to the forecast of future call demand and the eerie accuracy of the reports that allow the right resources to get there in time to make a difference in the outcome. Sometimes in the movie, as in real life, there is a considerable cost to achieve that goal as well. It is easy to get wrapped up in the technology, particularly the virtual reality user interface that Detective Anderton (Cruise) uses to make sense of the premonitions and quickly locate the scene. I like to end the analogy there before we learn the darker side of the way the technology works and can even be manipulated to put a stop to the whole project. Perhaps some EMS providers think they see a similar inherent darkness and hope for an eventual collapse of the whole dynamic deployment paradigm as well. This may be where the art of a story and our reality diverge, especially considering the current economic dynamics even given the admittedly sporadic successes. This may also be why we need a different analogy.

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More Reasons to Support Dynamic Deployment

The “Leverage Real-Time Data for Improved Ambulance Response Times” article that Zoll posted on their blog site did a good job of explaining response times and even the benefits of System Status Management (SSM) planning to the patient. But there is still more to the story that we have learned over the years since Jack Stout first introduced it.

Of course, it is best for the patient (and the service) when an ambulance arrives to the scene in a short time. The media often picks up on poor response times with stories like�the GSW patient dying in Cleveland�surrounded only by police and fire personnel. Even the doctors at JAMA can’t resist publishing an article showing response times as an inherent failure of EMS in certain cases. Unfortunately, many will read the solution as medics “speeding” to the scene, yet we have learned that lights and sirens have little impact on times and may even prevent some patients from calling for an ambulance in the first place. However, when the deployment of ambulances is responsive to the dynamic demand patterns throughout the day, ambulances can literally be moved closer to the scene even before they are dispatched. Literally hundreds of High Performance EMS agencies across the US have significantly reduced their 90th percentile response rates through technology. Forecasting the future does not involve magic, at least not for predictable phenomenon like emergency calls for service. Not only can we forecast the quantity and types of calls we will receive (necessary for adequate staffing), we can determine where they are likely to originate from with significant accuracy as well. Shortening the distance that an ambulance must travel is a safer alternative than asking a crew to speed in order to achieve the same result.

Another positive impact of shorter response times is patient satisfaction. There are many reasons that healthcare providers should be�using patient satisfaction surveys, both for the benefit of the patient as well as simplifying the accreditation process for your service.�Beyond safety, satisfaction and simplification; proper SSM can improve finances. Some services have recognized marked reductions in the number of post moves for crews and ultimately reduce the total number of unloaded (read unreimbursed) miles driven which saves on vehicle wear and tear in addition to fuel costs. Other agencies, particularly those who contract their services, can reduce financial penalties for “exceptions,” or late calls beyond the target response time.

Frankly, the public often expects performance measured in minutes. Whether we approve of the measure or not, we are often graded and compared based on response times. Whether the penalties for missing targets are financial, patient satisfaction, or driven by bad press reports, being late simply hurts. Until EMS is designated and funded as a critical service for government, it will be dependent on political funding allocations and insurance reimbursements. As long as performance is measured by how long it takes to be on scene, response times will be critical to the financial well-being of services. The least we can do is perform to the highest safe standards possible.

 

We Need Some New Stories

We always hear that EMS is still a relatively new discipline. And in the scheme of medicine, or even public safety, that is certainly true. But we shouldn’t let the fact of its youth keep us from acknowledging that it has already been around long enough to accumulate some of its very own antiquated dogma. If you have any doubt, consider the reaction to changes in protocol – even those with good evidence to support some new practice. Working cardiac arrests on scene, for instance, was not met, at least in my experience, with enthusiasm at the prospect of improving patient outcomes. What I heard were excuses for why something different wouldn’t work. I thought about that exchange this week as I was listening to a recent Medicast podcast on an entirely different topic. Near the end of that recording, Rob Lawrence remarked that we really need to do away with the old stories that start out with “back in my day…”

The stories of some grizzled professionals include not just memories of MAST pants or nitrous oxide, but the idea that tourniquets take limbs, not save lives. More recently stories have been spun about the movement away from the long-held reliance on the long spine board as an immobilization splint during transport or even the value of therapeutic hypothermia for cardiac arrests.

While there is no denying, or even stopping, a rapid state of change in EMS, we must be sure that it is not just change simply for the sake of change or even resistance for the same reason. Change must be meaningful change that is guided by reasoned thought and scientific evidence, not personal anecdote. And new practices should be carefully modified to address current issues or new understandings of the problem.

Another sacred, yet unjustified, belief among too many providers is that the dynamic deployment of resources (commonly referred to as “SSM”, or System Status Management) is an unmitigated failure of cost-consciousness that actually leads to increased expenses and provider dissatisfaction. The evidence, however, from many of the services who now employ some facet of dynamic deployment has proven that while it can be tricky to implement well; the savings in time, money, and lives are definitely real. And those savings need not come at the cost of provider safety or comfort either. Whether you have had bad experiences in the past, or just heard about it from others, it is time to set aside the old stories and take a new look at the current technology and practice in every aspect of EMS that leads to improved performance.

To advance our profession, we must completely ban the expression,  “but that’s how we’ve always done it” and look toward “how we can do it now!”

 

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!

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.

Gartner, 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.)

The Role of Response Time in EMS Performance

Several months ago, Rob Lawrence of the Richmond Ambulance Authority started a thread on the High Performance EMS Group of LinkedIn by asking “So what does the phrase ‘High Performance EMS’ mean to you?�? This innocent sounding question sparked immediate debate even within the small group at that time. Benjamin Podsiadlo of AMR quickly tied the quality of EMS performance to “experience�? and “outcomes�? stating further that “response time is not an evidence based factor in ALS performance.�? He later backed up his assertion by writing that “the catch 22 of pushing the workforce to be responsible and accountable drivers while simultaneously achieving narrow response time goals to the vast majority incidents that have no medical need for such high speed driving is also a bizarre and irresponsible contradiction.�? This is a point that even Lawrence admits could foster the “mentality of ‘arrive on time and the patient dies – good outcome, arrive late and the patient lives – bad outcome’�? that has already been affecting common sense both in the UK and increasingly in the US since NFPA 1710 set response time standards several years ago.

While there were other good comments, I would like to focus on the specific assertion that measuring response time (a well established practice today such as at Huron Valley Ambulance’s public web Performance Dashboard) is not an “evidence-based�? practice. There are many specific accounts of individual lives saved that I have heard mentioned by different agencies, but I will concede that the plural of “anecdote�? is not “data�?. However, one of the best stories of response time saving lives was made on February 9 when Richard Sposa of Jersey City Medical Center EMS discussed an interesting finding in a recent webcast. The chart reproduced here shows a correlation between

response time and the Return of Spontaneous Circulation (ROSC). This unexpected finding clearly traced an upward trend of ROSC with the decline in Average Response Time for Priority 1 Calls graphed quarterly from the beginning of 2005 to the end of 2007. This is a verified statistical trend (Mount Sinai Hospital reviewed these findings) and I suggest you click to view the graph in full detail. This shows not just living anecdotes, but a statistical increase patients with restored heartbeats.

Many things about our business can and should be questioned, but this is exactly the sort of evidence I would like to see investigated at other services. Can what Jersey City Medical Center is experiencing be reproduced elsewhere? And probably more importantly, does fast response necessarily mean “high speed driving�??

The point of System Status Management (SSM) is that ambulances can be effectively pre-positioned through scientific statistical forecasting in order to reduce the time of a response even without driving faster to the call.  Zoll Software Solutions, as an example, considers the elimination of inefficiencies to be a core component for closing the loop on your dispatch process and is even offering free medical equipment to customers who use this technology to improve their system. One customer who has done this already with Zoll technology is Grand Rapids who was also featured in the following FOX News video on Predicting Where your Next Emergency will Happen.

If you believe that knowing where your next calls are likely to come from in time to allow you to safely prepare for that response, the science is available today. You just need to be able to integrate that knowledge into your process.

Index of Suspicion Includes Me

It doesn’t take long in an EMT career before the excitement of “rushing to an emergency” turns in to “just another transport call.”  The philosophy of “you call, we haul” in nearly every service can break the community servant’s spirit by turning a skilled paramedic into just an ambulance driver.  But our system “just is what it is,” right?

Well, far from being a service based strictly on tradition, EMS is constantly challenging previous assumptions and struggling to reinvent itself.  How we administer CPR has changed (again), we question the effectiveness of C-spine immobilization that we do standard on nearly every trauma patient, or argue the very validity of the “Golden Hour” around which many services have been designed.  Almost all assumptions are open to be questioned.  I say “almost” because I have found that there still are some boundaries to the willingness of many EMS practitioners to consider change.  Some limitations are easily admitted, like the aversion to legal liability that means we transport anyone who asks us to do so regardless of their suspected need or ability to pay, but there are also less easily acknowledged sacred beliefs.

One of those that comes quickly to my mind is response time.  To many, a quick response indicates excessively fast driving and is contraindicated by safety concerns.  Besides that, we can justify ourselves since very few of our daily calls actually “require” a code response.  While that point may be strictly valid medically, I would argue that our performance is often measured by the public in the agonizing minutes between the 9-1-1 call and the ambulance arriving at the curb.  A patient does not need to be in some form of arrest in order for them, or their family members, to be distressed.  Part of our job is being a calming and supportive influence.  At the same time, I admit that it does not justify putting the driving public or ourselves at risk with an ambulance speeding to every call. But is it really a given that one means the other?

System Status Management – oops, another term laden with strong negative feelings in the field – is actually all about improving performance (both time and economic efficiency) without sacrificing safety.  As advocates for patients, medics see themselves sometimes fighting the system in order to provide the best possible care.  Talk of economic efficiency is seen as just making their job harder.  But again is it really a given that one necessitates the other?

Imagine a system where patient needs are accurately forecast in advance. Where the posting of ambulances is not just another place to sit and wait, but in a practical sense it is the staging for a call that has yet to be received.  Response is thereby improved not by excessive haste, but by the strategic pre-positioning of resources.  The cost savings is not simply an amount  taken from others in a “zero-sum game”, but effectively rescues budgets for proactive wellness programs or, in the current economy, may mean simply saving jobs that allows us in turn to save lives.  This process really works and these systems do exist.  They are called “High Performance EMS” systems and many are profiled here each month while others receive recognition through accreditation agencies like CAAS.  What sets them apart is often observed in technology, but the reality is that it is a culture of seeking constant improvement by the entire staff that makes a difference.

While we consider improvements to the many technical aspects of our profession, let us not neglect the philosophical perspectives that motivate us as individuals.  We operate as a team, not just the pair on the truck, but the whole EMS system is one team with a singular goal.  A goal to do even better each day. So, as we continue to assess our profession should the index of suspicion not include our attitudes toward improving the overall system?

Dynamic System Status Management

System Status Management (SSM) is the fluid deployment of ambulances based on the hour-of-the-day and day-of-the-week in order to match supply, defined as Unit Hours of Utilization (UHU), with expected demand, expressed as calls for service, in the attempt to provide faster response by locating ambulances at “posts” nearer their next calls.  While the practice is still not unanimously embraced by all services, it has a sound foundation both in the research literature dating back to the 1980’s as well as in practice today.  Experience has shown that ambulance response times can be dramatically decreased using this type of dynamic deployment, but it is also recognized that it is possible to reduce performance when these techniques are not applied properly.  The direction of the results of a system implementation are typically influenced by the system design, competence of the managers creating the plan, and commitment of the workforce in implementing it.  Therefore the best practice is a simple and straightforward implementation that will show positive results quickly.  This methodology ensures a positive return on investment along with garnering the necessary buy-in from staff to make the project a success.

In his article, “System Status Management – The Fact is, It’s Everywhere“,  published in the Journal of EMS (JEMS) magazine back in 1989, Jack Stout explained the concept of SSM and tried to dispel certain myths.  Based on foreseen Geographic Information System (GIS) technology and even general computing capabilities of that time, it was quite logical to assume in his Myth #2 that “no matter how thoroughly the response zone concept is fine-tuned in practice, it cannot be made to cope effectively with the dynamic realties of the EMS environment.”  But systems implemented today around the US are capable of calculating dynamic response zones in a small fraction of a second while even being based on time-aware historic driving patterns making a truly dynamic system status management process a reality.  A practical and proven example of a dynamically functioning system status management application is the Mobile Area Vehicle Routing and Location Information System, or simply MARVLIS.

The following Slideshare presentation does an excellent job of telling the story of why and how the system works:

High Performance EMS is MARVLIS

View more presentations from hp_ems

The Future of Prediction

I have read the positions stating that calls for emergency services are completely random (justifying the reason they are often called “accidents”) and therefore not able to be predicted.  But both academic literature and practical experience show that demand prediction can be an effective tool in helping to balance scarce resources (ambulances and their trained crews) with public demand (requests for emergency responses even without taking into account the abuses to the system as discussed in a previous posting on the problem of “frequent flyers”) while still improving response times and controlling costs.

For anyone who thinks all of this sounds too good to be true, there are examples of where expensive technology is not having the desired affect.  One such location is Lee County EMS in Florida where not only have response times not been improved, but ambulances are burning more fuel than ever and the critics include the very paramedics it is supposed to help.  While predicting where the next 911 call will come from may be similiar to “picking the winning card at a casino” as the Florida investigative news reporter suggests, that isn’t really the objective.  We don’t need to know which phone will make the next call, it is enough just knowing the probability of a call coming from any given location within the service area.  This may be a subtle distinction, but one that makes a huge difference at MedStar in Fort Worth or Life EMS in Grand Rapids where response times were dramatically improved by taking the next step beyond simple demand prediction and placing ambulances at positions where they can be the most effective.

Academic studies show that demand pattern analysis can be used without hourly, daily, or seasonal calibration to achieve potentially acceptable tolerances of demand prediction, but when adjusted with these appropriate corrections, software applications like MARVLIS (the Mobile Area Routing and Vehicle Location Information System) can effectively predict demand in practical situations.  According to Tony Bradshaw of BCS, the makers of MARVLIS, it routinely calculates where about 80% of demand will occur and when paired with realistic drive-time response zones it demonstrates valuable support for a dynamic System Status Management plan to pre-position, or “post” ambulances closer to their next call saving valuable time and increasingly expensive fuel costs.

What matters most, though, is what agencies experience in the field.  At SunStar they say ” the most significant result was improving our emergency response time from 90.2% to now over 93% in lieu of an increase in patient call volumes.  This equates to ambulances arriving on scene more than 1 minute quicker.  We additionally saw a savings of $400,000 in penalties by exceeding our contractual goal of 92% and performing above 93% compliance.”  Similarly, Steven Cotter, Director of Sedgewick EMS added that “the technology has opened our eyes to be able to understand how we are performing, where we are deficient in our performance and how we can make changes quickly and adapt to a changing environment.”  And beyond simple response times, “it’s what technology should do,” says Joe Penner, Executive Director at the Mecklenburg EMS Agency, ” take the complex and present useful, straightforward information.  It has helped us improve response times, resource utilization AND simultaneously reduce unnecessary post moves — your patients and employees will appreciate it!”

My conclusion is that proper demand prediction paired with realistic response creates significant opportunity to improve performance and cut costs even in growing communities.  When used properly, the future looks bright for High Performance EMS!