Improving Operational Performance

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Improving Operational Performance

• Presented By
• Jonathan D. Washko, BS-EMSA
• Director of Deployment REMSA
• President Washko Associates, LLC
• HPEMS Public Safety Consulting
• Partner Stout Solutions, LLC FirstWatch

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Some Food for Thought
Late 9-1-1 Wears The Late Crown
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Improving Operational Performance

• Notice in this video
• The media focused on problems created for
  9-1-1 center from this video
• They are actually talking about EMS only
• They are talking mostly about RESPONSE TIMES
• They are talking about customer service and
  clinical care

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Discussion Topics

• Successful Performance Defined
• Defining Operational Performance
• Measuring Operational Performance
• Improving Operational Performance

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Successful PerformanceDefined

• The EMS Success Triad
• A Balancing of
• Patient Care
• Employee Wellbeing
• Financial Stability

Success Triad
Patient Care
Economic Stability
Employee Wellbeing
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EMS Success Triad

• Patient Care
• Response Times
• Clinical Performance
• Customer Service

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EMS Success Triad

• Employee Wellbeing
• Retention
• Health / Safety / Welfare
• Satisfaction
• Compensation
• Recruitment

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EMS Success Triad

• Financial Stability
• A/R Billing Practices
• EMS Delivery Model / System Design
• Operational Efficiency Effectiveness
• Employee Compensation
• Safety Risk Management
• Systems Engineering

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The Balancing ActA Quality Unit Hour
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
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Defining / Measuring Improving Operational
Performance

• Limiting our Discussion to
• Response Times
• Key Operational Efficiency Effectiveness
  Measures

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Defining Response Time Performance

• Typically System Specific
• National Standards
• Measured Via
• Clock Start
• Clock Stop
• Measurement Methodologies
• Average Response Times
• Fractile Response Times

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Defining Response Time Performance

• Clock Start.a controversial topic (Smoke
  Mirrors)
• Time First Received at 9-1-1 PSAP
• Time First Received by Responding Agency
  (Secondary PSAP)
• Time Certain Info Obtained
• Time Dispatched
• Time Unit En Route
• Clock Stop (Pretty Definitive)
• Unit Staged
• Unit on Scene
• Crew at Patient

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Measuring Response Time Performance

• Typically two types of measurement
• Average
• Fractile (or frequency distribution)

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Measuring Response Time Performance

• Average
• Total Response Times for Sample divided by Total
  Sample Size
• Yields roughly the 50th percentile, or ½ of your
  responses are above and ½ of your responses are
  below the average numberor 5 out of 10 patients
  are receiving this level of response
• Old standard of measurement when we didnt care
  about this stuff as an industry

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Measuring Response Time Performance

• Fractile
• Frequency distribution of time that shows
  reliability percentage of responses based on
  specific time bins
• Many systems (and standards) are going to 90th
  percentile reliability standards (e.g. a response
  time standard of 000800 at 90 reliability)or
  9 out of 10 patients receive this level of
  response
• Best measurement approach for Patient Care and/or
  Customer Service
• Ability to achieve depends heavily on deployment
  methodology (demand vs. geographic based) and
  size of your pocketbook.

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Measuring Response Time Performance

• Response
• Time
• Measurements
• Fractile
• Measurement
• Example

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Measuring Response Time Performance

• Fractile Measurement Continued
• Response Time Exemptions
• Calls that are exempted from response time
  calculations due to uncontrollable factors that
  would require significant financial and human
  resources to overcome
• Examples
• Severe Weather
• Significant Hospital Diversions / Delays
• MCI
• Second Unit to Same Incident
• Others based on financial needs
• System Overload
• Un-notified Construction

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Improving Response Time Performance

• Emergency Calls
• Function of Volumetric and Geospatial Supply and
  Demand of Resources, Call Segment Efficiency and
  Effectiveness and Responding Unit Travel Time and
  Impedance
• Non-Emergency (Inter-facility Transport) Calls
• Function of Mostly Volumetric and Some Geospatial
  Supply and Demand of Resources, Effective Call
  Scheduling and Responding Unit Travel Time and
  Impedance

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Improving Response Time Performance

• Performance Variables
• Call Segment Processing
• Matching or Mismatching of Supply and Demand
  Curves
• Deployment Methodology
• Other System Issues
• Support Systems
• GIS / Mapping Systems
• Employee Performance

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Improving Response Time Performance

• Call Segment Processing
• A significant number of agencies can improve
  response time performance just by measuring and
  fixing two variables (based on how you measure
  Clock Start)
• Call Processing Times (Received to Assign)
• Unit Chute Times (Assign to En Route)
• This Increases Available Travel Time which
  Improves a Responding Units Effectiveness and
  Coverage Area

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Improving Response Time Performance
The net effect of a 2 minute improvement in call
processing / chute times on geospatial coverage
isochrones
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Improving Response Time Performance

• Matching Supply and Demand Curves
• EMS Demand curves are Predictable (see next
  session)
• Volumetric Basis (Temporal Demand Analysis)
• Geospatial Basis (Geographic Demand Analysis)
• Analysis of Existing Resource Supply to Demand
  curves will show if a mismatch of resources
  exists which definitely has a LARGE effect on
  response times
• Stoutian Theory (Prediction of Demand on EMS)

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Improving Response Time Performance
EMS Temporal Demand Static Supply
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Improving Response Time Performance
EMS Temporal Demand Static Supply
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Improving Response Time Performance
EMS Temporal Demand Static Supply
Lost Revenue Opportunities
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Improving Response Time Performance
EMS Temporal Demand Temporal Supply
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Improving Response Time Performance

• Deployment Methodology
• Another Significant Variable in Emergency
  Response Time Performance is your Agencys
  Geospatial Deployment Methodology
• Fixed (Static) Geographic Based
• Dynamic (Temporal) Demand Based
• Hybrid (Static Temporal) Demand / Geographic
  Based
• Effects How Response Ready You Are To Respond To
  The Next Call

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Improving Response Time Performance
EMS Temporal Demand Static Supply
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Improving Response Time Performance
EMS Temporal Demand Temporal Supply
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Improving Response Time Performance
EMS Temporal Demand Temporal Supply
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Improving Response Time Performance
EMS Temporal Demand Temporal Supply
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Improving Response Time Performance

• Other Variables
• Support Systems
• Fleet Maintenance
• CAD
• AVL
• Dispatch
• GIS / Mapping
• GIS Data ACCURACY!
• Reading a Map Book
• Employee Performance
• Culture
• Unions
• Management Style and Approach

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Improving Response Time Performance

• Overall Improvement Strategies
• Use Effective and Efficient Deployment
  Methodologies
• Root Cause Analysis on Each and Every Late Call
  Will Show a Pattern and Focus your Improvement
  Efforts
• Reliability, Accountability and Measuring are Key
• Systems Engineering that allows for Minute to
  Minute System Adjustments Based on Real-Time
  Performance Data is Vital for Success
• Daily After Action Review Processes (from the
  military) will improve situational awareness,
  identify trends, allow the organization to
  communicate and will eventually lead to improved
  performance (on all fronts)

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Improving FinancialPerformance

• Financial Performance
• Definitions
• Measurements
• Improvements

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Defining FinancialPerformance

• System Specific
• For Profit / Not For Profit / Non Profit
• Publicly Traded / Privately Held / Government
• Performance Based / Level of Effort Based
• Self Imposed / Contractually Imposed
• Performance
• Profitability
• Survival
• Growth

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Successful PerformanceDefined

• The EMS Success Triad
• A Balancing of
• Patient Care
• Employee Wellbeing
• Financial Stability

Success Triad
Patient Care
Economic Stability
Employee Wellbeing
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The Balancing ActA Quality Unit Hour
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
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Defining Operational Efficiency Effectiveness

• A Majority of Most EMS budgets Consist of Labor
  Costs (typically 60 to 80)
• Revenue Availability is a direct result of EMS
  system design and reimbursement methodologies
  (subsidy / billing insurance)
• Cost Structure is a direct result of EMS system
  design, efficiency and reimbursement
  methodologies (subsidy / billing insurance)
• Reimbursement rates are diminishing, tax dollars
  are tightening and public expectations are rising
• Because of this, only the most efficient and
  effective properly designed EMS systems will be
  successful in balancing the Triadif not
  something will have to give eventually (Patient
  Care, Employee Well Being or Financial Stability
  / Survival)

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Defining Operational Efficiency Effectiveness

• Given that EMS budgets are mostly labor based,
  focusing on this area when attempting to improve
  financial performance typically gives you some
  kind of return
• Equally important is revenue and collections, but
  for this discussion we will focus on operational
  improvements
• Other areas of significant budgetary allocations
  are also likely candidates

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Measuring Operational Efficiency Effectiveness

• Service Model versus Production Model EMS
  Strategy
• Measuring Key Performance Indicators (KPIs)
• Quality Unit Hours Unit Hour Utilization (UHU)
• Controlling Lost Unit Hours
• Managing Call Task Times
• Managing Pay Roll Leakage (or payroll UHU)
• Manage Headcount to Control Overtime
• Managing Response Errors
• Benchmarking and Trending Statistics
• Many Others

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Measuring Operational Efficiency Effectiveness
Quality Unit Hour Definition 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
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The Balancing ActA Quality Unit Hour
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
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Improving Operational Efficiency Effectiveness

• Control your Unit Hours and UHU
• Function of EMS System Design
• Properly Allocate Supply with Demand
• Geographic Deployment Methodology is HUGE in
  terms of efficiency and Demand Based Systems are
  usually the most cost efficient and effective

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Improving Operational Efficiency Effectiveness

• Controlling Lost Unit Hours
• A Lost Unit Hour is one that is not otherwise
  available to the deployment plan if not on a call
• Many causes
• Start / End of Shift Procedures
• Critical Failures
• Hospital Diversions / Off Load Delays
• Employee Problems
• Poor Management Practices
• Lowered lost hours means more available hours to
  the system
• More available hours may allow you to reduce
  scheduled hours

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Improving Operational Efficiency Effectiveness
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Improving Operational Efficiency Effectiveness

• Managing Call Task Times (somewhat controversial)
• Highly efficient systems can run a call in less
  then an hour
• Less time to run a call means less hours that are
  needed to meet the same response time performance
  standard
• Less hours needed results in financial savings
  (but may unbalance the triad on employee
  well-being or patient carebe careful!)

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Improving Operational Efficiency Effectiveness

• Managing Payroll Leakage
• Payroll leakage are unproductive dollars spent
  for various reasons
• Measuring Payroll UHU against Actual UHU defines
  leakage
• If a variance if found between these two numbers,
  then leakage is occurring or youre measuring
  wrong
• If these numbers match or are very close, then
  leakage is more then likely minimal
• Minimizing leakage helps to lower costs

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Improving Operational Efficiency Effectiveness

• Managing Headcount
• Manage your Headcount - Dont let it manage you!
• Perform bi-weekly headcount meetings as a means
  to anticipate attrition and therefore drive
  hiring practices
• Ensure you allocate your employee thru put times
  into the equation
• Also ensure you allocate proper FTEs to cover
  PTO, Sick, Vacation, LOA, FMLA, etc to avoid
  backfilling with overtime

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Improving Operational Efficiency Effectiveness

• Managing Response Errors
• Systems engineering flaws
• Unit Hour production problems
• Deployment Plan issues
• System support problems
• Human Error

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Improving Operational Efficiency Effectiveness

• Trending and Benchmarking Statistics
• Allows you to see where you have come from and
  where you are going
• Can be used to adjust your system dynamically in
  a real-time fashion thus keeping costs down
• Can be used to help predict the future
• Can be used to help find special cause variations
  that may be effecting financial performance

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Improving Operational Performance

• Closing Remarks
• REMEMBER the EMS Success Triad
• Patient Care
• Employee Well Being
• Financial Stability
• Questions