Inside the Mind of an EMS Manager

Asking what’s going on in the heads of EMS managers might elicit some colorful responses. But the truth is EMS managers necessarily have a lot on their minds—running an EMS agency isn’t easy and it requires managers to wear a variety of hats.

Management of Ambulance Services, a new textbook prepared by the National EMS Management Association, seeks to provide EMS managers an overview of what it takes to run an ambulance service; not an EMS system, as the book’s introduction is quick to point out, but a single agency providing patient care. Think of it like a blueprint for building more complete EMS managers for tomorrow.

EMS World spoke with the authors of several chapters covering a range of topics, from deployment and staffing models to finance and accounting, and everything in between, to get a peek inside the head of an EMS manager and see just a few of the things they need to consider in running day-to-day EMS operations. There’s more—a lot more—in the textbook than we can cover here, which only underscores the complexity of EMS management.

Deployment and Staffing Models

According to Steve Cotter, MBA, NREMT-P, at-large member of the Board of Directors for the National EMS Management Association, not much has changed fundamentally in the way EMS agencies make use of deployment models from the early days of the industry. What is different is the technology available to make more efficient, precise decisions about deployment, which allows EMS managers to make better use of available resources whether they’re using a geospatial or static deployment model, where ambulances are based out of a fixed station; a fully dynamic model, where they’re on street corners and they’re re-posted continuously based on what’s going on in the system; or a hybrid model, where it’s a combination of station units and little bit of street posting.

“You go back to the old days when I first started looking at deployment in the system I worked in. For geospatial deployment we took all the call locations—we didn’t even use latitude and longitude, we used addresses and intersections—and we literally plotted them on maps by hand; that process took forever.”

Cotter says it was imprecise because with the time it took to plot out maps, the process was only done once or at most twice per year. That made it nearly impossible to react dynamically to any changes the system where population growth or patient demand was growing. But while technology today lets managers very quickly and dynamically plot their environment and reassess it continuously, Cotter notes there’s a negative side to having all that information at your fingertips.

“You can become too wrapped up in the details or minutiae of the plan. When managers get wrapped up in trying to achieve 95% vs. 94% vs. 93% coverage effectiveness in the system, as an example, when they’re doing geospatial analysis, at what cost to your staff and potentially the safety of your patients and the community does that come at? Is 94% demand coverage vs. 93% demand coverage really worth it, especially in this environment where we understand that in most cases response times may not be as important in certain patients types as we once thought they were?”

Staffing models have changed, Cotter says, and they still vary widely across the industry.

“Recently I’ve seen schedules down where I live that are anywhere from 48–96 hours, as well as the 24–48 hour shifts that are still predominant in the industry. But more of us are going to 12 hour schedules. If you get into some of the performance-based systems you’ll see anything ranging from 8–14 hours typically. They’ve made schedules, through the use of technology and modern techniques, both more efficient in our ability to put the correct number of ambulances on the road so we don’t have too many or too few, and also more employee-friendly so they provide more schedule options to the employees.

“For instance, the 8s, 10s, 12s and 14s in some performance-based models allows for employees to kind of pick and bid for shifts that fit more of their lifestyle, whereas before in the old deployment and staffing models shifts were typically fixed and they may or may not fit employee lifestyle.”

Cotter also points out that today’s staffing models put greater emphasis on combating fatigue, which continues to be an industry-wide issue. “That’s one of the good evolutions you’re seeing, is our ability to leverage the tools to better define our environment and help our employees be more productive and healthy.”

Cotter advises managers to involve their staff, whether they still create schedules manually or whether they leverage technology.

“That human capital and expertise is what makes the system function. It’s paramount. We can plan as managers all day long, we can have the best technology, tools and techniques, but the people who have to execute it are those guys and gals on the trucks. We’ve used committees from a best practice standpoint. We have a deployment committee that helps us reexamine on at least a six month basis a comprehensive review of the system in terms of deployment, scheduling, lifestyles and those kinds of things. We also use polls of the staff to discuss schedules and get input from the staff in general and then take that to the committee to work out schedules that work best for everybody.”

As far as using people, Cotter adds deployment technology is great to an extent but when he’s posting locations in a computer system, those systems can’t tell him if those are safe posting locations, if there’s been crime in the area, are the facilities the employees need present, or if the area make sense from a functional standpoint. Involving staff in those decisions can help managers understand those environmental issues and also provide the staff with a sense of input and ownership in the process.

Ambulance Specification and Procurement

Few things are really the same when it comes to designing and purchasing ambulances from the old days. That’s a good thing, says Jon Olson, MBA, MHA, NREMT-P, EFO and chief of operations for Wake County (N.C.) EMS, because an emphasis is finally being placed on safety for crews and patients like never before. “Where we’re seeing today is we have more purpose-built vehicles. We’re not necessarily adapting commercial vehicles, although you still see van chassis ambulances, like the Sprinter.”

Olson says EMS managers need to consider what the mission is of their service when they look at the design and procurement of a new truck.

“If you’re working in an environment that requires you to have lots of specialized equipment, whether it’s personal protective equipment or things required for different clinical processes that you have to either do in the field or are responsible for when transporting from one location to another, that will significantly drive where you start with that vehicle. If you’re looking to purchase an ambulance and you’re a BLS service that may not be the primary 9-1-1 responder or you may not need to have space for all this other ALS gear, do you really need to buy an ambulance on a medium duty chassis? In order to be as respectful of the money you have, and a lot of us are spending taxpayer’s money to buy these vehicles, it’s incumbent upon us to make sure what it is we need and not just the biggest, brightest toy out there.”

He adds technology has gotten better in that ambulance manufacturers are able to use lighter materials so vehicles have more payload capacity. Fortunately a lot of the newer materials come with advances in technology, like the way aluminum frames are formed to provide ambulances with much more strength and integrity.

“How design differs today from in the past is I think we have learned that the safety of our folks and the patients in the backs of these vehicles has to be a priority. Not only has the response community come to that conclusion, the ambulance community has met us there as well. There was a time and place where practicality of the mission was the driver of design of ambulances. I think that generation has come to an end and now we’re  looking at how we incorporate these vehicles into a safer design.”

One way design has improved has been the introduction and adoption by many agencies of highly reflective decals in a variety of colors and patterns, which make ambulances more visible during the day or night.

“One of the things we identified several years ago is warning lights are not the only way to make our vehicles more visible, especially at night. With the advent of high-conspicuity vinyl graphics, and if they’re applied in an effective manner, when headlights are shined on a vehicle they can be nearly as bright as any light you can install on that vehicle.”

Patient Care Reporting Documentation and Documentation Systems

Until relatively recently, PCRs were all paper-based and the narrative was king, says Kevin Sullivan, MS, NREMT-P, vice president of operations at STAT Medical Solutions. “These paper PCRs were all very similar: carbon-copy type forms with a demographics section, a place to list meds, a couple of rows for vital signs and a large narrative portion. We focused on teaching people CHART and SOAP formats to aid their narratives. It was pretty difficult to do anything with all the data that was contained in those paper PCRs; in fact, most of them just went to a warehouse somewhere for storage.”

Sullivan says the introduction of the ePCR over the last 10–15 years has dramatically changed patient care reporting in virtually every way. “ePCR system design, which varies between vendors, has a significant impact finalized patient record. The importance of the narrative has been significantly diminished. In most platforms, the major focus is now some form of Activity Log, which is largely time-sequential and focused on treatment. Some platforms offer ‘auto-generated narratives’ based on information in other fields. Systems commonly import data from other data sources (CAD data, vital signs and ECGs from the cardiac monitor) in a way that makes documentation easier and, potentially, more accurate. NEMSIS has done a tremendous amount to standardize data collection across platforms, which has changed the platforms themselves.”

The next big step—and it’s already happening, Sullivan notes—is bi-directional data exchange. The EMS crew sends data from the PCR to the receiving hospital before arrival. By the time the ambulance arrives, the patient has already been registered and the ED staff knows the patient’s vitals and history. When the patient gets diagnoses and/or discharged from the ED, the EMS crew receives the ED diagnosis code and treatment information.

Sullivan notes ePCRs offer the potential for a wealth of information about an EMS system to managers; whether it’s being utilized is another story.

“When you think about all the data in the ‘collected works’ of an organization’s PCR database, and all that that data says about how well the organization is working or not working, you would think that leaders and managers in EMS would consider their ePCR system to be one of their most valuable resources. Yet, in most systems, the ePCR system is only partially implemented and is used for very little outside writing and limited review of completed PCRs. Some systems even have very sophisticated quality management tools that make performance improvement much easier—and yet those systems are basically gathering dust.

“The same is true in the back of the ambulance: many mobile PCR systems have the ability to provide documentation prompts, integrate and import data from other sources, give providers the opportunity to review clinical protocols in real time, and substantially reduce the amount of time that it takes to document a call. And yet, most systems do not take advantage of all this functionality either because they decide not to do the up-front set up work or they do not take the time to train their employees how to use these tools effectively.”

Sullivan offers these tips for EMS managers when it comes to ePCRs:

• First, look beyond cost as your primary purchasing variable. Buy a system that works for you. If you’re getting resistance from others, take the time to educate your stakeholders about the value of a good system.
• Second, think about the overall workflow that your ePCR system will create. It the ePCR platform isn’t saving you time and improving your ability to be efficient, that is a problem. Your crews should not need to go back to the station and spend hours on documentation following each call. A high-quality ePCR system that is well-implemented should be easier and faster to complete than a paper report. It should make life easier for your medics.
• Third, it’s worth the time and effort to make sure that your organization fully implements your ePCR system. Take the time to set things up correctly at the beginning. Budget and invest in ways that will make your system reliable and seamless. Test it with a select group of users before you roll it out to the rest of your staff. And, when you roll it out, take the time to train your staff to be competent with it. This isn’t something you can do with a one hour lecture or a “quick guide.” People need hands-on learning time with this before you expect them to work in the back of the ambulance.
• Lastly, an ePCR system does not replace the need to educate your medics on topics like documentation. Everyone should understand that the data in their ePCR is being used by a lot of other people. Like anything, junk in equals junk out. Similarly, managers need to keep up with the changes and developments in the ePCR product market.

The Finance and Accounting Functions

Finance and accounting probably seem dull at best for many EMS managers; at worst they’re downright scary. But EMS managers need to be comfortable in the world of talking about and understanding finance in order to run effective EMS operations at any level, says Sean Caffrey, MBA, CEMSO, NRP, and EMS system development coordinator for the state of Colorado.

“I think EMS leaders need to have a really solid understanding of how the money stuff works, or how the funding works, in their organization,” Caffrey explains. “And I think our higher education system at times does a disservice, because it introduces accounting and finance in courses that actually teach you how to do technical details of accounting. That’s actually not the point at a managerial level; the point is to be able to understand accounting and financial statements as opposed to being able to create and manage them. The technical details of accounting and finance can definitely be left to professionals in those areas but a good global overview and understanding of how those pieces work is the obligation of managers at all levels—especially at the top.”

That’s echoed by co-author Asbel Montes, BS, vice president of governmental relations & reimbursements for Acadian Ambulance Service, headquartered in Lafayette, LA. “Especially now with budget cuts and everything happening on county and city-based levels, those that are moving into the ambulance realm, finance is becoming even more important,” he says. “So you’re seeing a lot of agencies now beginning to look at their revenue cycle models, not just their cost-containment models.”

Both Caffrey and Montes note there’s probably not as much difference in the ways public and private EMS services operate as it might seem on the surface.

“Even though those funds come from different places, the structures around them are not all that different in terms of how they’re accounted for,” says Caffrey. “Clearly how you report and deal with income on the private sector side as a result of it being taxable and all that is a little different, but the underlying concepts of understanding how much is coming in and home much is going out is really unchanged in between public and private sector.”

Montes adds that one area of difference is how the revenue cycle impacts the way business decisions are made. For private EMS agencies that’s always been the case, but now even public agencies are adopting revenue cycle models because what they generate through billing is often what’s sustaining the agency. In the past public agencies could simply ask city or county government for more money, but now as public funds dry up, the revenue cycle has taken on greater importance.

The Affordable Care Act and the larger healthcare reform movement have also impacted the way agencies need to think about finance.

“I think a failure that healthcare in general has, and EMS probably has as well, is we need to understand the expense side of what we do because there are a lot of changes going on in terms of who and how we’re going to get paid moving forward,” says Caffrey. “The best way to deal with that is to understand what it actually costs for you to do what you do as an organization (e.g., how much every ambulance call costs, etc.). I think a lot of healthcare organizations struggle with what it costs them to do business. I think they know a lot about what they can charge to do business, but they don’t translate that to how much their production actually costs them. That’s going to be a big issue as we move through healthcare reform, because if you can’t do it more efficiently and don’t understand how to get it there in terms of a cost-effectiveness piece, organizations will start to struggle.

“EMS managers should not be scared of finance, accounting or financial statements. They are easy to understand with a little bit of study and they will give you a really good sense of how the resources in your organization come in and go out. And it’s having that understanding that at the end of the day allows you to run a great EMS organization,” Caffrey adds.

For EMS managers who still aren’t sure about revenue cycle management, Montes offers a cautionary word about outsourcing the functions completely.

“I think it depends on the size of your organization,” he says. “The way I like to discuss it if I’m dealing with a city manager or a for-profit company, if you’re entering into the business or you’re a new business I always suggest you outsource. I suggest you focus on operations and outsource your revenue cycle process and even some of your accounting functions.

“But if you’re not new in the business, depending upon the size of your company or the size of your service area, I’m all for bringing it in-house and then utilizing a system of vendors to kind of play that checks and balances for your own internal process. My perspective is it can be a mixture of both, it just depends on the size of the organization.”

Montes, who used to work for a revenue cycle consulting company, says he believes nobody goes after your money better than you and nobody is more passionate about your money than yourself. “If your service is doing more than 50,000 transports per year you should bring it back internally and never outsource. Now, you can outsource certain components of it to do a checks and balances against your own systems, but I never suggest outsourcing your total revenue cycle.”

Technology in Support of Ambulance Operations

When Skip Kirkwood, MS, JD, NREMT-P, EFO, CEMSO, and EMS director for Durham County, N.C., first started in EMS in 1973, there was no technology to support ambulance operations.

“The way it worked was you sat at a station, a call came in on the telephone and the dispatcher handed you a piece of paper that told you where your call was. You got in the ambulance and you either knew where the call was or you had a map book and you navigated using a paper map. When you were done with the call you wrote a report on a piece of paper. There really was no technology except for the two-way radio in the ambulance.”

Now, Kirkwood notes, every step of an EMS event involves technology of some sort. “A call comes into a 9-1-1 center, they pick the closest ambulance based on GPS data that shows where all the ambulances are, they use a computer, including sometimes a computerized voice, to dispatch the ambulance. You get in the ambulance and push a button to tell dispatch you’re on the way, then you push a button to tell them when you’ve arrived at the scene. Of course you take your ECG, blood pressure and all of that stuff using another technological device. You put the patient in the ambulance and in some cases you’ll use another wireless communication device or computer to send information about the patient to the hospital. You’ll get to hospital and use a computer to write your report. And in some of the more sophisticated systems that report will never be turned into a piece of paper. The medic will push a button and their report will move electronically into the patient’s electronic medical record at the hospital and back to the EMS organization for quality assurance. And then you do it all over again.”

Kirkwood says operationally technology has improved accuracy, if nothing else. Clinically, there are aspects where it’s easy to see where technology has improved patient care. “For instance, if someone is having a heart attack, right now instead of taking the patient to the ED and having them do another ECG there and spend a bunch of time trying to confirm what the paramedic is saying about the patient is correct, you can send that ECG right to the cardiologist and the patient can go directly to the cardiac cath lab to get their treatment, reducing the time from the event to treatment substantially.”

While Kirkwood says every EMS agency is different, and while have different technology requirements that need to be met, the one thing he would encourage every EMS manager to consider purchasing is a driver monitoring and feedback system. These are systems that monitor driver performance and provide both feedback to the driver and data for management to use for either training their drivers to drive more safely or take action when there are those who don’t.

He acknowledges some EMS providers might push back against this kind of “Big Brother” technology, but they’ll be thankful for it in the long run.

“In the beginning they may be scared to death of the systems because ‘management’s going to catch us doing something bad.’ But I know of a couple cases where that data has saved some careers. I heard of a case where some medics were accused of stopping the ambulance alongside the highway and sexually assaulting a patient in the back of the ambulance. And when the data was reviewed from the cameras and the driving system, it was pretty clear the ambulance never stopped anywhere. It carried the patient right to the hospital and what the patient was complaining of never could have happened. That was a career caver for those medics.”

Kirkwood is also an advocate for letting staff provide input on new technology and equipment whenever it’s possible.

“Most of the time I think it’s pretty important, if for no other reason than if the staff later have a complaint about it, it was their choice,” he says wryly. “Sometimes that’s not possible. If your dispatch center has this CAD system, you have to have this mobile data system—you don’t get a choice. But if you’re going down a new path, if you’ve never had in-vehicle data or computerized patient care reporting before, then absolutely you need to let the employees play with it, try it out and see which one they like better. If all of the systems being considered meet management’s needs, and as long as they're within budget and do what the company needs to do, why not let the medics have one that’s what they want?”

Kirkwood’s final takeaway lesson from his chapter could easily be applied to the entire textbook, which he helped edit. “What the chapter was trying to do was make folks aware of some of the technological options out there. One of the bad things about a book, of course, is it’s just a snapshot, so whatever’s in there is old the minute after the snapshot is taken. But while the textbook may not mention every driver feedback and monitoring system available, it does talk about them. So then the manager can take what they learn from the book and go out to look at the marketplace to see what’s available today and what’s the best choice for their organization.”