Title: How to Ratchet Up (and Squeeze Out Those Final Percentage Points of Performance)
1How to Ratchet Up (and Squeeze Out Those Final
Percentage Points of Performance)
- Jonathan D. Washko, BS-EMSA
- Director of Deployment REMSA
- President Washko Associates, LLC
- Partner Stout Solutions FirstWatch
2The journey of tightening up response time
performance can be daunting. Learn the tips,
tricks, traps and mental models that allow your
team to break the final barrier
3An EMS Fact
- Understand that all the training, equipment,
personnel, supplies, drugs, protocols, hardware,
vehicles, technology, maintenance, QI systems
etc, etc, etc dont mean a thing if
4An EMS Fact
- Understand that all the training, equipment,
personnel, supplies, drugs, protocols, hardware,
vehicles, technology, maintenance, QI systems
etc, etc, etc dont mean a thing if
We Cant get to the Patient in/on Time
5Session Overview
- Homeostasis The EMS Success Triad
- Production Model EMS Theory The Quality Unit
Hour Concept - Understanding The Theoretical Performance Model
- The Variables of Performance Improvement
- Strategies / Best Practices for Performance
Improvement - Performance Improvement Pitfalls Tips
- Summary / Review / Questions
6Homeostasis The EMS Success Triad
- The Constant Balancing of 3 Key Elements
- Patient Care
- Employee Well-Being
- Financial Success (however you define it)
Success Triad
Patient Care
Economic Stability
Employee Wellbeing
7Homeostasis The EMS Success Triad
- Patient Care
- Response Times
- Clinical Performance
- Customer Service
Success Triad
Patient Care
8Homeostasis The EMS Success Triad
- Employee Well-Being
- Retention
- Health / Safety / Welfare
- Satisfaction
- Schedules
- Work Environments
- Compensation
- Recruitment
- Family
Success Triad
Patient Care
Employee Wellbeing
9Homeostasis The EMS Success Triad
- Financial Success
- A/R Billing Practices
- EMS Delivery Model System Design
- Operational Efficiency Effectiveness
- Employee Compensation
- Safety Risk Management
- Systems Engineering
- Profitability
- Subsidy Needs
Success Triad
Patient Care
Economic Stability
Employee Wellbeing
10Production Model EMS Theory
- QUESTION
- Is EMS a Service Industry or Production Industry?
11Production Model EMS Theory
- High Performance EMS Systems Believe
- That EMS is a Production Industry that provides
its customers with a level of Quality Service as
an end result of a Quality Product
12Production Model EMS Theory
- Quality Services from Quality Products
- Examples
- Radio / Boom Box. The quality of the sound,
reception, etc. (Service) is based on the quality
of the Radio (Product) - Televisions. The quality of the picture provided
(Service) is based on the quality of the TV
(Product) - Etc, etc, etc
13Production Model EMS Theory
- Quality Services from Quality Products
- So what Widgets (or products)
- do HPEMS Systems Produce?
14A Quality Unit Hour
- A Quality Unit Hour is an ambulance that is
available to the EMS System for one hour that
responds to properly triaged calls for service,
is produced within a CQI environment that uses
modern technology to collect and assess accurate
data, is fully staffed, fully trained, fully
maintained, fully stocked, properly placed in
location and time, properly funded and safely
operates within an educated population
15The Quality Unit Hour Concept
Patient Care Employee Wellbeing
Financial Stability
Public Education
Control Center
Training Edu
Human Resources
Finance
Operations
The Quality Unit Hour
Supply / Logistics
Data Analytics
Safety Risk
QI / CQI / PI
Fleet Maint.
IT / Technology
PR/Marketing
16Production Model EMS Theory
The Quality Unit Hour Manufacturing / Production
Cycle Based on Supply Demand
17Ratcheting Up Performance
- Assumes you understand the EMS Success Triad
- Assumes you understand and/or operate under the
Production Model EMS Premise - Assumes you understand the Quality Unit Hour
Concept
Its never safe to assume so any questions before
we move on?
18The HPEMS Theoretical Performance Model
19The HPEMS Theoretical Performance Model
Its actually a graphic representation of my last
trip with my wife, twin two year old boys and my
5 year old little girl
20The HPEMS Theoretical Performance Model
21Understanding The HPEMS Theoretical Performance
Model
- The HPEMS-TPM is a graphical representation of
how HPEMS systems can progress over time in
relation to the EMS Success Triad based on
changing key deployment and performance
variables. This enables visualization of great
and not so great performance and the positive and
negative tradeoffs associated with changing these
performance variables. - It also allows for a visual representation of
HPEMS Homeostasis which is an achievable but
difficult band in the TPM to reach and then
maintain
22Understanding The HPEMS Theoretical Performance
Model
- Empirically Driven Common Denominator Model
Based on Years of HPEMS Exposure and Experiences - Variables (Color Coded)
- Response Time Reliability / Performance
- Patient Care
- Productivity / Unit Hour Utilization /
Profitability - Employee Well-being
- Zones
- Union Formation Zone
- Contractual Danger Zone
- Performance Comfort Threshold
- Performance Improvement Zone
- Triad Homeostasis
- Unit Hour Reduction Zone / The Triad Tradeoff
23Understanding The HPEMS Theoretical Performance
Model - Variables
Response Time Reliability / Performance
24Understanding The HPEMS Theoretical Performance
Model - Variables
- Response Time Reliability / Performance
- Depicts response time reliability based on
fractile measurement - The further up the matrix the higher the
performance, the lower on the matrix, the lower
the performance - Response Time Goal depicts contractual or self
imposed response time reliability standard - UHU Syndrome represents what can happen to many
HPEMS systems when productivity drops too low
25Understanding The HPEMS Theoretical Performance
Model - Variables
Patient Care
26Understanding The HPEMS Theoretical Performance
Model - Variables
- Patient Care
- Can represent many different aspects of patient
care - Survival rates / outcomes
- Customer Service Satisfaction
- Assumes patient care is proportional to response
times and employee well-being - The further up the matrix the better the patient
outcome, the lower on the matrix, the lower the
patient outcome - Notice that Patient Care degridation crosses over
Response Time Performance Why?
27Understanding The HPEMS Theoretical Performance
Model - Variables
Productivity / UHU / Profitability
28Understanding The HPEMS Theoretical Performance
Model - Variables
- Productivity / UHU / Profitability
- Represents the typical productivity curves seen
as HPEMS systems mature - Assumes profitability improves as performance and
productivity increases - The further up the matrix the higher the
performance, the lower on the matrix, the lower
the performance - Profit Departure
- When productivity hits a level of diminishing
returns based on poor performance outcomes
29Understanding The HPEMS Theoretical Performance
Model - Variables
Employee Well-being
30Understanding The HPEMS Theoretical Performance
Model - Variables
- Employee Well-being
- Represents employee satisfaction
- Turnover rates
- Health / safety / welfare
- Employee happiness
- Good employee satisfaction survey scores
- The further up the matrix the higher the
satisfaction / less turnover, the lower on the
matrix, the lower the satisfaction / higher
turnover rates - Note that employee satisfaction is the first to
go as systems attain higher performance.why?
31These Elements Should Look Familiar
- The Homeostatic Balancing of 3 Key Elements
- Patient Care
- Employee Well-Being
- Financial Success (however you define it -
Productivity)
Success Triad
Patient Care
Economic Stability
Employee Wellbeing
32Understanding The HPEMS Theoretical Performance
Model - Zones
33Understanding The HPEMS Theoretical Performance
Model - Zones
Union Formation Zone
34Understanding The HPEMS Theoretical Performance
Model - Zones
- Union Formation Zone
- Represents areas where HPEMS systems have
typically unionized, mostly due to poor
management communication / employee education or
area specific cultural issues - Key Union Formation Areas
- Beginning of a HPEMS System (largest change)
- When attempting to improve performance by holding
employees accountable for avoidable mistakes
without balancing employee needs / understanding - Dramatic increase in productivity (employee
workload) after performance improvement steps
taken - When Job security is threatened (real or assumed)
35Understanding The HPEMS Theoretical Performance
Model - Zones
Contractual Danger Zone
36Understanding The HPEMS Theoretical Performance
Model - Zones
- Contractual Danger Zone
- Represents an area where experienced operators
shy away from when managing response time
performance - Typically ½ to 1 percentage point above the
minimal contractual requirement - Less experienced operators will sometimes try to
manage their response times within this region,
however they typically burn out their management
teams and/or problems will begin to arise in
operator trustworthiness / integrity - Primary reason an operator manages in this zone
is due to poor financial performance (for a
variety of reasons)
37Understanding The HPEMS Theoretical Performance
Model - Zones
Performance Comfort Threshold
38Understanding The HPEMS Theoretical Performance
Model - Zones
- Performance Comfort Threshold
- Represents an area where most experienced
operators manage response time performance to - Typically 1 to 2 percentage point above the
minimal contractual requirement - Less experienced operators may get frozen in the
left side of this zone not understanding that
performance can be improved (What we will be
discussing today) - Some performance based contract systems force
their operators to live either on the left or
right in this zone and are sometimes have
disincentives to operate in the middle (at Triad
Homeostasis), however some do receive performance
bonuses for operating in the middle (through
performance penalty forgiveness)
39Understanding The HPEMS Theoretical Performance
Model - Zones
Performance Improvement Zone
40Understanding The HPEMS Theoretical Performance
Model - Zones
- Performance Improvement Zone
- Represents an area where experienced operators
improve systemic system performance - Can increase performance upwards of 3 or 4
percent based on approach that works for their
particular system and / or contractual need
without the need for additional unit hours - Takes time and patience to achieve and most
successful systems wait to reap the financial
rewards of this zone until the systems needed to
manage improvement are in place, tested and are
habitual - I believe the dollar pay-off for this is not as
great as the patient care and employee well-being
payoff (contrary to what many may believe),
however there are financial rewards if taken
advantage of
41Understanding The HPEMS Theoretical Performance
Model - Zones
Triad Homeostasis
42Understanding The HPEMS Theoretical Performance
Model - Zones
- Triad Homeostasis
- The HPEMS Sweet Spot!
- Where maximum response time reliability, best
patient care outcomes and almost best
employee-wellbeing collide - Purely due to the aggressive geospatial
deployment methodologies needed to achieve this
level of performance, employee well-being begins
to wane - Notice that maximal financial performance is not
yet achieved in this zone as they are typically
competing (based on contractual requirements)
although financial performance can come quicker
if an agency chooses to do so - May bring into question the need for
first-responder services for certain geographic
areas within a service area as typically
Ambulances will beat First Responder Services on
scene (upwards of 60 to 70 of the time and
sometimes higher)
43Understanding The HPEMS Theoretical Performance
Model - Zones
UH Reduction Zone / Triad Tradeoff
44Understanding The HPEMS Theoretical Performance
Model - Zones
- Unit Hour Reduction Zone / The Triad Tradeoff
- Where profitability or availability of system
funds will increase due to the lowering of unit
hours - Lower Unit Hours come from an increase in
production / UHU - Increased production / UHU comes from lowering
response time reliability back into the
Performance Comfort Threshold region - The Tradeoff
- Patient care begins to drop from slower response
times - Employee well-being will drop from increased
workload demands - Other problems may arise if Performance
Improvement Systems fail or apathy invades an
operation
45Understanding The HPEMS Theoretical Performance
Model - Zones
- Unit Hour Reduction Zone / The Triad Tradeoff
- Additional Facts
- Based on the make / model of your HPEMS system,
the dollars and/or unit hours may be used for
other things - Acceptance of increasing call volume on a
marginal cost basis - Better servicing of outlying (rural) service
areas - Increasing contiguous service area size on a
marginal cost basis - Attempting to shore up employee well-being though
increased compensation, benefits, appreciation
programs, etc.
46Understanding The HPEMS Theoretical Performance
Model - Zones
Deployment Aggression Zone
47Understanding The HPEMS Theoretical Performance
Model - Zones
- Deployment Aggression Zone
- Defines (on a sliding scale) the impact of
deployment tactics based on aggressiveness and
approach. - A key and necessary element in Performance
Improvement - Your success to performance improvement is
directly correlated to how you do your deployment
model - Least aggressive static models are on the far
left side of the scale - Most aggressive dynamic pure SSM models are on
the far right side of the scale - Everything in between is some form or mix of
these two extremes
48Understanding The HPEMS Theoretical Performance
Model - Discussion
49The Performance Improvement Zone
- The Performance Improvement Variables
- Simple Stuff (low hanging fruit can do
tomorrow) - Data Integrity Accuracy (is it)
- Measurement / Reporting Systems (are they
accurate) - Underlying Technology Systems (causing problems
with data) - Chute Times (dispatch unit) Clock Start to
Physically En Route - Open Minded Management Team Capable of Change!
- Intermediate Stuff (takes more time but can
happen quick) - Educate entire team on HPEMS SSM (VERY
important!!!) - Temporal Supply Demand Matching (do they?)
- Deployment Plan Aggressiveness Approach (simple
or complex) - Open Minded Management Team Capable of Change!
- Advanced Stuff (takes lots of time, patience
consistency) - Fix controllable response errors
- Implement USE Granular Accountability
Reliability Tracking Systems, find the problem
areas and fix them - Implement USE Real-time Situational Awareness
Systems (based on data driven and human driven
intelligence) to adjust as needed - Implement USE Bleeding Edge Technology (dont
kimp) - Open Minded Management Team Capable of Change!
50The Performance Improvement Zone
- Strategies for Performance Improvement
- Simple Stuff (low hanging fruit can do
tomorrow) - Data Integrity Accuracy
- Check data and dispatch practices / procedures to
ensure accuracyanalysis is only as good as the
data it is performed on - Reconcile missing data points (especially Call
Lat / Long) - Perform internal audits of every late call to
ensure they are in fact late (audit clock start
and stop times) - Measurement / Reporting Systems
- Make sure your data reporting systems used to
measure response time performance are accurate
and meet contractual obligations or internal
standards
51The Performance Improvement Zone
- Strategies for Performance Improvement
- Simple Stuff (low hanging fruit can do
tomorrow) - Underlying Technology Systems
- Check CAD to CAD interfaces, Atomic Clock
Synchronizations and CAD system itself to ensure
proper data collection accuracy call processing
efficiency - GIS systems are an integral part of todays
response systems. Ensure an up to date
geo-database and attempt to achieve 100 accurate
geo-validation of addresses (also check response
zones) - Chute Times (dispatch unit)
- Measure, monitor report on chute time
performance at the granular (employee) level - Work to mitigate remediate problems
- Open Minded Management Team Capable of Change!
52The Performance Improvement Zone
- Strategies for Performance Improvement
- Intermediate Stuff (takes more time but can
happen quick) - Educate entire team on HPEMS SSM (VERY
important!!!) - A common denominator of ALL successful HPEMS
operators - Provide advanced courses for management and
supervisors - Provide basic courses for the rest of the crowd
(including field) - Temporal Supply Demand Matching (do they?)
- Plot your Unit Hour supply against your Demand.
Do they match? If not, adjust schedules and unit
hour supply accordinglyyes it may be time for a
shift bid - Be sure to incorporate call task time into the
model as longer call task times require more
resources (most demand models assume 1 call takes
1 hour) - Investigate why task times are long and mitigate
if possible - Measure Control Lost Unit Hours.
Non-productive unit hours are commonly at the
root of many performance problems
53The Performance Improvement Zone
- Strategies for Performance Improvement
- Intermediate Stuff (takes more time but can
happen quick) - Deployment Plan Aggressiveness Approach
- Aggressive Deployment Models
- Hourly demand focused posting plans
- Strategic prioritized redeployment of resources
after each call is assigned to a unit - Short post roaming distances, post to post moves,
chute time tolerances - Typically use street corner posts only (quicker
chute times) - Less Aggressive Deployment Models
- Hour grouping of demand based plans
- Strategic prioritized redeployment of resources
after each call is assigned to a unit - Longer post roaming distances, post to post
moves, chute time tolerances - Typically use some stations intermixed with
street corner posts
54The Performance Improvement Zone
- Strategies for Performance Improvement
- Intermediate Stuff (takes more time but can
happen quick) - Deployment Plan Aggressiveness Approach
- Least aggressive Deployment Plans
- Typically one plan for all hours / all days, may
or may not be demand based (typically
geographically based) - Strategic prioritized redeployment of resources
after each call is assigned to a unit is less
aggressive and dominant - Longer post roaming distances, post to post moves
and chute time tolerances usually apply - Typically use more stations then street corner
posts - Open Minded Management Team Capable of Change!
55The Performance Improvement Zone
- Strategies for Improving Performance
- Advanced Stuff (takes lots of time, patience
consistency) - Fix controllable response errors
- ACCURATELY perform root cause analysis of all
late calls - Categorize into controllable and non-controllable
errors at the granular (employee) level - Fix controllable errors as causes unveil
themselves / patterns arise (and they will!) - Implement USE Granular Accountability
Reliability Tracking Systems, find the problem
areas and fix them - Measure and monitor KPIs (key performance
indicators) - Design reporting systems so that data can be
drilled down into so problem areas can be easily
identified - Trend history and use this to help predict future
events, then act upon prediction models before
problems arise (a novel concept for many of us
EMS folks -)
56The Performance Improvement Zone
- Strategies for Improving Performance
- Advanced Stuff (takes lots of time, patience
consistency) - Implement USE Real-time Situational Awareness
Systems (based on data driven and human driven
intelligence) to adjust as needed - PULSE Process / After Action Reviews (see last
day) - Daily meeting of management key players
- Based on military After Action Review process
- Assess Late Calls, System Performance, Scheduling
- Gain information about your system and act on it
to improve performance - Many broken systems and sub-systems will become
evident the more you look.you just have to look! - Manage headcount by anticipating losses, properly
calculating requirements and FTE weights and
hiring ahead of the curve
57The Performance Improvement Zone
- Strategies for Improving Performance
- Advanced Stuff (takes lots of time, patience
consistency) - Implement USE Bleeding Edge Technology
- Dont kimp go see the vendors outside!!!!!!
- AVL/GIS/In Vehicle Mapping systems that work are
worth their weight in gold - Deployment tools like MARVLIS, SIREN, MUM (and
others) are taking the guess work out of
deployment plans with scary, dead on accuracy - Scheduling tools like Zolls Resource Planner
Crew Scheduler, eCores NetScheduler Pro, ADPs
HR/Scheduling/Payroll suites and others are
taking supply chain management online and are
making it an easier and a much more efficient /
accurate process - Electronic charting is opening up new horizons
for billing DSO, clinical research and call
processing time minimization - Operational intelligence systems such as
FirstWatch and Microsoft Office Live provide
easy, customizable and real-time data dashboards
used for benchmarking process improvement - Open Minded Management Team Capable of Change!
58Performance Improvement Pitfalls Tips
- Closed minded management incapable of change
- Without a good solid team youre dead in the
water. I recommend not moving forward until you
have one - Assume Nothing Question Everything
- Even your most trusted team-mates should be
questioning their own expertise and always
attempting to improveisnt this how we grow and
learn - Hasty Greed Kills EMS Systems!
- A balanced EMS Success Triad is just that
BALANCED. Short term profiteering will lead to a
long term death, lets take a lesson from the
Japanese business approach - Dont kimp on your employees or their families
- Without them, youre dead in the water
- Spend the extra bucks to make their office more
livable especially in an aggressive deployment
model system
59Performance Improvement Pitfalls Tips
- Find the mix of performance improvements that
work best for younot all will and not all are
necessary - Taking an EMS system to the profit / performance
edge and keeping it there will give you grey hair
(it has me). Do yourself, employees and patients
a favor, only use what you have to - Many performance improvements are strongly based
on technology so hire only the best IT folks and
pay them as such - Often times EMS systems skimp in this area and
end up paying dearly for it in the end - You must be consistent and unwavering in using
newly developed tools, systems approaches for
the long haul - Many systems are able to obtain the holy grail
(triad homeostasis) but keeping it is the most
difficult thing you will ever do
60Performance Improvement Pitfalls Tips
- Use caution in the union formation zone
- Unless you like unions, you need to listen to
your employees, compensate them appropriately,
take care of their families and most importantly
do your best to educate them on why you are doing
what you are doingand all should turn out well - During your performance improvement, stay in tune
with your employees and meet often with them - Really this should be done all the time but is
really important when trying to move mountains - Increased productivity / UHU / profitability is
possible within the performance improvement zone
if necessary but use caution (its why its the
same color) - Remember hasty Greed Kills EMS Systems
- Slow and steady wins the race
61Performance Improvement Pitfalls Tips
- Avoid the Contractual Danger Zone like the plague
- Living in this zone will burn you up, places
patients, employees and contracts in jeopardy and
eventually may lead you down a path you never
want to be in (survival mode) - The Theoretical Performance Model is Cyclical
- Unfortunately, many HPEMS systems are based on 5
to 7 year operational cycles and then go out to
bid. A new operations contractor will have to
learn how to walk all over againand this can be
painfulespecially for the employees and patients - Unfortunately, cycles also happen within bid
periods within the same operations contractor.
This typically happens when the present team
masters its domain and the parent company moves
them to fix another system, leaving huge
experience holes which starts the cycle all over
again - THEREFORE - DO SUCCESSION PLANNING TRAINING!
62Summary / Review / Questions
63Jonathan D. Washko
- Contact Information
- REMSA
- Phone 775-858-5700 x140
- Email jwashko_at_remsa-cf.com
- Website www.remsa-cf.com
- Washko Associates, LLC.
- Phone 804-347-3337 / 775-626-4459
- Email jw_at_washkoassoc.com
- Website www.washkoassoc.com
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