Q&A with Mike Taigman

Mike Taigman worked his first full-time shift as an EMT in 1977—the day after he turned 18—in Castle Rock, CO, and has been in EMS ever since.
After stints as a paramedic instructor and flight medic in Englewood, CO, a field training officer in Denver and assistant to the medical director in Pinellas County, FL, he became the clinical and quality improvement manager for BayStar Medical Services (then owned by MedTrans) in San Mateo County, CA. In 1992, he was promoted to corporate director of quality and research and national manager of staff development. In 1997, shortly after MedTrans merged with American Medical Response, he left that position to focus on his consulting, education and clinical research firm. Over the next 12 years, he worked with EMS agencies on quality and performance improvement programs.

In 2009, Taigman was hired by AMR to run its Alameda County, CA, operation, which includes the city of Oakland. In 2011, after AMR lost its Alameda contract to Paramedics Plus in a competitive bidding process, Taigman became general manager for AMR in Ventura County, CA, where he oversees 220 employees in a system that responds to 45,000 calls annually. He recently spoke about AMR’s quality improvement efforts, and his vision for what EMS has to offer patients and the healthcare system.

The following excerpted interview can be found in its entirety on the Best Practices in Emergency Services website at emergencybestpractices.com.

You’ve been in EMS for 39 years. Where have you seen progress?
There certainly has been progress in system design and delivery. It used to be, ‘Try really hard and do the best we can.’ But there wasn’t a lot of measurement and understanding of the results we can produce. We know much more about that today.
I’ve also seen a lot of progress in the integration of EMS into the rest of medicine, and a better understanding of our contributions to the overall system of health care, particularly with cardiac arrest, myocardial infarction, stroke, sepsis and probably trauma, although that’s not as well established. Most of what we do in trauma is get patients to the right place.

Another area that comes to mind is the significant increase in the focus on reducing suffering from pain or nausea in the prehospital realm. That follows a shift in the rest of healthcare, where pain management has become a higher priority.

What’s your take on community paramedicine?
There are two schools of thought regarding community paramedicine. One is that we put together a curriculum and have standards and build this animal and then try to find problems to use it for, which seems to be the prevailing model. The approach I’m attracted to tends to be a little bit more epidemiological. You go into a community and ask, “What are the issues here? What are the unmet health needs or health improvement opportunities, and how can we contribute?”

If you are using a true community-centered or patient-centered approach, EMS may not be doing all the work. Instead, we may be partnering with other groups.
For example, when I was working in Oakland, one of the major health issues was unrecognized hypertension. We collaborated with the Ethnic Health Institute, the Alameda County Public Health Department, hospitals, clinics, a nursing school and a medical school to do “Hypertension Sundays.” There’s a higher percentage of hypertension and stroke in the African-American population. So we would go out to 25 or 30 primarily African-American churches with EMTs, paramedics, nursing students, medical school students, public health folks and physicians and take blood pressures.

On a typical Sunday, we’d find 45%– 50% had normal blood pressure. The other half were hypertensive, and half of those didn’t know they had hypertension. We’d write a note for their physician if they had one, or if they didn’t have a physician, our volunteer physician would do an assessment and make a referral to a community clinic or write a prescription if necessary.

This sounds a lot like community paramedicine, but you’re not calling it community paramedicine.Why?

I call it community health improvement, though I wouldn’t necessarily label it community paramedicine. We don’t need to own it. We can help other people doing good work, and you don’t have to be trained as a community paramedic to do that.

For example, I had breakfast with one of my EMTs this morning. We talked about the importance of the reduction of suffering. Among homeless patients, the primary suffering is often that they are hungry. So we said, ‘Let’s get a list of all the soup kitchens in town, what times of day they serve meals, their addresses, and let’s make it available to all of our crews.’

In Ventura County, one of the biggest challenges and needs we’re facing now is with tuberculosis, a highly contagious disease that, if left unmanaged, can be fatal. The course of treatment is to take medications every day for 90 days, and sometimes longer than that. Those patients need to be monitored. So we’re working with the health department to do “documented observed therapy”—essentially, you bring patients their medications, watch them take them and fill out a questionnaire that asks about side effects.

The TB program is going to get started as soon as we can finalize the agreement with the county, which we hope will be in early 2013.

Will AMR be compensated?
Not yet. We’re doing a demonstration project based on the Institute for Healthcare Improvement’s “Model for Improvement.” The goal is to prove the concept before we discuss compensation.

The Model for Improvement starts with asking questions: What are we trying to accomplish? How will we know that a change is an improvement? What changes can we make that will result in improvement? Then we’ll test changes on a small scale using a Plan-Do-Study-Act cycle, also known as the PDSA cycle. The first PDSA cycle may involve just one patient, and then we will build from there, repeating the PDSA cycle as we learn and expand.

What are the goals of AMR’s national clinical improvement collaborative?

We’re doing it in partnership with the Institute for Healthcare Improvement. It’s about teaching the science of improvement to our operations all across the country, and having them do improvement projects using the Model for Improvement framework and sharing all of their trials, tribulations, data, results, successes and challenges with each other so we can all learn from each other about ways to make significant improvements in our performance.

We’ve named it “Caring for Maria.” Maria is the name of a fictional patient. It’s so easy when you do corporate programs to lose track of the individual patient; this program is designed to make a difference for individual patients, and the name keeps everyone focused that our works needs to align with making things better for people who are sick and hurt.

Caring for Maria is focused on the seven things that matter: cardiac arrest/resuscitation; assuring safe patient care in transportation; the safe and effective maintenance of airways and ventilation; reduction of pain and discomfort; relief from respiratory distress; STEMI/stroke; and effective and timely trauma care.

Jenifer Goodwin is an associate editor for Best Practices in Emergency Services.