This is the eighth in a yearlong series of articles developed by the Academy of International Mobile Healthcare Integration (AIMHI) to help educate EMS agencies on the hallmarks and attributes of high-performance/high-value EMS system design and operation. For more on AIMHI, visit www.aimhi.mobi.
In many EMS systems, the role of medical director often lands somewhere between senior leadership and off to the side of the operations division, sometimes creating an ongoing and almost-palpable tension between operations and medical oversight. Most would agree that both the medical director and operations leadership should want the same things: to provide high-quality patient care; transport the patient to the next appropriate level of care as expeditiously as possible; and get the patient there in the best possible medical condition. While it is likely that both areas share those overarching goals, the drivers to each area may not be directly aligned with each other, and often the desired path to reach these goals may differ greatly.
Medical oversight is tasked with looking at the medical care being delivered. This can include quality of care, medical efficacy, opportunities for continuing education and remediation, and protecting the organization from liability through rigorous review, protocol development and thorough orientation and onboarding processes. Staffing, regulatory compliance and daily operational challenges do not typically find their way to the top of the list for medical directors, nor should they.
Operations, on the other hand, is focused on staffing, response volume, compliance issues such as response times, and ensuring the system functions and provides the tools, policies and procedures to make certain staff can respond and provide the care needed by each patient. Adhering to protocols and maintaining the certifications required to work under the medical director’s license are part of the job but not necessarily the focus of each day.
Everyone is driven to provide quality medical care. Medical oversight and operations both want to meet the standard of care. But the standard of care is not always a black-and-white or even measurable objective. Standard of care is generally a continuum of acceptable care ranging from minimally acceptable to optimal. Anywhere along that continuum is still within the acceptable standard. It is only when care falls outside that continuum that it potentially violates a standard of care. It is especially difficult for medical directors who want to provide optimal care to lower their expectations and support a lower level of care that’s still within the acceptable standard.
Another area of conflict relates to practice and procedures. Prehospital healthcare providers tend to be action-oriented people. They want to “do” and take care of those in need. Providers tend to take umbrage at anything that puts limitations on their ability to “do” things. But medical oversight tends to see the situation differently: Medical directors look at published data and usually fall into one of three groups: early, moderate or late adopters. They also tend to focus on doing only those things medically necessary to get the patient safely to the emergency department. Where operations and medical oversight come into conflict in this scenario is when medical oversight wants to change a policy or procedure and operations views it as a limitation on their previous scope of practice. An example of this would be limiting intraosseous insertion to one site or only allowing endotracheal intubation if attempting BVM ventilation or placing a supraglottic airway is unsuccessful.
While medical oversight and operations sometimes have conflicting drivers, they also have drivers that are synchronized. The challenge is balancing these drivers while retaining the goal of providing the best possible care for the patient. Finding the balance and honoring the importance of both perspectives is critical to the overall success of a system, especially as EMS identifies itself as a critical component of the healthcare spectrum.
Oversight and Operations
Here are some strategies to balance medical oversight and operations.
1. Create a seat at the table—Both sides need a seat at the leadership table. Providing opportunities to share perspectives, problem-solve and collectively work toward greater organizational goals creates opportunities to turn barriers into catapults and leads to a better-integrated organization prepared to meet the growing needs of our patients and communities.
2. Understand the paths leading toward success—The goal is clearly defined, yet the path to achieve it may be different for operations than for medical oversight. Both sides need to be willing to walk each other’s path to achieve better understanding of their needs, barriers and challenges. This can be accomplished through increased interaction and involvement in stepping outside defined roles and experiencing what it takes to run the operation or understanding the liability and challenges of medical oversight.
3. Focus on healthcare—Prehospital healthcare is a rapidly changing and evolving discipline. Operations and medical oversight must agree that the services being provided are part of the bigger healthcare picture and the decisions made operationally and clinically have a large impact on the patients and systems in our communities.
Here are some scenarios to discuss between your operations and clinical leaders to help find balance.
Case #1: Video laryngoscopes
The medical director wants to add video laryngoscopes to every ambulance. He argues that endotracheal intubation is a perishable skill and that with the service performing only 30 intubations a month and more than 60 paramedics working, there is only a 50% chance of a given paramedic getting to practice this skill each month. Your first-pass intubation rate is not as high as desired even though the successful airway rate is very good.
Video laryngoscopes cost $800–$1,500 each. The CEO argues that to outfit the entire fleet of 40 ambulances would be cost-prohibitive, especially since the expense of the laryngoscope must be absorbed by the company and cannot be passed on to the patient. What is one to do?
Case #2: Community paramedics
Currently your nurse health line fields 9-1-1 calls that have been determined to have no priority. The CEO wants to allow the nurses to refer these calls to community paramedics who can visit the patient’s home and treat them. The medical director objects because paramedics don’t diagnose, and to treat a patient without a diagnosis or a primary care physician subjects the company, and medical director, to unnecessary liability. What is the best decision?
Case #3: BLS units and fly cars
The CEO wants to introduce BLS ambulances and fly cars (single-resource vehicles) to an all-ALS system. He thinks this will help relieve pressure on the ALS system and cut costs. The medical director argues that determining which calls will result in ALS services puts an enormous burden on dispatch and increases liability. Additionally it will result in greatly increased costs because BLS units will be in addition to, not instead of, ALS units and because fly cars are a nonreimbursable expense. Which course of action should be followed?
Case #4: Ultrasound
The EMS CEO has been convinced by the hospital CEO that adding portable ultrasound to each ambulance will greatly enhance patient care. Units are small, light and fairly inexpensive, and the hospital CEO says he will foot the bill. The medical director objects to the technology for a more pragmatic reason: Use of portable ultrasound will delay scene time, is operator-dependent, is a very perishable skill and, most important, will not materially change the behavior of the EMS service. Is modern technology always to be embraced, even if it’s free and useful, if it won’t change behavior?
While medical oversight and operations are both working toward common goals, they may often hold different priorities on how best to get there. But with open communication and understanding all perspectives, a well-run EMS system can establish itself as a leader in superior patient care.
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Bradford H. Lee, MD, JD, MBA, is medical director for the Regional Emergency Medical Services Authority (REMSA) in Reno, Nev. Lee retired from the U.S. Air Force after a nearly 30-year career during which he held several positions, including department chair at a medical center, chief of medical staff, CEO of both bedded and nonbedded facilities, and corporate medical director overseeing practice at 65 different facilities in the United States and overseas. Prior to joining REMSA in 2013, he served as Nevada State Health Officer; in that position he was the primary public health medical advisor to two governors.
Dean Dow, MBA, CMTE, joined REMSA in 2015 and is the organization’s president and CEO. Prior to joining REMSA, Dow was the owner of Drawing Board LLC, where he assisted in the planning of strategic growth for ground and air medical services. He also helped develop and integrate external service lines with medical centers, including the nation’s largest hospital systems. His professional career includes roles as regional vice president of Air Methods’ Southeast Region; program director for LifeNet of New York; director of business development and quality assurance for EagleMed/Ballard Aviation Inc.; fire chief for Ford County Fire & EMS in Kansas; and program director for Alaska Regional Hospital’s two medical aircraft.