This month's article provides an overview of the development of a total quality management (TQM) environment in which operational information obtained on every aspect of service delivery is collected, collated, analyzed and assessed to provide evidence for service and healthcare improvement.
With the advent of initiatives such as NEMSIS and EMS Compass, information and metric collection has become less of a mystery to many. However, while we operate in a high-tech information age, it is still surprising how many agencies and organizations say they don't have enough information to act on.
The information-collection cycle begins with the 9-1-1 call, a request for nonemergency transport or, in an MIH environment, a request for service or visit. As each type of call is conducted, further information is gained at each phase in the cycle.
In the business world, companies use market demand analysis to understand how much consumer demand exists for a product or service. This analysis helps management determine if they can successfully enter a market and generate enough profits to advance their operations. From an EMS perspective, the analysis identifies the time and space in which a call occurs to identify where and when a responding resource needs to be in order to meet the response time, clinical or patient requirement.
The information needed to conduct a demand analysis consists exclusively of historical data that provides a statement of "how we did." The trick is then to apply a reasonable estimate of service growth or loss to identify the requirement for the future. By understanding the temporal and geospatial demand, in other words—the where and the when—a picture of demand can be constructed. This information provides management valuable information on how many hours and staff are needed to complete a task.
From a 9-1-1 perspective, lifesaving begins with a phone call. As soon as the phone is answered and the caller interrogated, information flows in. Metrics gathered provide the main body of demand analysis. Additionally modern CAD systems are capable of many live alerting and reporting functions to ensure the flow of resources remains constant, thus avoiding delays and logjams.
The great response time debate rages on, with some services extending their requirements based on clinical outcomes, while others stick to the measurement of driving time based on political expedience and customer satisfaction. A patient will have little knowledge that a provider employed the wrong gauge needle but certainly understands if the crew is late. Response time management and measurement remains a requirement, and while it may not be clinically statistically significant, it is a necessary requisite.
Clinical Delivery and Care
Clinical data is collected during and hopefully immediately after patient contact. Electronic patient care record (ePCR) systems provide the platforms to capture this vital information. The ePCR is the only contemporaneous record of the encounter, and the old adage that "if it wasn't written down, it didn't happen" is as true today as it ever was.
Information gained from the clinical encounter provides the necessary source to initiate a bill (and with 64,000 ICD-10 codes to choose from now, the more accurate the record, the less chance a submitted bill is rejected, particularly by Medicare and Medicaid).
The record demonstrates that appropriate and proportionate care was delivered to enable the call to be scrutinized for quality assurance purposes. Documentation proves the patient has a stretcher-bound medical necessity. Under current Part A rules, reimbursement only occurs for transport and is only payable for the patient who demonstrably has a stretcher-bound need. Good and measurable documentation is an enabling foundation to all of this subsequent activity.
Measuring Outcomes and Quality
The physical response time is a political and patient satisfaction measure, but clinical treatment metrics are crucial to demonstrate clinical care, quality and outcomes. In a true total quality environment, the QA/QI process ensures the delivery of solid paramedical skills but also leads to adjustment of protocols where evidence warrants it, as well as training solutions to ensure issues identified are rectified.
An example of this is in the first-time intubation rate achieved by medics. In one case the QA/QI process identified a cohort of medics whose rate was lower than expected. The performance improvement plan determined that an intubation station be set up at the employee clocking-in area—on arrival, staff booked in and then practiced an intubation. The result was an immediate and measurable increase in first-time success.
Show Me the Money
EMS is a business, like it or not. Bottom lines and solvency are important, and the days of bottomless municipal coffers are past. Whether an EMS system bills for service to generate income or receives an annual municipal budget, good business checks and balances are vital. Next year's budget uses last year's data to identify demand, hours and income, and accuracy in information is essential to develop the future spreadsheet. Nor is ownership of the budget book the responsibility of the finance director and chief alone; all managers must understand how their actions and reactions affect solvency and financial balance.
In an organization that bills for service and the private sector in particular, understanding the budget tempo is a major information need—how quickly does a patient contact resulting in a complete record get coded, converted into a bill and then paid out? If this takes months, cash flow could be an issue. What is the organizational daily/weekly/monthly collection rate? Are more billers and coders required to increase the rate? Information collection and collation does not end with the medic.
In the new world of EMS 3.0, as we move away from a "you call, we haul," bill-only-for-transport mode, reimbursement may well follow hospital trends and move to a "value, not volume" model. An increasingly important source of information is the patient satisfaction survey. EMS organizations now retain survey companies to audit a random sample of patients and elicit their responses to set questions. The answers not only provide a snapshot of customer service but also allow benchmarking against other organizations offering the same services. While it is not commonplace at this time, high-value EMS systems are beginning to assemble a body of survey data in anticipation of future reimbursement changes.
The gathering of all information begins with three numbers and eight words: 9-1-1 followed by "Paramedics, what is the address of the emergency?" Thereafter every word and keystroke—in the call center, in the cab, at the patient's side and at the hospital—represents data and information that, when processed, becomes actionable intelligence that will improve the next cycle of care. EMS lives in a data-rich environment, and to maintain operational efficiency, every metric matters.
For a full list of reports and data collection types amassed by the members of AIMHI, visit www.aimhi.mobi.
Rob Lawrence, MCMI, is chief operating officer of the Richmond (VA) Ambulance Authority. Before coming to the USA in 2008 to work with RAA, he held the same position with the English county of Suffolk as part of the East of England Ambulance Service. He is a graduate of the Royal Military Academy Sandhurst and served in the Royal Army Medical Corps. After a 22-year military career in many prehospital and evacuation leadership roles, Rob joined the National Health Service, initially as the Commissioner of Ambulance Services in the East of England. He later served with the East Anglian Ambulance Service as director of operations. He is also a member of the EMS World editorial advisory board.