Measure Hunting

   Everyone likes to think they put patients first. But in reality, few aspects of most EMS systems are truly designed with the patient foremost in mind.

   "In EMS, the patient has never really been the center of any of its design," says consultant Dave Williams, PhD, late of Fitch & Associates and now working with the Institute for Healthcare Improvement. "And there's not a lot of evidence to say what's the right thing in most situations. So most of the design you see in the industry has been developed around personal experience or opinion."

   Williams spent several years studying patient-centrism in the field--what it is and what inhibits it--as part of his doctoral pursuit. He described his findings at the Pinnacle EMS Leadership & Management Conference in July 2010.

Defining Patient-Focused

   What constitutes a patient-centric system? Through review of scientific journals, trade publications and historical documents, Williams identified 15 defining factors--six related to system design, nine to operational practices:

System design features

• Public intervention--Training and equipping laypersons to deliver needed actions (e.g., CPR, PAD);
• No call screening--9-1-1 calls are triaged but not screened;
• Demand-based deployment--Managing resources to correspond to demand;
• ALS--A paramedic responds to every call;
• Full service--Systems provide both emergency response and routine services like interfacility transports;
• Alternative transport destinations--Patients can go to clinics, doctors' offices and other facilities when they're more appropriate than EDs.

Operational practice features

• Response time reliability--Calls are dependably answered in a timely way;
• Reduced call time--Especially for things like trauma, stroke and STEMI;
• Balanced scorecard--Taking measures that yield a broad view of an organization's overall performance;
• Outcome-based performance measurement--Measures demonstrating a system is achieving the results it aspires to;
• Customer satisfaction measurement--Evaluating what patients think of their experiences;
• Quality improvement--Gauging the effectiveness of changes to care or processes;
• Economic efficiency--High-quality service at the lowest possible cost;
• Preparedness--For terrorist acts, natural disasters and other large-scale events;
• EMS health monitoring--Helping patients through proactive assessment and care (e.g., evaluation of risks in homes, wellness and medication-compliance checks, etc.).

   Williams then zoomed in on five different EMS system types--fire department, third service, private, hospital-based and public utility model--as case studies, reviewing internal data and documents and quizzing leaders about obstructions they faced in these 15 areas. Their answers spanned a predictably broad gamut, but were grouped down to 38 general categories of results.

   The top five resulting obstacles were:

• Cost/funding;
• Data measurement;
• Process and outcome focus (i.e., defining what a system wants to achieve, then figuring out how to go about it);
• Systems view or design (i.e., interdependence on other entities); and
• Public information and education.

   The cost/funding and process/outcome focus obstacles were within the top five cited as inhibiting both system design and operational practice features, suggesting they are the two primary overall obstacles to the design of more patient-centric EMS systems.

Process and Outcome

   Cost is a more complex concept than you might think, and Williams had some important findings in this area. But the issue of process and outcome focus can be even harder to wrap a mind around, though it is relevant to every EMS system out there.

   Determining exactly what you want to accomplish, and then how to accomplish it in an evidence-based, data-driven way, isn't always easy.