Improving Operational
Performance
Presented By:
Jonathan D. Washko, BS-EMSA
Director of Deployment – REMSA
President – Washko & Associates, LLC
HPEMS & Public Safety Consulting
Partner – Stout Solutions, LLC & FirstWatch
Some Food for Thought…
Late 9-1-1 Wears The Late Crown
Improving Operational
Performance
• Notice in this video
– The media focused on problems created for
9-1-1 center from this video
– They are actually talking about EMS only
– They are talking mostly about RESPONSE
TIMES
– They are talking about customer service and
clinical care
Discussion Topics
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Successful Performance Defined
Defining Operational Performance
Measuring Operational Performance
Improving Operational Performance
Successful Performance
Defined
The EMS Success Triad
– A Balancing of…
• Patient Care
• Employee Wellbeing
• Financial Stability
Success
Triad
Employee Wellbeing
EMS Success Triad
Patient Care
– Response Times
– Clinical Performance
– Customer Service
EMS Success Triad
Employee Wellbeing
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Retention
Health / Safety / Welfare
Satisfaction
Compensation
Recruitment
EMS Success Triad
Financial Stability
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A/R & Billing Practices
EMS Delivery Model / System Design
Operational Efficiency & Effectiveness
Employee Compensation
Safety & Risk Management
Systems Engineering
The Balancing Act…
A Quality Unit Hour
PR/Marketing
The
Quality
Unit Hour
Defining / Measuring & Improving
Operational Performance
Limiting our Discussion to…
– Response Times
– Key Operational Efficiency & Effectiveness
Measures
Defining Response Time
Performance
• Typically System Specific
• National Standards
• Measured Via
– Clock Start
– Clock Stop
• Measurement Methodologies
– Average Response Times
– Fractile Response Times
Defining Response Time
Performance
Clock Start….a controversial topic (Smoke & Mirrors)
– Time First Received at 9-1-1 PSAP
– Time First Received by Responding Agency
(Secondary PSAP)
– Time Certain Info Obtained
– Time Dispatched
– Time Unit En Route
Clock Stop (Pretty Definitive)
– Unit Staged
– Unit on Scene
– Crew at Patient
Measuring Response Time
Performance
Typically two types of measurement
– Average
– Fractile (or frequency distribution)
Measuring Response Time
Performance
Average
– Total Response Times for Sample divided by
Total Sample Size
– Yields roughly the 50th percentile, or ½ of your
responses are above and ½ of your responses
are below the average number…or 5 out of 10
patients are receiving this level of response
– Old standard of measurement when we didn’t
care about this stuff as an industry
Measuring Response Time
Performance
Fractile
– Frequency distribution of time that shows reliability
percentage of responses based on specific time bins
– Many systems (and standards) are going to 90th
percentile reliability standards (e.g. a response time
standard of 00:08:00 at 90% reliability)…or 9 out of 10
patients receive this level of response
– Best measurement approach for Patient Care and/or
Customer Service
– Ability to achieve depends heavily on deployment
methodology (demand vs. geographic based) and size
of your pocketbook.
Measuring Response Time
Performance
Response
Time
Measurements
Fractile
Measurement
Example
Measuring Response Time
Performance
Fractile Measurement Continued
Response Time Exemptions
– Calls that are exempted from response time calculations
due to uncontrollable factors that would require
significant financial and human resources to
overcome…
• Examples:
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Severe Weather
Significant Hospital Diversions / Delays
MCI
Second Unit to Same Incident
Others based on financial needs
» System Overload
» Un-notified Construction
Improving Response Time
Performance
Emergency Calls
– Function of Volumetric and Geospatial Supply and
Demand of Resources, Call Segment Efficiency and
Effectiveness and Responding Unit Travel Time and
Impedance
Non-Emergency (Inter-facility Transport) Calls
– Function of Mostly Volumetric and Some Geospatial
Supply and Demand of Resources, Effective Call
Scheduling and Responding Unit Travel Time and
Impedance
Improving Response Time
Performance
Performance Variables
– Call Segment Processing
– Matching or Mismatching of Supply and
Demand Curves
– Deployment Methodology
– Other System Issues
• Support Systems
• GIS / Mapping Systems
• Employee Performance
Improving Response Time
Performance
Call Segment Processing
– A significant number of agencies can improve
response time performance just by measuring
and fixing two variables (based on how you
measure Clock Start):
• Call Processing Times (Received to Assign)
• Unit Chute Times (Assign to En Route)
• This Increases Available Travel Time which
Improves a Responding Unit’s Effectiveness and
Coverage Area
Improving Response Time
Performance
The net effect of a 2 minute improvement in call processing / chute times
on geospatial coverage isochrones
Improving Response Time
Performance
Matching Supply and Demand Curves
– EMS Demand curves are Predictable (see next session)
• Volumetric Basis (Temporal Demand Analysis)
• Geospatial Basis (Geographic Demand Analysis)
– Analysis of Existing Resource Supply to Demand
curves will show if a mismatch of resources exists
which definitely has a LARGE effect on response times
– Stoutian Theory (Prediction of Demand on EMS)
Improving Response Time
Performance
EMS Temporal Demand & Static Supply
Demand / Supply
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30
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Hour of Day
EMS Temporal Demand
Static EMS Supply
Improving Response Time
Performance
EMS Temporal Demand & Static Supply
Demand / Supply
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Hour of Day
EMS Temporal Demand
Static EMS Supply
Improving Response Time
Performance
EMS Temporal Demand & Static Supply
Demand / Supply
35
30
25
20
15
Lost Revenue Opportunities
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Hour of Day
EMS Temporal Demand
Static EMS Supply
Improving Response Time
Performance
EMS Temporal Demand & Temporal Supply
Demand / Supply
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15
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Hour of Day
EMS Temporal Demand
EMS Temporal Supply
Improving Response Time
Performance
Deployment Methodology
– Another Significant Variable in Emergency Response
Time Performance is your Agency’s Geospatial
Deployment Methodology:
• Fixed (Static) Geographic Based
• Dynamic (Temporal) Demand Based
• Hybrid (Static & Temporal) Demand / Geographic Based
– Effects How Response Ready You Are To Respond To
The Next Call
Improving Response Time
Performance
EMS Temporal Demand & Static Supply
Improving Response Time
Performance
EMS Temporal Demand & Temporal Supply
Improving Response Time
Performance
EMS Temporal Demand & Temporal Supply
Improving Response Time
Performance
EMS Temporal Demand & Temporal Supply
Improving Response Time
Performance
Other Variables
– Support Systems
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Fleet Maintenance
CAD
AVL
Dispatch
– GIS / Mapping
• GIS Data ACCURACY!
• Reading a Map Book
– Employee Performance
• Culture
• Unions
• Management Style and Approach
Improving Response Time
Performance
– Overall Improvement Strategies
• Use Effective and Efficient Deployment Methodologies
• Root Cause Analysis on Each and Every Late Call Will
Show a Pattern and Focus your Improvement Efforts
• Reliability, Accountability and Measuring are Key
• Systems Engineering that allows for Minute to Minute
System Adjustments Based on Real-Time Performance
Data is Vital for Success
• Daily After Action Review Processes (from the military)
will improve situational awareness, identify trends,
allow the organization to communicate and will
eventually lead to improved performance (on all fronts)
Improving Financial
Performance
– Financial Performance
• Definitions
• Measurements
• Improvements
Defining Financial
Performance
– System Specific
• For Profit / Not For Profit / Non Profit
• Publicly Traded / Privately Held / Government
• Performance Based / Level of Effort Based
– Self Imposed / Contractually Imposed
– Performance
• Profitability
• Survival
• Growth
Successful Performance
Defined
The EMS Success Triad
– A Balancing of…
• Patient Care
• Employee Wellbeing
• Financial Stability
Success
Triad
Employee Wellbeing
The Balancing Act…
A Quality Unit Hour
PR/Marketing
The
Quality
Unit Hour
Defining Operational Efficiency &
Effectiveness
• A Majority of Most EMS budgets Consist of Labor Costs
(typically 60% to 80%)
• Revenue Availability is a direct result of EMS system
design and reimbursement methodologies (subsidy /
billing insurance)
• Cost Structure is a direct result of EMS system design,
efficiency and reimbursement methodologies (subsidy /
billing insurance)
• Reimbursement rates are diminishing, tax dollars are
tightening and public expectations are rising
• Because of this, only the most efficient and effective
properly designed EMS systems will be successful in
balancing the Triad…if not something will have to give
eventually (Patient Care, Employee Well Being or
Financial Stability / Survival)
Defining Operational Efficiency &
Effectiveness
• Given that EMS budgets are mostly labor based,
focusing on this area when attempting to improve
financial performance typically gives you some
kind of return
• Equally important is revenue and collections, but
for this discussion we will focus on operational
improvements
• Other areas of significant budgetary allocations
are also likely candidates
Measuring Operational Efficiency &
Effectiveness
• Service Model versus Production Model EMS
Strategy
• Measuring Key Performance Indicators (KPI’s)
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Quality Unit Hours & Unit Hour Utilization (UHU)
Controlling Lost Unit Hours
Managing Call Task Times
Managing Pay Roll Leakage (or payroll UHU)
Manage Headcount to Control Overtime
Managing Response Errors
Benchmarking and Trending Statistics
Many Others
Measuring Operational Efficiency &
Effectiveness
Quality Unit Hour Definition
A “Quality Unit Hour” is an ambulance that is
available to the EMS System for one hour that
responds to properly triaged calls for service, is
produced within a CQI environment that uses
modern technology to collect and assess
accurate data, is fully staffed, fully trained, fully
maintained, fully stocked, properly placed in
location and time, properly funded and safely
operates within an educated population
The Balancing Act…
A Quality Unit Hour
PR/Marketing
The
Quality
Unit Hour
Improving Operational Efficiency &
Effectiveness
• Control your Unit Hours and UHU
– Function of EMS System Design
– Properly Allocate Supply with Demand
– Geographic Deployment Methodology is
HUGE in terms of efficiency and Demand
Based Systems are usually the most cost
efficient and effective
Improving Operational Efficiency &
Effectiveness
• Controlling Lost Unit Hours
– A Lost Unit Hour is one that is not otherwise available
to the deployment plan if not on a call
– Many causes
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Start / End of Shift Procedures
Critical Failures
Hospital Diversions / Off Load Delays
Employee Problems
Poor Management Practices
• Lowered lost hours means more available hours
to the system
• More available hours may allow you to reduce
scheduled hours
Improving Operational Efficiency &
Effectiveness
20
100%
19
18
17
16
90%
15
14
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12
80%
11
10
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70%
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60%
3
2
1
0
50%
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Total Consumption
Priority 0 - Responses
Priority 1 - Responses
Priority 2 - Responses
Priority 3 - Responses
Priority 4 - Responses
Priority 5 - Responses
Scheduled Unit Hours
Actual Unit Hours
Effective Unit Hours
Priority 1 - Late
Total Status 99 Declarations
Total Transports
Total LDT's
Running P1 Compliance
Improving Operational Efficiency &
Effectiveness
• Managing Call Task Times (somewhat controversial)
– Highly efficient systems can run a call in less
then an hour
– Less time to run a call means less hours that are
needed to meet the same response time
performance standard
– Less hours needed results in financial savings
(but may unbalance the triad on employee wellbeing or patient care…be careful!)
Improving Operational Efficiency &
Effectiveness
• Managing Payroll Leakage
– Payroll leakage are unproductive dollars spent for
various reasons
– Measuring Payroll UHU against Actual UHU defines
leakage
– If a variance if found between these two numbers, then
leakage is occurring or you’re measuring wrong
– If these numbers match or are very close, then leakage
is more then likely minimal
– Minimizing leakage helps to lower costs
Improving Operational Efficiency &
Effectiveness
• Managing Headcount
– Manage your Headcount - Don’t let it manage you!
– Perform bi-weekly headcount meetings as a means to
anticipate attrition and therefore drive hiring practices
– Ensure you allocate your employee thru put times into
the equation
– Also ensure you allocate proper FTEs to cover PTO,
Sick, Vacation, LOA, FMLA, etc to avoid backfilling
with overtime
Improving Operational Efficiency &
Effectiveness
• Managing Response Errors
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Systems engineering flaws
Unit Hour production problems
Deployment Plan issues
System support problems
Human Error
Improving Operational Efficiency &
Effectiveness
• Trending and Benchmarking Statistics
– Allows you to see where you have come from
and where you are going
– Can be used to adjust your system dynamically
in a real-time fashion thus keeping costs down
– Can be used to help predict the future
– Can be used to help find special cause
variations that may be effecting financial
performance
Improving Operational Performance
• Closing Remarks
• REMEMBER the EMS Success Triad
– Patient Care
– Employee Well Being
– Financial Stability
• Questions