improving operational performance presented by: jonathan d. washko, bs-emsa director of deployment...

Improving Operational Performance

Presented By:

Jonathan D. Washko, BS-EMSA

Director of Deployment – REMSAPresident – Washko & Associates, LLC

HPEMS & Public Safety Consulting Partner – Stout Solutions, LLC & FirstWatch

Some Food for Thought…

Late 9-1-1 Wears The Late Crown

• 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

Discussion Topics

• Successful Performance Defined

• Defining Operational Performance

• Measuring Operational Performance

• Improving Operational Performance

Successful PerformanceDefined

The EMS Success Triad– A Balancing of…

• Patient Care

• Employee Wellbeing

• Financial StabilityPat

ient Car

Employee Wellbeing

omic S

tability

SuccessTriad

EMS Success Triad

Patient Care– Response Times– Clinical Performance– Customer Service

EMS Success Triad

Employee Wellbeing– Retention– Health / Safety / Welfare– Satisfaction– Compensation– Recruitment

EMS Success Triad

Financial Stability– A/R & Billing Practices

– EMS Delivery Model / System Design

– Operational Efficiency & Effectiveness

– Employee Compensation

– Safety & Risk Management

– Systems Engineering

The Balancing Act…A Quality Unit Hour

TheQuality

Unit Hour

Human Resources

blic E

cation C

Operations Finance

Supply / Logistics Data Analytics

QI / CQI /

Safety & Risk

IT / TechnologyP

Defining / Measuring & Improving Operational Performance

Limiting our Discussion to…– Response Times– Key Operational Efficiency & Effectiveness

Measures

Defining Response Time Performance

• Typically System Specific

• National Standards

• Measured Via– Clock Start– Clock Stop

• Measurement Methodologies– Average Response Times– Fractile Response Times

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

Measuring Response Time Performance

Typically two types of measurement– Average– Fractile (or frequency distribution)

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

Fractile– Frequency distribution of time that shows reliability

percentage of responses based on specific time bins– Many systems (and standards) are going to 90th 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.

Response

Measurements

Fractile

Measurement

Example

Fractile Measurement ContinuedResponse 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

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

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

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

The net effect of a 2 minute improvement in call processing / chute times on geospatial coverage isochrones

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)

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

Hour of Day

EMS Temporal Demand Static EMS Supply

EMS Temporal Demand & Static Supply

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

Hour of Day

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

Hour of Day

Lost Revenue Opportunities

EMS Temporal Demand & Temporal Supply

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

Hour of Day

EMS Temporal Demand EMS Temporal Supply

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

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

– 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)

Improving FinancialPerformance

– Financial Performance• Definitions

• Measurements

• Improvements

Defining FinancialPerformance

– 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

Successful PerformanceDefined

The EMS Success Triad– A Balancing of…

• Patient Care

• Employee Wellbeing

• Financial StabilityPat

ient Car

Employee Wellbeing

omic S

tability

SuccessTriad

TheQuality

Unit Hour

Human Resources

blic E

cation C

Operations Finance

QI / CQI /

Safety & Risk

IT / TechnologyP

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)

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

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

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

TheQuality

Unit Hour

Human Resources

blic E

cation C

Operations Finance

QI / CQI /

Safety & Risk

IT / TechnologyP

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

• 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

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

Total Consumption Priority 0 - Responses Priority 1 - Responses Priority 2 - Responses Priority 3 - Responses

Priority 4 - Responses Priority 5 - Responses Scheduled Unit Hours Actual Unit Hours Effective Unit Hours

Priority 1 - Late Total Status 99 Declarations Total Transports Total LDT's Running P1 Compliance

• 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!)

• 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

• 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

• Managing Response Errors– Systems engineering flaws– Unit Hour production problems– Deployment Plan issues– System support problems– Human Error

• 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

• Closing Remarks

• REMEMBER the EMS Success Triad– Patient Care– Employee Well Being– Financial Stability

• Questions

improving operational performance presented by: jonathan d. washko, bs-emsa director of deployment...

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