A Squirrels Perspective -revisited

A Squirrels Perspective

of Legislation Affecting EMS and Good Decision Making

By Alan Perry 7/24/2013

Introduction

I have been trying to understand the pushes in EMS toward Mobile Integrated Healthcare Practice (MIHP), Community Paramedicine and the function of Accountable Care Organizations (ACO’s). It appears I have been looking at it from the wrong perspective, assuming that it has been driven internally by the healthcare community delivering on recommendations made by the National Highway Traffic Safety Administration (NHTSA), the Institutes of Medicine (IOM) and others which have spelled out clearly what steps need to be taken to integrate our healthcare system and move pre-hospital EMS into full partnership with other healthcare fields. While the power of these recommendations has moved many organizations and systems forward, they have failed to garner widespread adoption in the years since they were written. What is pushing the change now, at this late hour?

Methodology

I proceeded to work backward studying applicable portions of various programs, exploring the contents of pending legislation and healthcare law. I will admit that this process was not very methodical; I focused my attention on pieces that were overtly related to EMS and limited that material to what was most applicable to daily pre-hospital EMS operations, financing and coordination with other healthcare organizations. I compare my actions, and that of many EMS systems, to that of the squirrel finding itself in the middle of the road and not being able to decide which way to run, therefore my focus has jumped around quite a bit and I still see the vehicle of healthcare system reform coming at me! I hope I can illustrate for my own benefit, and others, what the options and potential consequences are before we simply get plowed over by the changes before we can react. My opinions here are by no means “expert” and I encourage everyone to read the actual documents before taking any action or embarking on a substantial project.

The Patient Protection and Affordable Care Act

Enter Obamacare; Section 5101(d)(2) of the Patient Protection and Affordable Care Act (Affordable Care act) Titles III & V provide the impetus for change in payment strategies, development of ACO’s, community healthcare teams and coordinated care. The mandates are very broad and do not specify the “how” or “who” just the desired outcome, leaving the whole process up to substantial interpretation, funding is achieved through costs savings to successful participants. The intended effects of the Affordable Care Act are sweeping change to business as usual in the healthcare arena; Emergency Medical Services (EMS) is no exception. The mandated changes will occur by adoption of new and more effective delivery methods by the existing providers within each region, or their replacement by new ones. This is not a suggestion; it is a flat out requirement. The federal government is using a carrot/stick approach, with financial rewards for performers and penalties for failure, such an approach will be game changing, spelling financial ruin for those who cannot adapt and creating much more competition, EMS systems will be no exception. This has created renewed interest in the ancient texts written by NHTSA and IOM, leaving me personally wondering if we may have waited too long. I can see control of EMS systems and organizations being slowly taken away and replaced with something we will have no hand in developing, unless we act quickly, deliberately and intelligently.

References:

HR 3590, Patient Protection and Affordable Care Act

http://www.gpo.gov/fdsys/pkg/BILLS-111hr3590enr/pdf/BILLS-111hr3590enr.pdf

HR 809, Field EMS Quality, Innovation, and Cost Effectiveness Improvements Act of 2013

http://beta.congress.gov/bill/113th-congress/house-bill/809

GovTrack website

http://www.govtrack.us/

National Academies Press, Best Healthcare at Lower Cost

http://www.nap.edu/openbook.php?record_id=13444

National Academies Press, EMS at the crossroads

http://www.nap.edu/openbook.php?record_id=11629

National Highway Traffic Safety Administration, EMS Agenda for the Future: A Systems Approach

http://www.nhtsa.gov/people/injury/ems/EdAgenda/final/agenda6-00.htm

University of Exeter School of Psychology, Animal Cognition

http://psychology.exeter.ac.uk/latestnews/researchnews/title_36307_en.html

Apathy and the Art of Apparatus Maintenance

Apathy and the Art of Apparatus Maintenance

By Alan Perry

How does your organization manage vehicle maintenance? Do you fix it as it breaks, a system driven by complaints and failure? Do you let an independent or municipal shop manage it, a system frequently fraught with excessive cost and repair delays?  Do you manage it yourself, or some combination of the three? I have been working on machinery, cars & trucks professionally since I was seventeen years old. I have been certified as an ASE master auto and truck technician multiple times. I managed my own shop for 25 years, performed fleet maintenance on ambulances, and served as logistics officer for my rescue squad. As my interest in emergency services grew so did my interest in emergency vehicle service and maintenance practices. There are three primary goals when managing a fleet of emergency vehicles, safety, reliability and controlled cost. All of these goals are important and directly affect patients, providers and the organizations stability. I hope to convey to you some practical thoughts that can guide you to development of a rational, efficient and cost effective vehicle maintenance program that will suit your organization’s needs.

I have been exposed to all of the aforementioned strategies, some can be good, and some must be avoided. How do you decide? The person responsible for apparatus maintenance does not have to be a mechanic although a background in that area would be helpful, access to an honest and respectable technician or shop owner would be a reasonable alternative. The pitfall here is that the individual managing your fleet may not be up to speed with modern apparatus, vehicle engineering and effective maintenance strategies. Motor oil does not need to be changed every 3,000 miles anymore, buying cheap tires does not save money, preventive maintenance is not an oil change and tire pressure check, in other words what works for your mom’s car does not work for emergency equipment.

So what does an effective emergency apparatus maintenance plan look like, and what should you know going into this process? It will depend on your circumstances, climate, geography and type of equipment. You will need a thorough understanding of your equipment, the manufacturer’s recommendations for service, and the meaning of the terminology used. Record keeping plays an important role in tracking and identifying recurring needs and potential failures in your maintenance program, these records must be kept in sufficient detail to make the data useful. Simply keeping all the receipts in a folder will typically meet government requirements, but you need to go well beyond that if you are serious. A simple spreadsheet will usually suffice, at a minimum it should track fluid services such as engine oil, transmission fluid, coolant, brakes, tires and electrical system checks and repairs documenting the date, mileage, cost and reason for each service. If you collect the data for a period of several years you will notice patterns in certain types of failures, in this way you can predict both service life of certain components and potential costs involved. If you apply this data you will be able to schedule your services in advance of equipment failure reducing both cost and downtime, improving reliability of your equipment.

I have found that the 3,000 mile traditional service interval usually used for emergency equipment is excessive, it is frequently referred to as preventive maintenance, but very few actually adhere to the definition of that description with predictable failures occurring between scheduled PM’s routinely. So how do you fix that? It’s really very simple; you use the historical data for each unit and you change the nature of your PM to fit the definition. Change the maintenance interval to 5,000 miles, create a check list that the technician responsible for servicing the truck must complete, include all of the items that would normally be inspected during a state vehicle safety or DOT inspection on the sheet requiring documentation that each item is not only good, but will remain serviceable until the next inspection. This must include checking all the tires, brakes, lights, suspension, fluids and the electrical system. Any item that is not likely to remain functional and safe until the next service gets replaced right then and there. The overall goal here is to keep all of your equipment in the best shape it can be, improving reliability and reducing cost. I applied this very system to a fleet of 6 type I & III ambulances and saw a 20% reduction in overall repair costs each year for two years. Initially all the trucks rotated through the program took a little additional work to bring them up to speed, but the results were exactly as expected and the reliability of the fleet improved noticeably.

In contrast, let’s look at the typical municipal or private garage that is overworked and under budget constraints which frequently cause cost avoidance via delay or omission rather than an attempt to control cost via effective management of maintenance programs. Typically you schedule your PM, the truck goes in and gets the oil changed and if you’re lucky the primary fluids checked, you pick it up, and a week later you notice the state inspection is due, when you take the truck back they discover the rear brakes need to be replaced and the parts have to be ordered because they don’t keep them in stock. You pick up your truck a week later, it requires a jump start when you pick it up but keeps working for another week before the alternator burns up trying to accommodate the bad batteries. You see where I’m going with this? This is the typical result when the personnel or facility maintaining your equipment does not have a vested interest in truly maintaining the safety and reliability of your equipment; in fact they actually spend/make more money this way.

Your logistics officer or whoever is responsible for managing your maintenance program must be committed to a program that is proactive instead of reactive, and this individual must have the support of the organizations leadership to implement this type of program. You cannot manage ambulance maintenance like your personal vehicle or a garbage truck, there is too much at stake, the safety of your staff, the outcome for the patient, and the costs to the organization’s reputation and finances are at risk.

Happy motoring,

Fire Based EMS Advantages

Advantages and Strengths of Fire Based EMS

By Alan Perry 7/12/2013

Introduction

I have frequently questioned the commitment of the fire service when it comes providing emergency medical services (EMS). I have observed through my own experiences that the fire service has reluctantly accepted provision of this service as a necessary evil in order to secure funding for its own programs and preservation of career firefighter positions. I am a career paramedic/firefighter in a large municipal fire department, my initial training as a paramedic was obtained while I was a volunteer in a neighboring city because my city did not encourage volunteerism. I eventually sought employment in my home town as a paramedic/firefighter and was given some preference in hiring due to my paramedic certification. My department began as separate EMS and Fire divisions which merged before I was hired with separate career paths for fire and civilian EMS personnel. Over the years through attrition the numbers of civilian employees have dwindled to but a handful with the majority of supervisory EMS positions being filled by aspiring Fire company officers who have not given up their ALS certifications. The EMS command structure falls completely under the Fire chain of command with no parallel structure or career path for EMS. Our current staffing model is dictated by the Fire Administration’s desire to have one ALS provider available in each station, ambulances are staffed with two BLS providers, ALS is available by simultaneous dispatch or requests for an ALS provider via an engine company response. In this way the best use is made of the departments limited ALS resources. There are many other models used in the fire services ranging from this extreme to all ALS apparatus and systems where even officers are expected to do some time on the “box”. If anything, we are flexible. We almost universally, as part of our fire based culture, play down and degrade the value and importance of the EMS services we provide. We portray this duty as a punishment or undesirable assignment even though it accounts for over 80% of the services we provide. These observations aside, I believe the fire service is in a better position to provide EMS services due to the culture, resources and stability the fire service possesses.

The fire service culture

Normally I would count this as a negative, but I have come to realize that the fire service does many things right when it comes to producing an atmosphere of cooperation and teamwork. There is also the mentality that no job is too daunting or extends beyond the capabilities of the fire service. These attitudes have been tested, and although applied slowly to the practice of EMS, it is changing. The fire service has the correct mind set needed to take on the challenges facing changes in EMS that are occurring now and those on the horizon, the test will be if it can react with sufficient agility to maintain control of its own system.

The resources of the fire service

The nature of the fire department is to handle any emergency, of any kind, at any time. We train for every conceivable type of scenario. Because of this fact the fire service is the best prepared to handle any type of patient presentation, and equipped to begin treatment immediately even in the most difficult circumstances. The additional training and equipment available allows for safer and more effective treatment of patients and minimal risk to providers. One of the biggest strengths of the fire service is its ability to organize and mobilize resources both physical and human. Through unions and public goodwill we frequently can convince both the public and government officials that our needs should be met in the public’s best interest if our cause is a just one. The fire service can bring extreme amounts of physical and human resources to bear when disasters occur locally, regionally or nationally. The agility of the fire service will be tested in the near future, challenging our ability to improve and keep up with changes in EMS. The political power of the organization can be used to improve EMS systems or expended trying to maintain the status quo.

The stability of the fire service

Fire departments are paramilitary organizations that rely on rigid command structure both in emergencies and routine operations. Because of this fire departments are able to produce more consistent and reliable results, personnel at all levels are held accountable for their actions. Individual preferences, variations and freelancing are minimized, safety procedures are followed, and most actions other than local EMS protocol are based on established national standards creating little variation from one department to the next. Fire departments are publicly funded, they are required to submit and adhere to budgets and long-term plans. The finances and activities of the fire department are very public. Fire departments do not get into trouble quickly or without the public’s participation. These facts make fire departments inherently more stable and free from the vacillations in financial and leadership performance often plaguing non-profit and volunteer organizations engaged in providing EMS services. This stability in leadership, oversight and financial affairs make fire departments much better suited to provide a stable environment for the improvement of EMS service and system development.

Conclusion

I believe that in spite of my past experience with the fire service, it is far better suited to take on the challenges facing EMS at this time. Those in the fire service have become acclimated to EMS as much more than a “box” that takes people to the hospital. They realize it is an important service that greatly affects the lives of those we serve. The fire service possesses all the resources needed to confront the changes EMS is facing now and in the foreseeable future. My hope is that we will be able to do so with the agility and efficiency required, after all the fire service as a whole is a huge organization, it has traditionally been very slow to change. The only obstacle remaining is the Fire Service Culture, if we can change our attitudes toward EMS across our organizations from the top down, no one will dispute our ability.

Be Safe,

Budget Request Example for EMS Non-Profit

Budget Request to the City of Waynesboro, Virginia.

To provide adequate funding of EMS volunteer retention,

Training and marketing

Background

The Waynesboro First Aid Crew (WFAC) is a volunteer/career combination non-profit organization that provides emergency medical services to the city of Waynesboro and the surrounding areas of Augusta County.

WFAC participates in revenue recovery; however this only recovers a 65% of the cost associated with providing a reliable, 24 hour 911 emergency medical response, treatment and transport system.

Operating shortfalls are partially offset by donations and contributions from the community, Donors, Subscriptions, the State of Virginia through 4-for-life funds and the City of Waynesboro.

The effect of the shortfall has been a steady decline in the resources available to properly sustain volunteer marketing, training and retention. The cycle thus begins with declining volunteer numbers and the necessity of hiring more paid staff to provide adequate service, and increasing operating costs.

The Code of Virginia 15.2-955, 1, B as amended states” Each locality shall seek to ensure that emergency medical services are maintained throughout the entire locality.”

The Code of Virginia 32.1-111.3 requires the Virginia Office of EMS to develop a comprehensive plan to improve the effectiveness and efficiency of the State EMS system. This has been accomplished by the publication of the VAOEMS State Strategic and Operational Plan. Several of the strategic initiatives in that plan pertain directly to the issues currently faced: Community based initiatives to increase recruitment and retention of EMS providers (Strategic Initiative 1.2.2), Develop, implement and promote a comprehensive recruitment and retention campaign for EMS personnel (Strategic Initiative 3.2.1) and Educate local government officials and communities about the value of a high quality EMS system (Strategic Initiative 3.5.3)

Current state of relationship

The city of Waynesboro supports the activities of the WFAC in a number of ways; provision of various city benefits to volunteer and career staff, communications infrastructure and dispatching, and annual contributions (currently $37,000). WFAC assists the City with various expenses as well; repayment for volunteer incentives provided by the city ($12,000), EMS supplies for the Waynesboro Fire Department (WFD) ($10,000), and EMS equipment maintenance for WFD ($3,000). Effectively, the City contribution offsets less than 1/10^th of 1% (.008% or $12,000) of operating expenses.

WFAC pays all of its own payroll and operating costs, as well as capital outlays for new equipment, and apparatus saving the City millions of dollars annually. Volunteers contribute over 18,000 hours (18,226 hrs.), or the equivalent of 6.2 full-time city public safety workers a year. This amounts to another $275,000+ savings to the city.

Desired goals

This budget request seeks to increase the level of support provided by the City of Waynesboro to its primary 911 EMS service agency, the Waynesboro First Aid Crew. It also seeks to educate the public and local officials about the environment and desired goals of the organization. It is reasonable to have the contribution provided by the City directly linked to some objective measure reflecting the value of the organization to the community and local government rather than a purely arbitrary and insufficient amount. A contribution of 50% of the minimum wage value of the volunteer hours provided by WFAC members ($84,000), for the sole purpose of funding marketing, training and retention programs for the volunteers of the organization is a realistic consideration. In addition to this modest contribution the city should absorb the cost of materials and services provided to the WFD and the cost of tax incentives to volunteers.

Budget requests

1.     Objectively link the City of Waynesboro contribution for primary 911 emergency medical services provided by the Waynesboro First Aid Crew to the value of the volunteers to the City and community.

The City of Waynesboro shall provide an annual contribution to the Waynesboro First aid Crew equal to 50% of documented volunteer hours at minimum wage x 1.27; which represents one-half the value of a minimum wage employee, including payroll taxes.

2.     The City of Waynesboro will absorb the cost of EMS supplies and equipment maintenance currently provided to the Waynesboro Fire Department by the Waynesboro First Aid crew.

The City of Waynesboro shall assume financial responsibility for all expenses incurred by the Waynesboro Fire Department, any supplies, services or maintenance provided by the Waynesboro First Aid Crew will be reimbursed by the City of Waynesboro.

3.     The City of Waynesboro will absorb the cost of tax incentives to volunteers, acknowledging the value of their contribution to the City and the community.

The City of Waynesboro will continue to provide tax incentives to active volunteers of the Waynesboro First Aid Crew without the expectation that these funds will be reimbursed by the Waynesboro First Aid Crew.

4.     The city of Waynesboro will provide a modest contribution to offset the cost of Marketing Volunteerism, recruitment and retention that reflects the value of the organization and Volunteers.

The city of Waynesboro will provide a monetary contribution to the Waynesboro First Aid Crew to adequately support a multi-faceted Marketing program for the purpose of public education and volunteer recruitment and retention.

Expected outcome & benefit to city

It is in the interest of the citizens, the community, and the City of Waynesboro to promote the success of the Waynesboro First Aid Crew. The organization provides an essential public service, saves the taxpayers money, and is an integral part of the social infrastructure of the community. With the cooperation and support of the City of Waynesboro the Waynesboro First Aid Crew will be able to more adequately market the value of volunteers, recruit new volunteers and increase volunteer participation within the community. Existing volunteers will be adequately supported, trained and promoted, increasing morale and participation. With a strong volunteer base the organization will be able to control expansion of career staff and remain financially viable well into the future.

Being proactive in the support of a quality EMS system for the City of Waynesboro will satisfy the requirements of State Code and the comply with several of the objectives of the Virginia Office of Emergency Medical Services Strategic and Operational Plan. Demonstrating a cooperative attitude toward solving these national, regional and local problems will put Waynesboro in a position of leadership on these issues.

Conclusion

The City of Waynesboro has the opportunity to more adequately fund its primary EMS response agency, the Waynesboro First Aid Crew, by providing an objective contribution that minimally represents the value of the organization to the community. Doing so will have a dramatic and positive effect on the ability of the organization to attract and support volunteers from the community willing to provide this vital public service. The end result will be a vital and sustainable organization that cost the City a fraction of the cost of operating a similar organization as a separate municipal entity or expanding the services of others.

References:

Code of Virginia, 15.2-955 1, B

Code of Virginia, 32.1-111.3

Virginia Office of Emergency Medical Services, Strategic and Operational Plan 2012-2013

What a Glorious Union

What a Glorious Union,

Union Basics in Right-to-Work States

By Alan Perry

                  

Many think that labor unions in right-to-work states have very little power; I suppose that depends on how you measure power. Unions are considered beneficial to workers in various trades and professions including fire and emergency medical services. The common advantages being the ability to negotiate labor contracts through collective bargaining, union representation in disputes and the ability to strike as a unit if all else fails. These are advantages that workers in right-to-work states such as The Commonwealth of Virginia lack.

So why join a union? The union may not possess much in the way of formal power when it comes to negotiating labor contracts in Virginia, but when the members come together and pool their resources and influence, the power generated will be felt in the form of public opinion and political pressure. These forces can and should be used to benefit the community and the public safety organizations responsible for their defense. An educated and informed public is the best ally of the firefighter, Paramedic and Police Officer. The unions exist to further the needs of these and other public servants as well as other organized labor groups with or without the legal authority granted in some states.

A union in a right-to-work state can exert influence through effective public education, promotion and cultivation of media resources to build a machine that honestly and fairly brings the needs of the worker and the organization to the attention of the public. A just cause or reasonable request will receive public support, generate political pressure, lubricate the sticky wheels of government and achieve what a thousand polite proposals and requests can never do. Municipal leaders will hide behind budgets, feasibility studies and consultants opinions to justify bad ideas, poor judgment and indecisiveness in managing the affairs of local government. These arguments melt away in the face of public opinion and pressure.

Of course power corrupts, and unions are no exception, the union and its leadership must remember that they serve both the public and the union members. Union leaders who seek personal gain, favors, or lead the union in a direction motivated by greed and selfishness will destroy the public trust and the union itself. This is why participation is so important, your union leaders need you as a sounding board to make sure they make decisions that are righteous and uphold the reputation and values of public safety employees.

Union members who find themselves in ineffective unions, with poor attendance and participation should be looking for some serious change. The union is your best tool to promote your organizations needs and your needs as an employee, you need to fight for it, participate and drive the discussion toward taking the action your union was intended to take on behalf of your community and your career. Perhaps if my union ever asked me to join, I would do so gladly, volunteer to run for president and show them how its done.

Sincerely….

Limitations of Web-Based Instruction

The Limitations of Web-Based Instruction

By Alan Perry

Online and web-based instruction have become very popular over the years due to the limitations of individuals time and resources. Many public safety organizations have discovered its benefits due to shrinking training budgets and greater personnel resource utilization. Without on-line and web-based options many individuals and organizations would have no other alternative to provide necessary and frequently required training. But where does this leave us as instructors and students? We all know the cognitive, affective & psychomotor domains of education, how can this satisfy them all? I am not alone in my concern for the outcome of this situation.

The risk is that online and web-based training options may be used to completely replace other forms of training. This presents a problem when it comes to training that requires conveying a technique or psychomotor activity. Take intubation as but one example; you can discuss the anatomy, the procedure, look at videos of it being done, and answer multiple choice questions to get your airway CE. We all know that does not work, how does this get passed-off as somehow being adequate? For some providers that is as close as they will get to performing an actual or simulated intubation. No wonder our skills are declining.

Most of us as providers recognize that the training we receive at times is more of an exercise to satisfy some administrative requirement than a true attempt to impart a meaningful and beneficial education experience. We take it upon ourselves, for our patient’s sake, to obtain and maintain the required skills and knowledge that will benefit them. I take my EMS training seriously; I do not rely on my organization to provide all the education I need to do my job and stay on top of my profession.

As an instructor and education coordinator I know how challenging it can be to find good quality training offerings, especially for large organizations. The ease and consistency of on-line programs is tempting, however the training must match the needs of the providers, especially when QI programs indicate a need for specific training such as intubation. It may be necessary to collect the necessary training equipment, find the space, and schedule hands-on training for your staff. If you know that a problem exist and you fail to effectively mitigate it you are culpable for the failure of the system and the provider when things go wrong. My advice: don’t wait till then.

For those general refresher topics, and routine procedural reviews web-based training is an excellent choice. You still need to do your homework and make sure the program you select is relevant for your service, mirrors your protocols, and is not prone to errors and omissions. Don’t assume that the flashy training website has reviewed the material for accuracy and consistency, that’s your job. Providing online training that is confusing, irrelevant or incorrect will only make things worse and sour your staff’s attitude towards it in the future.

EMS and EMS training are both changing rapidly, not all change is good so we still need to do our homework whether we are the trainer or the trainee. Always remember that your skills can and will make a big difference in the outcomes of your patients. Staying on top of developments in the practice of EMS as a profession and of training opportunities available for your staff will always be a challenge, but that’s why you got into this business in the first place, right?

Be safe, do good work