This is part of a series of articles from MONOC Mobile Health Services, New Jersey's largest provider of EMS and medical transportation and first CAAS-accredited agency. The goal of this series is to provide insight and solutions for the different managerial and operational challenges facing the EMS leaders of tomorrow. For more, see www.monoc.org.
You want to make a protocol change for your EMS department. You draft the change and present it to your medical director for his review and approval. You discuss your feelings with him and what it would take to implement the new protocol, and deal with any specific bias that he may have either from his education, practice or the practice of the facility where he works. You make adjustments to the protocol that he requests and then present it to your staff for implementation.
But what if your medical direction is from a board of physicians from different hospital systems, all with equal say in drafting that protocol? You may have multiple biases to deal with, as well as vast differences in practice from facility to facility. This is a key issue when dealing with a medical advisory board versus an individual medical director. The dynamic can be very frustrating, but it can also be very fulfilling.
The model we use at our service consists of a medical advisory board with 12 physicians who represent 11 different hospitals. The system's medical director is elected from among these physicians to chair meetings and for regulatory purposes. Some of the physicians on the board work at university hospitals, while some work at community hospitals. Within a group this size, there will be some physicians who are very progressive in their approach to prehospital patient care and are a true ally to a clinical department that wants to keep its service on the cutting edge, while others may tend to be more conservative, acting as a counterbalance and ensuring that the agency takes its time and fully considers each new protocol prior to its implementation. Both mindsets can be an asset to an EMS service.
Some of the physicians on a medical advisory board may be prolific researchers with several published projects; while others may work in hospital systems that have not "grown with the times" and therefore had little opportunity to participate in research of any type. Physicians from less progressive hospitals may be conservative in their thinking and practice, and therefore may take a great deal of convincing when it comes to seeing the value of a new procedure or protocol. This can of course be frustrating for a clinical department that is working to develop what it considers to be best practices within an agency. One thing is certain—the progressive vs. conservative dynamic will lead to some very interesting discussions. At the end of the day, these discussions will serve to make sure a decision has been fully weighed before its implementation.
In many cases, the extra effort it takes to win over the conservative physicians on a medical advisory board may actually lead to your EMS system driving procedures or protocols in those physicians' emergency departments. Your EMS system may begin utilizing a procedure in the field that a smaller emergency department is not familiar with. The smaller department may at first question the procedure, but the influence of your hard-won medical advisory board member will help them realize that this will benefit patient care and thus hasten the process of bringing the procedure to their ED.
This was the case for our service when we began to use EZ-IO for vascular access on critical patients. Our clinical department visited several emergency departments within our system to in-service their staff on this device. As those staff members began to see how easily and effectively the drill was being used in the field, they began to ask why it was not being used within their own hospitals. Because of their familiarity with the device, members of our medical advisory board who represent those hospitals were able to take the lead in bringing this new tool to their facilities.
In some cases, physicians of progressive hospital systems may want to steer an EMS service toward a procedure that falls outside its current regulatory scope of practice in order to streamline procedures that are currently being performed in their facilities. It can be a precarious balancing act to keep these physicians feeling content and equally valued. In these cases, conservative physicians can serve as a braking mechanism when progressive physicians want to initiate treatment protocols that an EMS service might not be prepared for.
When it comes to chart reviews and questions of quality assurance, an individual medical director will use his or her training and bias to make a unilateral decision on the quality of care. With a medical advisory board, there are no unilateral decisions. This can lead to some very interesting discussions about the field treatment of patients.
In New Jersey, where our EMS service operates, approximately 80% of all treatment rendered to a patient during any given encounter is regulated by state-issued protocols. Once we have exhausted these protocols, we are required to contact an on-line medical command physician for any additional treatment orders we may require. If we are unable to contact on-line medical control for any reason, we can revert to a set of radio failure treatment protocols, which are determined by an EMS service’s medical director or, in our case, our medical advisory board. Here again, there can be a significant difference in how the physicians on a medical advisory board feel a patient should be treated under radio failure protocols.
Although our agency services 11 different hospitals, our on-line medical command comes from one hospital in the system. While the emergency department's medical director of that hospital has a seat on our medical advisory board, the dozen or so physicians who provide medical command and report to her do not. These medical command physicians go through quality assurance in the same fashion as our field staff. In cases where a medical advisory board physician disagrees with a medical command order, the matter will be discussed by the entire board. Again, the biases of different hospitals come into play in the discussion until the board comes to a resolution on the issue. The task of providing feedback to the medical command physician will fall to the ED medical director of that hospital.
There is also the issue of dealing with the overall EMS system in your region. This is where a medical advisory board can truly shine in its ability to disseminate information across a large geographic area. While an individual medical director may only interact with a limited number of providers from other EMS agencies, such as volunteer basic life support or even other ALS services, members of a medical advisory board are far more likely to interact with a much larger number of providers and agencies. Dissemination of information through the members of the medical advisory board can reinforce and even enhance the message of proper prehospital medical care to the EMS community at large. Medical advisory board physicians also serve to educate staff members of their respective emergency departments, keeping them up to date on what is new in the prehospital arena, thus enhancing the relationship between emergency department staff and an EMS agency.
When all is said and done, it is hard to say which system of medical direction works better. The pros of a single medical director system are a much more streamlined decision-making process where new protocols can be rapidly developed and implemented. The cons of a system like this include reliance on a single person’s point of view with little room for dissenting opinion. The major advantage of an advisory board system of medical direction is that no one person has the ability to make a decision. This ensures that there will be significant input from all stakeholders in the development of new protocols. The other side of that coin is that change may tend to come at what feels like a glacial pace. If you have an involved progressive medical director who is supportive of your EMS agency's vision, then a single director system might be to your advantage. If the opposite is true, or if you put a premium on the ability to gain broad insight during the decision-making process, then the medical advisory board is probably your best bet. Both systems can work well under the right circumstances.
Robert Bauter, MAS, CPM, NREMT-P, is director of clinical services for MONOC Mobile Health Services, where he oversees the quality assurance and quality improvement programs for the company. Robert has been a paramedic since 1986, is a Certified Public Manager and holds a master's degree in administrative science.
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