I was working an overnight shift in a busy metropolitan EMS system when we were called to the home of Mae, an elderly female who was short of breath. She said she was having difficulty dealing with the loss of a loved one, and awoke 30 minutes ago feeling anxious and sad. She did better with a little oxygen and a lot of sympathy.
Having learned long ago that there isn't enough equipment or expertise in the back of an ambulance to rule out a cardiac event, I suggested we proceed to the nearest ED for a more definitive assessment. En route Mae asked if I'd handled a lot of cases like hers. I caught myself parroting the usual platitudes about my agency's experience with all things medical, but then it occurred to me that I didn't know what she meant. A lot of cardiac calls? Anxiety cases? Geriatric patients? Middle-of-the-night runs? It didn't matter. I had no idea how our alarms were distributed by age, time of day, chief complaint or any other criteria.
Next my inquisitive patient wanted to know what the charge for the ambulance ride would be. After another pensive pause, I replied that I wasn't sure, but her insurance probably would cover it. Truthfully, I didn't have a clue. I wondered what it cost us to do a call like this, or any other call. Surely someone in our company must keep track of those things.
MINDING YOUR BUSINESS
In Search of Excellence, by Tom Peters and Robert Waterman, was considered a must-read manifesto for entrepreneurs and corporate leaders in the mid 1980s. The premise of the book was that common indicators of management excellence prevailed in the most successful U.S. companies. By postulating and dissecting eight commonsense characteristics, they offered a blueprint for building new businesses and renovating struggling ones. The authors pointed out that "the companies that we have called excellent are among the best at getting the numbers, analyzing them, and solving problems with them."1 Is there any reason EMS organizations should be exempt from such diligence? How well do we measure company and employee performance? Are there business tools we can adapt and apply in EMS to help us?
This article focuses on five attributes worth quantifying in almost any professional setting. The methodology is tailored to EMS.
Most of us have been horizontal in a hospital or ambulance at least once. When I'm a patient, my priorities are clear: I want to feel better, and I want someone with medical training to tell me, "I know what your problem is, and I'm going to fix it." When that happens, I'm so grateful, I could rename my children after my healthcare providers.
As EMS managers, however, we confront the challenge of evaluating care delivered by third parties: our employees. There are many complicating variables: time, standards of care, patient cooperation, environment, etc. The key to grading prehospital care is to recognize practical limitations to data collection, quantify what we can, and treat spurious conclusions with skepticism.
One method of measuring outcome is called PET, for prehospital evaluation technique. PET specializes in grading quality of care. It's not just a number-crunching tool; it's also a process, requiring planning and preparation before implementation.
PET highlights three indicators of EMS performance: prehospital impression, prehospital care and hospital diagnosis. PET pundits compare prehospital care to the other two data elements by assigning common codes to each, based on local protocols. The goal is to determine whether prehospital care matched prehospital impression and hospital diagnosis. When that is not possible due to ambiguous information, matches are assigned null values so those cases aren't included in subsequent analysis.