improving operational performance presented by: jonathan d. washko, bs-emsa director of deployment...
TRANSCRIPT
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
Improving Operational Performance
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
e
Employee Wellbeing
Econ
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
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Operations Finance
Supply / Logistics Data Analytics
QI / CQI /
PI
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Safety & Risk
IT / TechnologyP
R/M
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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)
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
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 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.
Measuring Response Time Performance
Response
Time
Measurements
Fractile
Measurement
Example
Measuring Response Time Performance
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
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
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
Improving Response Time Performance
The net effect of a 2 minute improvement in call processing / chute times on geospatial coverage isochrones
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)
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Hour of Day
Dem
and
/ Su
pply
EMS Temporal Demand Static EMS Supply
EMS Temporal Demand & Static Supply
Improving Response Time Performance
Improving Response Time Performance
EMS Temporal Demand & Static Supply
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Hour of Day
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EMS Temporal Demand Static EMS Supply
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EMS Temporal Demand Static EMS Supply
Lost Revenue Opportunities
EMS Temporal Demand & Static Supply
Improving Response Time Performance
EMS Temporal Demand & Temporal Supply
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Hour of Day
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EMS Temporal Demand EMS Temporal Supply
Improving Response Time Performance
Improving Response Time Performance
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
Improving Response Time Performance
EMS Temporal Demand & Static Supply
EMS Temporal Demand & Temporal Supply
Improving Response Time Performance
EMS Temporal Demand & Temporal Supply
Improving Response Time Performance
EMS Temporal Demand & Temporal Supply
Improving Response Time Performance
Improving Response Time Performance
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
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)
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
e
Employee Wellbeing
Econ
omic S
tability
SuccessTriad
The Balancing Act…A Quality Unit Hour
TheQuality
Unit Hour
Human Resources
Pu
blic E
du
cation C
on
tro
l Cen
ter
Trai
ning
& E
du
Operations Finance
Supply / Logistics Data Analytics
QI / CQI /
PI
Flee
t Mai
nt.
Safety & Risk
IT / TechnologyP
R/M
arke
tin
g
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
The Balancing Act…A Quality Unit Hour
TheQuality
Unit Hour
Human Resources
Pu
blic E
du
cation C
on
tro
l Cen
ter
Trai
ning
& E
du
Operations Finance
Supply / Logistics Data Analytics
QI / CQI /
PI
Flee
t Mai
nt.
Safety & Risk
IT / TechnologyP
R/M
arke
tin
g
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
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
Improving Operational Efficiency & Effectiveness
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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
Improving Operational Efficiency & Effectiveness
• 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!)
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
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
Improving Operational Efficiency & Effectiveness
• Managing Response Errors– Systems engineering flaws– Unit Hour production problems– Deployment Plan issues– System support problems– Human Error
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
Improving Operational Performance
• Closing Remarks
• REMEMBER the EMS Success Triad– Patient Care– Employee Well Being– Financial Stability
• Questions