Darkness and the Dawn

   It started with a mugging.

   On January 6, 2006, a resident of the District of Columbia's Gramercy Street NW found an unknown man lying on the sidewalk, unable to speak. A call to 9-1-1 brought police and fire/EMS. The arriving EMTs, focusing on the patient's vomiting and an odor of alcohol, did not recognize the seriousness of the man's condition or the underlying cause of his altered mental status, and did not request advanced life support or an expedited transport response. The patient was ultimately taken, after some delays, to Howard University Hospital, where it took another four hours for a neurological evaluation.

   Two days later, the man died of head injuries sustained in the assault. He was New York Times journalist David Rosenbaum, and the resulting story went national.

   In response, Mayor Anthony Williams had his inspector general review the chain of events that preceded Rosenbaum's death. The report came five months later and had fault for a range of players, including the Howard ED staff, district police and the district's fire and EMS department. Multiple personnel from agencies involved that night failed to follow their protocols, the IG concluded, suggesting "alarming levels of complacency and indifference" and even an "impaired work ethic."

   Bad stuff--but this is where a bad story turns good. In response to the findings, district leaders took swift action. In March 2007, new Mayor Adrian Fenty announced a settlement that included the creation of a task force on EMS to investigate the response and make recommendations for D.C. Fire & EMS. If, in a year, Rosenbaum's survivors were happy with the progress the department was making in implementing the task force's recommendations, they agreed not to sue.

   As 2008 came and went, they didn't. The department had made good progress in instituting the improvements the task force sought. That progress continues today, and continues to yield benefit.

   "I think it's an example of a leadership commitment that demonstrates that change and improvement are both possible and practical," says Rafael Sa'adah, the service's assistant fire chief for emergency medical services. "The commitment from our mayor and Chief [Dennis] Rubin was rock solid. And beyond just a policy commitment, the mayor committed resources to make these changes a reality."

   The task force made six major recommendations for the department:

• Transition to a fully integrated all-hazards agency;
• Elevate and strengthen the EMS mission;
• Improve care through enhanced training and education, performance evaluation and quality assurance, and employee qualifications and discipline;
• Revise deployment and staffing procedures;
• Reduce misuse of EMS and delays in patient transfers;
• Strengthen Department of Health oversight of EMS.

   Within each of these recommendations were individual action items. As it worked toward these changes, the department reported its progress on each on its website, allowing anyone interested to track its efforts.

   "I think the fact that the public can monitor our progress is hugely important," says Sa'adah. "We're very proud of our progress and have tried to be very open about the areas where we haven't completed the goals we set forth and the reasons why."

   That's all available at https://fems.dc.gov. Some of the changes chronicled there have been profound.

Mission Quest

   By the time Sa'adah updated attendees of the Pinnacle EMS Leadership & Management Conference on the department's progress last July, D.C. Fire & EMS had completed 39 of the task force's 50 total action items, including all related to elevating the EMS mission. Eight, overall, were still in progress; only three had passed with deadlines unmet.

   Elevating the EMS mission had several components: A panel to ferret out practices suggesting a lower priority to EMS. A medical director at the AFC (assistant fire chief) level. An AFC for EMS, reporting directly to the chief. Additional EMS battalion chief and captain positions to ensure better 24/7 supervision and career options.

   Missions accomplished: The panel was meeting by October '07. Dr. Jim Augustine became medical director (though he's since departed). Sa'adah, the first certified paramedic to rise through the competitive fire officer promotional process to reach the rank of chief officer, assumed the AFC for EMS role permanently in March 2009 (he'd filled it on an acting basis since December 2007). And in May 2009, four new battalion chiefs hit the field. The department also created a new position of EMS battalion supervisor (captain) and doubled the minimum number of those on duty. Four months later, its first competitive EMS supervisory promotional exam yielded 37 promotions to EMS battalion supervisor. D.C. Fire & EMS now has dedicated around-the-clock EMS supervisors for each of its seven battalions (some supervisors previously covered two), plus two performing system management at its communications office. Every shift is overseen by an EMS battalion chief, and EMS battalion supervisors serve on the medical director's staff and in quality management.

   "We recognized that a key problem was that the EMS supervisors were not integrated into the overall management structure of the department," Sa'adah says. "So the first thing we did was change their work schedules so they were on the same schedule as the battalion fire chiefs and firefighters who constitute the vast majority of our EMS providers. We moved their desks adjacent to the battalion fire chiefs', and we increased the number of EMS supervisors so there was one for each battalion."

   That EMS supervisor, battalion fire chief and chief's aide now constitute a three-person Battalion Management Team that manages the unit collectively.

   "That may seem like a simple change," Sa'adah says, "but as we talk with these veteran EMS supervisors about the initiatives that have had the most impact in changing the way they feel about the agency's direction and quality of care, it's repeatedly cited as among the most significant we undertook."

   Another important piece was creating a merit-based competitive process for promotion to EMS supervisor--a position itself advanced in rank from lieutenant to captain. Previously, the department's single-role EMS supervisors never faced assessments or exams. Incumbent supervisors and five-year medics were eligible to compete, which meant the entire population of single-role lieutenants, as well as numerous medics who'd never been able to compete before, could go through the promotional process together.

   Opening things up this way emphasized learning and focused personnel on improvement. Some of those lieutenants naturally felt they were competing for their own jobs. But ultimately, Sa'adah says, they recognized the benefit.

   "The incumbent EMS supervisors were exposed, often for the first time, to the full range of competencies operational supervisors in the agency have to master--things like Metrorail and hazardous-materials procedures," he says. "They benefited from that, and we also enabled many bright young firefighter/paramedics and single-role paramedics who had not previously been eligible to compete and step into these leadership positions as well."

Institutionalized Improvement

   The third recommendation, focused on care, involved improving training and education, performance evaluation and quality assurance. There were two dozen total action items here. Some high points:

• For a required comprehensive training and educational program, the district is moving all medically certified operational personnel to National Registry certification. It expects to complete that in early 2011.
• To measure and analyze patient outcomes, the department is working on data-sharing agreements with area hospitals and also joined the CARES (Cardiac Arrest Registry to Enhance Survival) registry.
• To support competency, it established regular holistic evaluations for all paramedics, conducted under supervision of the medical director. These include practical skills stations, written tests, oral interviews and reviews of documentation and medical quality. Information gathered during these assessments leads to both individual remediation and systemwide training and education.
• In 2010, the department completed a transition to electronic PCRs.
• It established an internal affairs unit and new complaint-investigation system.

   A focus of all this assessment is not only to improve individual performance, but to help shape education for everyone. The first cycle of ALS evaluations, conducted at the request of the medical director by an outside vendor (the Maryland Fire & Rescue Institute), led to all ALS providers receiving standardized training on STEMI, ACS and 12-lead EKGs. Those who did not meet competency objectives during the initial training got focused remediation until they demonstrated proficiency.

   "We've worked to institutionalize the idea of regularly assessing our paramedics and improving with each cycle," says Interim Medical Director Geoffrey Mountvarner, MD. "We use the areas where we see trends or broader-based knowledge gaps to guide the next round of training initiatives."

   It's important here, if your goal is better care, to separate the QM and discipline processes. The purpose of this kind of assessment is to identify and improve, not punish. Medics with problem areas go into remedial pathways. This both supports valuable employees and serves to protect the public.

   Along with all this, the department implemented a new STEMI protocol and worked with local hospitals to establish the first STEMI system in the region.

   "That was a tremendous system accomplishment that's directly led to improved outcomes," Sa'adah adds. "It's an example of how regular assessment of the workforce can identify issues that can then be successfully addressed through training and education."

Conclusion

   There was plenty more to work on in the task force's report; it's all detailed, along with resulting actions, on the department's website. The road forward has not been without potholes. But five years after Rosenbaum's death, there's no question EMS delivery in the U.S. capital has been improved in many ways.

   "By and large, the task force recommendations that can be accomplished have been accomplished, with a couple of key exceptions," Sa'adah says. "We've not yet achieved the mayor's vision for true unification--out of an operational workforce of about 2,000, we still have approximately 150 remaining single-role EMS providers who are not fully integrated as all-hazards personnel, and about 70 firefighters not yet certified as EMTs. Many challenges remain, but I think we've demonstrated that a unified, all-hazards EMS system can deliver high-quality care, and we're going to continue to demonstrate that."

Other Advances

   Additional changes made by D.C. Fire & EMS following the task force report of 2007:

• First comprehensive revision of medical protocols in eight years;
• Paramedic engine companies to improve response times in problem areas;
• Use of performance measures developed in 2007 by the Consortium of U.S. Metropolitan Municipalities' EMS Medical Directors;
• Customer satisfaction surveys;
• Two full-time EMS liaison officers (paramedic supervisors) at the Office of Unified Communications to determine hospital destinations;
• A no-diversion policy as of October 2009;
• Monthly meetings with hospital leadership;
• Street Calls program to reduce demand from high-volume users.