Wednesday, July 25, 2018

EMS Logistical Support Unit Program


Proposal:
EMS Logistical Support Unit Program- EMS-LSU
Alan Perry
7/25/2018

Overview
In high performance EMS systems, unit delays at receiving facilities and down-time for equipment failure and provider rehab have serious implications for system response capability. The goal of an EMS-LSU program is to provide a resource that does not compete with operational assets, people or equipment, which supports operational units during their recovery phase, returning both equipment and personnel to a state of readiness in a timely manner. This will reduce stresses on the system and providers when call volumes peak and improve the overall resilience of the VBEMS system.

Background
Support units are nothing new, they have been used in the fire service for decades and larger metropolitan EMS systems use them as well. The City of Virginia Beach EMS system has staffed support units in the past, but never specifically for ambulance logistical support. EMS supervisors attempt to partially fill this role when able, and the MCI capability serves a specific role for large scale localized incidents. The EMS-LSU program seeks to fill this gap in operational support.

Purpose
The EMS-LSU will serve as a resource specifically for ambulances, and their crews, assisting with routine cleaning, maintenance and minor repairs to units while in quarters and reaching into the field to assist with turn-around at hospitals at times of high call demand. It will have the capability to take care of routine cleaning, decontamination, resupply, battery and oxygen exchange, simple vehicle maintenance, vehicle livery and crew rehab.

Functions of EMS LSU
  • ·         Inventory, check-off and clean reserve units.
  • ·         Assist with inventory, check-off and cleaning of staffed units.
  • ·         Minor maintenance and repair of all units (fluids, bulbs, wiper blades,            tire pressures).
  • ·         Periodic detailing of units.
  • ·         Station upkeep.
  • ·         Responding to hospitals non-emergency when multiple units are                   transporting to facilitate unit recycling and crew rehab.
  • ·         Performing targeted public safety training, home safety inspections,              school demonstrations.

Staffing
The EMS-LSU will be staffed by administrative members and providers who are on light duty. In this role these members may more fully participate in EMS operations without being involved in patient care. A brief training program will be provided covering the equipment and supplies carried on the ambulances, the specific maintenance requirements and procedures for our units and OSHA blood-born pathogen training.

Equipment
The EMS-LSU can be any vehicle capable of carrying the required personnel, equipment and supplies. A decommissioned ambulance seems like a logical choice.

Cleaning equipment
·         Shop vac, brooms, mops/bucket w/wringer, rags and brushes
·         Water tank w/pump
·         Pressure washer
·         Cleaning/detailing chemicals
Vehicle Supplies
·         Vehicle oil, ATF, def fluid, washer fluid, brake fluid
·         Bulbs for interior and exterior
·         Wiper blades
·         Battery jump box
·         Basic hand tools
·         Air compressor, hose reel, tire chucks and gauges
EMS supplies
·         Soft goods. PPE, Tyvek
·         Oxygen tanks, oxygen delivery devices, CPAP, BVM etc.
·         Life-pack 15 supplies including spare cables & cuffs
·         Charger & Batteries for LP-15, radios, Lucas, power stretcher
·         Backboards and straps, stretcher straps
Rehab Supplies
·         Refrigerated cooler or ice chest for drinks and water
·         Single serve snacks
·         OTC self-care packs
·         Loaner rain gear, traffic vests
Public Education, recruitment
·         Display materials
·         Home safety/pool safety/ bicycle/ firearm safety handouts

Benefits
An EMS-LSU program will have multiple advantages
·         Improve system performance by reducing readiness and turn-around times
·         Reduced stress on operational members, improving job satisfaction & retention
·         More immersive experience for administrative members
·         Recruitment and retention tool

Conclusion:
An EMS-LSU program is easily achievable and beneficial to the VBEMS system. This program has multiple tangible benefits and will improve both performance and morale. The program can serve as a recruitment and retention tool providing a gateway between administrative and operational positions. If successfully deployed it will serve as an easily reproducible program for use elsewhere within the VBEMS system.

Saturday, July 21, 2018

MIH Implementation guide for Virginia


A proposal:

Implementation Guide for Mobile Integrated Healthcare 
and Community Paramedics in Virginia


Prepared by:
Alan Perry
7/21/2018




Introduction & history

Mobile Integrated healthcare (MIH) and Community Paramedicine (CP) have been around for a long time. They were first conceived to serve rural populations with limited healthcare resources. With the introduction of the Affordable Care Act (ACA) the healthcare system in the United States was transformed by the new emphasis on patient experience, outcomes and reduce costs. The ACA promoted the development of Accountable Care Organizations (ACO’s) which consisted of collaborations across the healthcare system to achieve the results required and the financial incentives. Simultaneously Emergency Medical Service (EMS) systems have experienced explosive growth in call volumes and a general decline in call acuity due to the shift of Primary Care Providers (PCP’s) away from private practice to Emergency Rooms (ER’s) and freestanding clinics in response to increased insurance and operating costs. The gap left in the healthcare system fell largely on EMS which now routinely fields calls for minor ailments and exacerbations of disease processes that would have been handled by the PCP. The situation EMS systems now find themselves in is complicated, and once again we will adapt and bring our resources to bear to address the health of the community in this new environment.

The goal of any MIH or CP program must be in line with the Institute for Healthcare Innovation’s (IHI) triple aim of improving outcomes, reducing costs and improving the healthcare experience for the community it serves. With these general principals the system will work collaboratively with the stakeholders to do what it can to achieve those goals. Patients are the highest priority in any program, you must always do what is best for them through intervention, education, navigation and collaboration with other resources. We have reached a point in the evolution of healthcare that we realize our patients need solutions, not just a ride to the ER. Providers are the backbone of EMS, they are intelligent and capable individuals, that understand the system they currently work in is broken. Empowering these individuals to identify and help connect their patient to resources that will solve their problems long-term, will give them ownership, pride, and an opportunity for professional growth. The EMS system can be directly involved in improving the quality of life and overall health of the entire community while providing services that produce meaningful positive long-term outcomes. By connecting the community with more appropriate resources the system will be less stressed and better able to meet day-to-day demand with its current resources and improve recruitment and retention rates.

The responsibility for developing these  programs in Virginia is defined in the Code of Virginia 32.1-111.3 as the Board of Health, however neither the Board or the State Legislature have taken any action to address this need.  This code also specifies that EMS will transport to Hospitals and "emergency care facilities", seemingly limiting the ability of an EMS system to offer alternative destinations.The development of new programs such as MIH and CP are broadly covered in the The Virginia Office of EMS (VAOEMS) Strategic Plan 2017-2019, in section 4.3.4. but no guidance is provided. The VAOEMS recommends that systems wishing to pursue MIH and CP programs submit an application for a Home Healthcare Licence describing the services to be offered to determine if a Home Healthcare License will be required. 

Where to start

There is no one MIH or CP program that will work for every community, there is too much diversity in our region to come up with a “one size fits all” program. You must make a list of other stakeholders involved in the healthcare of the community including Hospital Systems, Public Health, Public Safety, Mental Health, Social Services, Home Healthcare, Transport Services, Physicians, Insurers, and anyone else with a vested interest in your activity. This step is vital to achieving cooperation and participation in the process. Your success may be limited or even thwarted if you fail to do this. Look at your data, assure that it is valid, and if so, what can it tell you about care gaps and opportunities for your organization, improved public health and costs reduction. A logical approach would be to schedule individual meetings, or small groups, to iron out the general parameters and goals of the program. Bring them together and take an inventory of your regional system assets, and what challenges you may be facing that a MIH or CP program might be able to address.

Discussion with stakeholders

The process of identifying and gaining support among the stakeholders in a MIH or CP program will take some time, perhaps more than a year depending on the level of interest and marketing of the general idea. Your internal stakeholders; City Manager, OMD, EMS Chief, City attorney, Providers, will be the easiest to draw in. The external stakeholders; Hospitals, Physician groups, Home health agencies, Transport, Public health, Social Services, Shelters, and assisted living facilities will be more difficult. You will need to develop contacts within each group that are willing to participate and have authority to make decisions for their respective organizations. You will want to create a limited number of concise talking points to help keep the message consistent and on point. Meeting in smaller like-minded groups will produce more discussion eventually evolving into a core council or board that will remain in an advisory role once your program is up and running. Keep your contact list current and communicate often enough to maintain interest and awareness.

Defining the scope and goals of the program

After sifting through the potential projects, you will need to decide which ones to pursue based on a simple formula categorizing and scoring each one based on value and your ability to successfully accomplish the goal. This should produce an outcome that differentiates between the can-do verses should do, and is preferential to bridging care gaps verses filling gaps with new services. This is a decision you will need to make with your internal stakeholders since they will all be responsible for supporting the decisions and sharing in the consequences. Share your plan with the full stakeholder group for by-in and minor tweaks prior to implementation. Based on what is known about this region an obtainable and realistic program would likely be healthcare navigation accessed by referrals from providers and external stakeholders. It will be simple, of limited scope and demonstrated on a small control group before implemented system wide.

Organization Preparation

Any new program will require thoughtful development of policy and protocols to standardize and define the parameters of the program. These will describe in detail the selection, training and expectations of providers, which patients will be eligible for the program, how they will be enrolled and graduate from the program,what data points will be collected before, during and after graduation from the program, and how the program will be marketed to participants, providers and stakeholders. The training division will develop a training program, and perhaps internships with stakeholders, to educate providers in healthcare system navigation, documentation and patient coaching techniques. A coordinated public education program that integrates program offerings and goals into existing education and marketing efforts will help stimulate interest in MIH programs and bolster the organization's perceived value to the community. 

Program Development

The scope of the program may include clinical services, transportation alternatives and healthcare navigation. It may be a single service or combination of services once fully developed. In the beginning you will want to keep a narrow focus and only consider expansion when you are capable and there is proven benefit. The easiest service to provide is healthcare navigation, it will only require that your provider be able to identify what resources will benefit the patient and facilitate the connection to that resource. An important concept here is that providers should have and expanded role in community healthcare verses and an expanded scope of practice. As the program matures it could take on transportation to alternative destinations such as behavioral health clinics, substance abuse centers, or merely arrange transportation to clinics and urgent care centers. In maturity, and after building on successful collaborations with other stakeholders, services may include community paramedic interaction and intervention with patients suffering from chronic conditions such as CHF or Diabetes to prevent unnecessary re-admissions.

Program launch

After you have developed your program, have all the requisite support systems in place, and have the support of your stakeholders, you can launch your program. Keep it small, limited in scope, and document every detail. Adjustments will be required, with every obstacle encountered you must communicate with the team, work out a resolution, and ultimately do what is best for the patient. Share the experience with all your stakeholders so everyone will be satisfied with the transparency and level of communication in your process. In this way you will create trust and build upon each experience to develop a program everyone is happy with and which meets the goal of improved patient satisfaction, reduced cost and better outcomes.
           

Quality Improvement (QI) & Quality assurance (QA)

With the transition to an outcome-based healthcare system QA & QI programs have never been more important. The fact that a MIH/CP program is something completely new to this region will make accurate collection of data and patient outcomes that much more important. If your data is not solid now, it probably won’t be when your program get up and running, and/or you will have based your program design on data that is flawed. This would be a great time to look at the consistency and quality of the data your system is generating now. Good data will be critical to identifying what your community needs are now and in the future. Once your program is in place that data will be used as a benchmark for your programs impact on community health. Data will also guide your decision to expand the program or create new alternatives.

Cost recovery

A successful program will generate savings for your stakeholders, operational benefits for your organization, greater job satisfaction for your providers, and improve the general health of your community. Insurers, Medicare & Medicaid are beginning to recognize and pay for the types of services described here. You may be able to get start-up funding from your stake-holders if your plan is sound. Every dollar recovered can help fund equipment, supplies, training, support services, and resources for your community. Its money the community has already paid-in through taxes and insurance premiums which they have every right to permit the system to recover. Cost recovery has been advocated for across the country in both career and volunteer systems for these very reasons. The act of not using cost recovery is, in effect, throwing away the community’s taxes and insurance premiums and giving them back to insurance companies and the government at the expense of the local EMS system. It takes a certain amount of fortitude to confront and educate the public, but the logic of the argument is sound and must be made unless you have a plan to fund your system as an essential public service like Police & Fire strictly through local taxes.

Conclusion

This evolution of EMS will bring it into the broader healthcare system, improve the quality of life within the community, reduce the cost of healthcare within the community, and improve patient outcomes while bringing EMS providers to a place where they will have greater influence and ownership in the healthcare system. Mobile Integrated Healthcare and Community Paramedicine are here to stay, we can take the necessary steps to implement a model for that in Virginia, or we can wait for it to be pushed on us without our input. You choose.



Why would I Leave?


Why would I leave?

Providing a climate for provider satisfaction and community pride

By Alan Perry
July 21, 2018


Whether you are managing a volunteer, career, or combination workforce, you must recognize that your human assets are the life and future of your organization. It is easy to be distracted by your daily operations, organization goals, projects, politics and public relations and forget the needs of the front-line providers. The expectations you have of them may be reasonable, but what are their expectations of you?

Stressors, the hidden cost

Public safety is a difficult industry to work in, not everyone is cut out for it. Some cave under the stress of the public interaction, for others it is the structure of the job itself, long hours and difficult schedules. A lack of adequate physical resources, good equipment and working infrastructure, inadequate educational and emotional support, little sense of ownership, poor communication and ineffective processes, are all negative forces. Reducing or eliminating these additional, not-inherent stressors for your people can help provide you with a more engaged and effective workforce that has high job satisfaction which the public can see and feel.

Benefit v. Costs

If you are tasked with the responsibilities of workforce morale, productivity, or recruitment and retention, start making a list of these stressors so you can systematically begin the process of reducing or eliminating them. For most people it’s not just about the reward they find in a job, and for any reward there will be a cost point at which it will no longer be attractive or beneficial. Losing people that you have invested time and treasure into because the costs of these non-inherent stressors is too high and should be unacceptable.

Mitigating non-inherent stressors

Communication- When things go wrong this is frequently the culprit, the reciprocal is also true, effective, timely and appropriate information keeps everyone on the same page, reduces rumors, incorrect conclusions and reduces stress while improving performance and agility for the organization.

Scheduling- Schedules are necessary, when system utilization increases however, shifts exceeding 8 hours can produce greater stress among providers with increased errors, poor customer service and accidents being the symptoms of the stress they experience. Even shorter shifts between 4-8 hours and strategic power shifts, can give your providers, especially volunteers, more opportunities to participate on terms that are less stressful, yet still meet the needs of the system.

Work environment- Going to work should never be something you are fearful, apprehensive or resentful of. Does your organization welcome and nurture its own? Or do you eat them? Does your inner circle represent your membership? The community? Are fairness and ethics part of your regular discussion? Are planning and decision-making processes open and inclusive? It is a challenge to gauge the health of the organizations climate from within, I am certain a new member will be able to give you an objective size-up. You should also have some sort of exit interview or survey to determine honestly why someone is leaving and what, if anything, the organizations climate had to do with it. Do you have a process to get rid of dead wood, laggards and mean people? Failing to confront personnel issues can create a hostile environment for everyone.

Training- Failing to train is training to fail. Aside from initial certification training, your organization should support re-certification and organization specific training that is genuinely useful and appropriate for your providers. Simply going through the motions and having providers sit in a chair for the required hours serves no purpose and has no benefit to the provider or the organization. Wasting time, or the appearance thereof, creates stress and shows contempt for other’s time. Provide a career development program for operational, administrative and logistical functions so everyone has an opportunity to expand their abilities. Consider adding "skills drills" and other hands-on experiences for providers to practice perishable skills in a non-punitive, competitive environment.

Physical Resources- The quality of the work environment, the physical facility, its condition and amenities, help convey the members value to the organization. It should be pleasant and accommodating, with enough room for resting, working and taking care of the necessities of life. It also includes infrastructure, computer/communication equipment in sufficient quantity and quality for all scheduled personnel to accomplish required and routine communications, and documentation tasks. Your providers spend a significant portion of their shifts in your apparatus, it must be safe, reliable, comfortable and properly and consistently equipped. Persistent equipment and/or vehicle problems are great stressors and potentially affect the reliability of the organization.

Logistical Support- It’s not just EMS supplies and toilet paper, it should be an accessible, dependable system. The system should work seamlessly in the background keeping primary and reserve units clean, stocked and serviced to minimize unit and crew down-time due to lack of readiness. In busy systems this may require a team approach to maintain consistency and continuity across multiple shifts/stations. You may even consider staffing a logistical support unit to assist your crews in returning to service at the hospitals when the poo hits the fan.

Adding value for the organization and community

Administrative functions- Not everyone in your community may be ready to jump into a public safety role, giving these souls an outlet to explore the profession, serve the community and get comfortable with its role, and their capabilities, will enhance the organizations relationship with the public it serves and get some key functional roles filled. It will also serve as a conduit for bringing in new operational members. To be clear, I’m not just talking about desk jobs or bake sales, your organization can benefit by placing them in logistical roles, facility & equipment maintenance, housekeeping, marketing, recruitment and retention.

Public education- Does your organization take an active role in public education, school demonstrations, home safety inspections or CPR/Stop-the bleed programs? These are all excellent opportunities to improve your community ties and recruit new members. Partnering with a local Scout organization, school club or religious group can produce similar benefits. In many cases you can partner with other like-minded groups and use this as part of your marketing program as well. Develop speaking points so that anyone from your organization speaking at an event can deliver a consistent and useful  message. The more the public knows about you and the organization the better they will be prepared to react in an emergency. 

Bottom line

Keep your workforce happy by providing the best resources you can for them, and provide the best asset possible for your community as both a service and a source of community pride. You may need to take a fresh approach by looking at everything you do to determine what value it provides and how it helps you achieve your mission. If you don’t already, start using data to identify what the needs of the community and the organization are and take meaning steps to address them and document your progress. Not every idea will be a good one, but working with outdated management styles and artificial barriers to progress is a sure recipe for disaster.       

Be Safe,
Alan