Best Practices in
Emergency Medical Services
Presented By:
Jonathan D. Washko, BS-EMSA, NREMT-P, EMD
Director – REMSA
AVP for CEMS Operations – North Shore/Long Island Jewish Health System
President – Washko & Associates, LLC
Best Practices in EMS Overview
What is a best practice
Why EMS needs best practices
The theory of EMS Darwinism
The economy and best practices
Best practices dissected & discussed
Not so best practices
Wrap up / Q&A
REMSA’s Military Support
• REMSA was a 2008 Recipient of the
Freedom Award
• Recently had 5 Medics on active duty
in Afghanistan
• Supported our troops in various ways
– Keep REMSA Salary whole while on
Active Duty
– Provide 100% Benefits coverage while
on Active Duty Including Family
– Send along laptops, software & other
needed items
– Send monthly care packages to our
What is a “Best Practice”
Wikipedia defines it as…
A Best Practice is the belief that there is a
technique, method, process, activity, incentive or
reward that is more effective at delivering a
particular outcome than any other technique,
method, process, etc. The idea is that with
proper processes, checks, and testing, a desired
outcome can be delivered with fewer problems
and unforeseen complications. Best practices can
also be defined as the most efficient (least
amount of effort) and effective (best results) way
of accomplishing a task, based on repeatable
procedures that have proven themselves over
time for large numbers of people.
Why EMS Needs “Best Practices”
• The Theory of EMS Darwinism
• Service delivery model variations / inconsistencies
• Lack of commonly accepted operational standards (like
NFPA for Fire Service)
• Mix of public / private / government ownership
• Mix of for profit / non-profit models
• Lack of standardized advanced managerial education
• Industry has attempted to bridge educational gap with
limited success
• Success lies in sharing clinical & billing best practices but
not operational ones
Why Best Practices?
“As EMS providers, we invite the public to literally trust us with their lives. We advise
the public that, during a medical emergency, they should rely upon our organization,
and not any other. We even suggest that it is safer to count on us, than the resources
of one’s own family and friends. We had better be right.
Regardless of actual performance, EMS organizations do not differ significantly in
their claimed goals and values. Public and private, nearly all claim dedication to
patient care. Efficient or not, most claim an intent to give the community its money’s
worth. And whether the money comes from user fees or local tax sources, the claim
is the same—the best patient care for the dollars available. It’s almost never true.
Our moral obligation to pursue clinical and response time improvement is widely
accepted. But our related obligation to pursue economic efficiency is poorly
understood. Many believe these are separate issues. They are not. Economic
efficiency is nothing more than the ability to convert dollars into service. If we could
do better with the dollars we have available, but we don’t, the responsibility must be
ours. In EMS, that responsibility is enormous—it is impossible to waste dollars
without also wasting lives.”
Jack L. Stout
The Theory of EMS Darwinism
• Darwinism / Evolutionary
– Isolated environments produce
similar species that evolve in
different ways from each other
– Evolutionary adaptation to the
environment occurs to ensure
survival of the species
– EMS has “evolved” under these
The Theory of EMS Darwinism
• EMS agencies are isolated from each other due to proprietary
barriers created by varying system designs, ownership models
and funding sources
• Gives credence to the phrase “If you’ve seen one EMS system,
you’ve seen one EMS system”
• However, they are still of the same species…
• Common operational denominators exist for every EMS system
which provide the foundation for “Best Practices”
• Acceptance of these “Best Practices” depends on your system
design, necessity for change, culture and other factors
The Theory of EMS Darwinism
My industry “Best Practice”
experience has been…
Necessity may be the mother
invention however…
…it also drives acceptance of the
previously unacceptable
Current / Future Economic and
Demographic Conditions
• If there ever has been a time where necessity will drive
innovation, acceptance of the unacceptable and the
merging of separately evolved species into one, it is now!
• Shrinking public funding mechanisms, uncertain
healthcare dollars and rising unemployment in the face of
a large aging boomer generation will force industry
innovation and change
• Funding / service level / employment compensation
tradeoff’s or service delivery model design changes…you
decide (as may the current presidential administration)
Best Practices in EMS - Disclaimer
• Best practices mentioned in this presentation are
based on my personal exposure / experience with
numerous EMS systems across the US, Canada
and other European nations
• I know many other best practices beyond those
mentioned in the presentation exist, I have just
not had the privilege of seeing or learning about
all of them as of yet
• If you know of a best practice and would like to
share it please feel free to do so anytime during
the presentation
Best Practices in EMS
Deployment Science
Supply / Logistics
Fleet maintenance
Human resources
Training / education
Quality Improvement
Billing / Finance
Technology Trends
EMS System Designs
EMS Response to Pandemic
Deployment Science
Best Practices in EMS
Best Practices in EMS
Deployment Science
• Setting service reliability standards and then meeting
them for emergency and non-emergency service
– e.g. Life threatening emergencies responded to within 8
minutes 90% of the time
• Measure response times ACCURATELY (no smoke and
– Fractile measurement approach not average
– Call received in 9-1-1 center to on scene
Best Practices in EMS
Deployment Science
• Using deployment methodologies that match supply and demand
both temporally and geospatially
– Production Model EMS / SSM / Peak Load Staffing
– Station/post move-ups based on demand not geography
• Realize that deployment methodology and response time service
reliability are just as important as the medicine we provide
– Life-saving treatment is worthless if it is not provided in time
– Deployment methodology drives labor costs up or down which
has a direct effect on the quality of medicine we can afford to
provide given the current reimbursement mechanisms
Best Practices in EMS
Deployment Science
• Technological edge
– Live decision support tools for making resource deployment
decisions in real-time
• CAD vendor specific features
– Balanced matching of service demand needs with human needs
• Zoll Resource Planner
– In-vehicle smart routing systems that use live or historical road
network data to adjust routes and candidate rankings
Ambulance Operations
Best Practices in EMS
Best Practices in EMS - Operations
• Vehicle design conducive to long-term, in
ambulance shifts
– DVD / entertainment systems
– Larger front cabs to allow for reclining in front of unit
• Field supervisors capable of on-site / on demand
lost unit hour mitigation
– Solve a variety of issues that would take an ambulance
out of service or cause service inefficiency
– Resupply of medical supplies, fixing of vehicle
problems, availability of backup equipment, bariatric
stretcher delivery
Best Practices in EMS - Operations
• Managerial Front
– Recognition of “generational differences” and how to
overcome them
– Moving away from performance based compensation
– Recognition that physical separation of employees
from management leads to unions and/or poor
employee / employer communications
– Recognition that the best clinicians don’t necessarily
make the best organizational leaders
Best Practices in EMS - Operations
• Managerial Front Continued…
– Recognition that our leaders and managers need
training in leading and managing people not just
systems and processes
– You don’t have had to grow up in it to lead it and
manage it (especially if these things come naturally)
– Recognize the importance of balancing internal
promotional opportunities and the need for outside
talent to stay fresh
Best Practices in EMS - Operations
• Recognition that 24 hour shifts in busy urban EMS systems are
not conducive for safety or quality patient care
– Appropriate for suburban / rural areas with high difficulty
of coverage indexes or proper economics
• Recognition that EMS is a 24x7 business and should be
managed as such
– Lessons from other public safety disciplines
• FD / PD management systems
• Integration of ICS into daily routines to improve EMS
– FD is using this against many private EMS services
Best Practices in EMS - Operations
• Technological Edge
– Online scheduling systems
• Allow for online management of schedule, shift trades, PTO, OT
pickup, etc.
• Integration into CAD or other decision support tools
• Zoll Crew Scheduler, eCore, ADP, Telestaff, eSchedule, Others
– Employee communications
• Twitter / Facebook VERY effective tool if managed and
administrated properly (push based messaging vs pull)
• Many ePCR / eScheduling / time and attendance systems allow for
broadcast and individual messaging
• Email systems may or may not be effective
• Reader boards with “Flash & Pizzazz”
• Office Live / SharePoint Server
Best Practices in EMS - Operations
• Affordable and simple situational awareness &
interoperability systems
– CAD companies solutions often lack or lag
– New industry popping up to solve these issues
Best Practices in EMS - Operations
• Recognition of the fact that our patients care about:
Customer Service
Look & Feel (Professionalism)
Ambulance (Ride, Cleanliness, Organization)
Quality Patient Care (Assumed)
• Measurement & benchmarking of these quality
markers (if you can’t measure it you can’t manage it)
– MHR’s EMS Survey Team (Operational outcomes QI)
– Traditional Clinical QI
Best Practices in EMS - Operations
• Demand Management Systems
– Community / advanced paramedic programs
• Help to mitigate system abusers that fall through the
social safety net
• Provide recidivism protection for certain patient
demographics for hospital readmissions (CHF example)
• Specialized services (Echo, SCT, SWAT, Haz-Mat)
– 911 call centers match right patient to right
resource type at the right time and right cost
• Medical necessity screening system for 9-1-1
Supply & Logistics
Best Practices in EMS
Best Practices in EMS - Supply & Logistics
• Centralized deployment facilities / hubs
• EMS providers not responsible for checking supply
levels, washing vehicles or maintaining vehicles
• Fleet-wide standardization of ambulance design
• Assembly line style standardized resupply systems
“speed loaders”
Streamlined restocking processes
Improves supply reliability
Improves resupply efficiency
Eliminates waste
“Lean Manufacturing”
Service Points Workflow
“Once Around The Ambulance”
Best Practices in EMS - Supply & Logistics
• Technological Edge
– Just in time ordering systems that minimize the need
for warehousing of vast amounts of supplies
– Online inventory, asset tracking and ordering systems
provided by vendors
• AmbuTrak
– Bar coding / RF ID systems
– Electronic check-in/out equipment accountability
Fleet Practices
Best Practices in EMS
Best Practices in EMS - Fleet Practices
• Preventative maintenance (PM) programs that
mimic the airline industry
• “Green” initiatives including solar charging
systems, bio-fuels, lighter/smaller vehicles,
etc. (carbon fiber boxes coming soon)
• Bridging the Ford 6.0 liter issues
– Refurbishing 7.3 liter chassis
– Class action law suit
– Gas / diesel
Best Practices in EMS - Fleet Practices
• Technological Edge
– Onboard “black box” driving computers that provide Gforce feedback and record/transmit data wirelessly
• Road Safety
– Cameras that capture significant events
• DriveCam, EnVision Cam
– Wireless in-vehicle routers that provide internet access via
the cellular data networks
• InMotion / Sierra Wireless
– Convergence technologies (combine all of the above - plus)
• GPSLogic
– Fleet maintenance tracking software that allows for part
failure analysis that is integrated into the PM system
Best Practices in EMS – Fleet Practices
• Safety
– Vehicle safety initiatives
• Concept Vehicles
– AMR, LifeEMS, SJC Side Load
– Stretcher improvements
• Improved patient loading systems
– Bariatric management systems
– NFPA 1917 vs KKK ???
Human Resources
Best Practices in EMS
Best Practices in EMS - HR Management
• Proactive headcount management practices
– Measurement of certain KPIs
• FTE weighting (FT, PT, PRN)
• PTO usage
• Turnover management (anticipate loss)
• Streamlined policies & procedures directly linked with
accreditation standards (C.A.A.S. / C.A.M.T.S. / A.C.E.)
• Academy style orientation programs for new hire
• Internal EMS education for EMT & Paramedic certifications
with working scholarships
– Paid PD/FD style educational academy
• Policies on social networking impacts on the workplace
Best Practices in EMS - HR Management
• Technological Edge
– Online employee tools for benefit management
and administration
– Online policies and procedures access
– Paperless employee files with secure access
available to management 24x7
– Streamlined business systems that talk to each
• HR Systems <-> eScheduling <-> Pay Roll <-> CAD <->
ePCR <-> eCertification Systems
Best Practices in EMS – HR Management
• Candidate selection
– Personality and intelligence screens that match
job functions
• Criticall
Training / Education
Best Practices in EMS
Best Practices in EMS - Training / Education
• Online systems for off-site training & Certification
– Web based meetings / presentation systems
• WebEx, GoToMeeting, NEFSIS, etc.
– On demand content provision (proprietary or purchased)
– Online testing / certification systems
– Industry specific applications (Centrelearn, Ninth Brain)
• Simulation Labs
– Sophisticated simulators / manikins
– Lab designed just for simulation training scenarios
• Real-time on-duty scenario training / testing
Best Practices in EMS - Training / Education
• Using training and education programs to supplement your
system’s revenue and offset training overhead costs
AHA training
Private industry training
Ancillary healthcare services training
Government / military
• Portable training programs with portable simulation labs
– Increase training reach to remote markets
– Open up new opportunities
– Rural services
• Accreditation of training programs and centers
• Affiliations with higher educational institutions
• In-house Paramedic training programs
Quality Improvement
Best Practices in EMS
Best Practices In EMS - Quality Improvement
• Using ePCR systems to improve QI efficiency,
effectiveness and portability
• Using advanced automated QI systems that enable
100% auditing of charts against clinical
documentation and protocol standards
• Adopting QI workflows that improve employee
communication, feedback loops and remediation for
improved behavior modification
Best Practices in EMS – Quality Improvement
• Recognition that CLINICAL QI and BILLING QI
go hand in hand and should be closely tied
– Break barriers between Billing and Ops/QI
• Peer review programs more viable with ePCR
• Using data to drive decision making on clinical
upgrades, downgrades and changes
• Using clinical data in assessing operational
Billing / Finance
Best Practices in EMS
Best Practices in EMS - Billing / Finance
• Paperless ePCR systems making A/R a much more
efficient and effective process
• Granular financial statements that group each service
line and operation individually for improved decision
making abilities
• A/R tracking by customer with monthly financial trigger
processes to identify payer/patient problems
• Invisible Bracelet technology emerging that
supplements the old Medical ID Bracelet with
demographic information (Meds, Allergies, Contacts,
Insurance information)
Best Practices in EMS - Billing / Finance
• Lean business processes that measure
productivity and performance
• Internal Federal Compliance auditing by an
independent agency / auditor
• Quality based reimbursement initiatives at the
Federal level
• Online payment and account management
• Electronic insurance clearing houses will limit the
need for skip-tracing efforts (but at a cost)
Best Practices in EMS
Best Practices in EMS - Communications
• “Situational awareness” / “decision support”
• EMD System
– Call classification for resource triage (priority based
dispatching processes)
– Pre-arrival instructions
– Demand management systems
– Pandemic / CBRN screening system
• Live data surveillance systems
Syndromic / bio-terrorism
Sentinel event
Best Practices in EMS - Communications
• CAD systems
– AVL / GPS integrated
– Dynamic road network speed algorithms for routing
and candidate ranking
– Real-time demand surveillance
– Real-time deployment decision support systems
– Live off-site redundancy & backup systems
• Phone / Radio systems
– Phase II wireless compliance
– IP based communications systems (NG911)
– Digital IP based radio systems
Best Practices in EMS - Communications
• Non-emergency trip optimization decision
support systems are coming soon
– System that analyzes the mathematics associated
with the performing and scheduling NET trips
• Requested / Promised Pickup Time
• Call segment weights (on-scene time, drop-off time)
• Route travel times (travel – transport)
– Provides predictive availability of system resources
for improved throughput (more with less) and
accurate scheduling of calls for patients
Technology Trends
Best Practices in EMS
Best Practices in EMS – Technology Trends
• Traditional EMS centric software business models are
set to fail us as an industry (and already have)
– Once market penetration hits, maintenance fees can’t
sustain the infrastructure therefore these companies are
forced to diversify to survive and customer service /
enhancement cycles don’t meet our expectations or needs
– Compare and contrast any SAAS based business model
against this traditional one
ePCR / eScheduling / eHR / ePayroll / eBilling vs ANY CAD System
Emergence of “CAD can’t so we will” companies
Ability to meet our needs (new functions and features)
Customer service
Best Practices in EMS – Technology Trends
• Software as a service (SAAS) will soon dominate
most (if not all) of our technologies
– Cloud based computing & data storage
– Billing / CAD / Payroll systems are HERE or coming!
– Highly cost effective due to economies of scale
these systems bring without the need for
infrastructure or on-site support
– High reliability due to “groups” ability to buy into
technology they could never afford on their own
Best Practices in EMS – Technology Trends
• EMS Industry has been fickle in accepting SAAS
– Customer ROI, cost effectiveness or “Flash and
Pizzazz” appears to drive adaptation
– Senior leadership whom don’t trust the technology or
think they have to have it local to maintain control
– Reliability / Redundancy issues (internet)
– Private industry quicker to adopt then government
(jobs at stake)
– K.I.S.S. principle typically used may keep some away
• E.g. The use of OTC GPS units
EMS System Design
Best Practices in EMS
Best Practices in EMS - EMS System Designs
• System designs must comprehend EMS economics to
– Not effected by typical elasticity of supply & demand
• Population size, age, socio-economics & other demographics
– Pricing / quantity does not drive increases or decreases in
overall service area demands (volume)
• May shift it from one provider to another however
– Free market competition drives up costs / prices down /
drives down quality / forces stupid loss leader ideologies in
order to gain market share
– System fragmentation decreases economies of scale,
significantly increases costs of operations and typically
provides for poor patient care (response times)
Best Practices in EMS - EMS System Designs
• No EMS system design is “perfect”
• “Successful” ones include the following
– Limited or zero local tax subsidy
– Service accountability through performance
guarantees and standards
– Ability to replace the provider for performance
Best Practices in EMS - EMS System Designs
• “Successful” ones include the following features:
– Closed market with sole source provider performing
emergency and non-emergency services (most
economically efficient model)
– Rates and performance controlled through publically
accountable external entities (not internal)
• Ham & Eggs breakfast analogy
– (Chicken has a stake but the pig is committed)
– Balance patient care, employee wellbeing and financial
Best Practices in EMS - EMS System Designs
• Recognition that the deployment model used within an
EMS system has a direct correlation on system costs
and patient care effectiveness and outcomes
– Demand driven systems provide considerably better
service reliability to a much larger patient population
– Fixed geographic based systems provide good service to
the first patient, but not necessarily the second, third and
so on (work well for areas with low second call probability)
– History, economics, unions and politics are typical
determiners of EMS system design type until the EMS
system kills the wrong person or costs too much money
Best Practices in EMS - EMS System Designs
• Recognition that we may not make as large of an
impact as we once thought
– So busy proving that we could no one ever stopped to ask
the questions if we should (until recently)
– ALS may not be as important as once thought
– True clinically significant response times
– Understanding Risk/Cost/Benefit (Read Freakonomics)
• Low risk/ROI probabilities coupled with “scary” public perception
situations drives irrational responses / behaviors
– Pediatric Drowning vs. Gun Ownership & Child Shootings
• Foundation that IAFF/IAFC is using to sway public opinion and
Pandemic Response
Best Practices in EMS
Best Practices in EMS - Pandemic Response
• EARLY screening / surveillance during the 9-1-1 call
– NAED SRI Screening / Card 36 Pandemic Flu
• Based on findings, first responders (FD/PD) and EMS
personnel “suit up” PRIOR to entry / patient contact
– Protect your assets (lessons learned from SARS)
– Reverse isolation of patient
• Protocols / processes for system overload, denial of
service or altered response configurations
– 6-1-1 Information lines / 9-1-1 call center demand shifting
– Public & public safety information systems imperative
Best Practices in EMS - Pandemic Response
• Consider supply needs PRIOR to the incident
– Isolation supply caches
– Cleaning / decontamination supply caches
– Enough for everyone (FD/PD/EMS/Family)?
• ICS system / Command & Control may rest with
the Health Department
– Poor experience with ICS / EMS / Public Safety
– Public health focus on the epidemiology / medicine /
– Communication channels may be limited or nonexistent
Best Practices in EMS - Pandemic Response
• Consider personnel needs (different then disaster)
– Shelter in place requirements / isolation impact
– Logistical needs of your personnel
• Consider other infrastructure support needs
– All items needed to provide service
– AMFYOYO – remember this will be large scale, wide spread
and concurrent events nation / world wide
• Communicate / Communicate / Communicate
The public
Employees & their families
Public safety agencies
Health Department / CDC / WHO
Worst Practices in EMS
Worst Practices in EMS
• Lack of Standardization (we need an NFPA for EMS!)
– Standardization of operational, clinical & financial
– Standardization of technology
• EKG Data (move away from proprietary
– Standardization of clinical data (on our way)
• Limited common industry voice in Washington on
issues other then reimbursement
Worst Practices in EMS
• Funding/reimbursement INSANITY
• Over regulation that drives up system costs
and complexity with VERY small return on
investment (lives saved)
• Allowing the Fire Service to “scare” the public
with emotionally based tactics to sway
politically based outcomes (Freakonomics)
– Private EMS is under attack!!! (in case you haven’t
figured that out yet)
Worst Practices in EMS
• Lack of a common union representing the
industry…Luke….if you only knew the power of
the dark side of the force….
– Good for employers…bad for industry…also based
on who is in political power
• Lack of substantial lobbying dollars
– The fact that I am having to say this is a worst
practice for our political process
A Final Thought…
• A new web resource now available on line
• Sponsored by / provided by
Todd Stout of FirstWatch
Jonathan Washko of Washko & Associates, LLC
CAEMS (Coalition of Advanced Emergency Medical Systems)
David Williams (Help to collect the articles for this collection)
• All of Jack’s writings now available for download
– JEMS Interface Articles
– 4th Party Manuals
– Other writings
• Looking for help to transcribe his works to make them
searchable on the internet
Best Practices in EMS
Questions & Answers
Share Your Best Practices…
Copies of this presentation will be available at:

Best Practices in EMS 2010