19 April 2016
EMS Assessment Report
Marquette County EMS P.O. Box 181 Marquette, WI 53949
CONSULTANT REPORT
Prepared by:
Marquette County Emergency Medical Service, Inc. Page ©Fitch &FITCH Associates, & ASSOCIATES, LLC LLC EMS Assessment 2901 Williamsburg Terrace #G . Platte City19 April . Missouri 2016 . 64079 816.431.2600 . www.fitchassoc.com
Marquette County EMS EMS Assessment
Table of Contents
EXECUTIVE SUMMARY ______1 Key recommendations include: ______2 METHODOLOGY ______3 SYSTEM BACKGROUND AND DEMOGRAPHICS ______4
THE COMMUNITY ______4 MARQUETTE COUNTY EMERGENCY MEDICAL SERVICES ______5 THE OPTIMAL EMS SYSTEM ______6 EMS DESIGNS, BEST PRACTICES AND BEST PRACTICE SYSTEMS ______8 PROCESS AREA SUMMARIES ______9
COMMUNITY ACCESS AND EMERGENCY COMMUNICATIONS ______9 Description of Best Practices ______9 Observations and Findings ______10 Community Access and Emergency Communications Recommendations ______13 MEDICAL FIRST RESPONSE ______13 Description of Best Practices ______13 Observations and Findings ______13 Medical First Response Recommendations ______14 AMBULANCE OPERATIONS AND CLINICAL PERFORMANCE ______14 Description of Best Practices ______14 Observations and Findings ______15 CLINICAL SERVICE LEVELS ______15 Clinical Service Levels Recommendations ______16 RESOURCE UTILIZATION AND DEMAND ______17 Description of Best Practices ______17 Observations and Findings ______17 Resource Utilization and Demand Recommendations ______33 FLEET AND LOGISTICS ______34 Description of Best Practices ______37 Observations and Findings ______37 Fleet and Logistics Recommendations ______38 PREPAREDNESS ______39 Preparedness Recommendations ______40 MEDICAL DIRECTION AND ACCOUNTABILITY ______40 Description of Best Practices ______40 Observation and Findings______40 EDUCATION AND QUALITY MANAGEMENT ______41
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Observations and Findings ______41 Medical Direction and Accountability Recommendations ______45 CUSTOMER AND COMMUNITY ACCOUNTABILITY ______45 Description of Best Practices ______45 Observations and Findings ______46 Customer and Community Accountability Recommendations ______46 PREVENTION AND COMMUNITY EDUCATION ______46 Description of Best Practices ______46 Observations and Findings ______46 Prevention and Community Education Recommendations ______47 GOVERNANCE, GROWTH, ORGANIZATIONAL STRUCTURE AND LEADERSHIP ______47 Description of Best Practices ______47 Observations and Findings ______48 Governance, Growth, Organizational Structure, and Leadership Recommendations ______51 SYSTEM FINANCES AND FUNDING ______51 Description of Best Practices ______51 Observations and Findings ______52 Observations and Findings ______56 System Finances and Funding Recommendations ______58 THE FUTURE ______59
THE WAY FORWARD ______59 STATUS QUO IS NOT AN OPTION ______60 STATUS QUO IMPROVED ______60 SUMMARY OF RECOMMENDATIONS ______61 Community Access and Emergency Communications Recommendations ______61 Resource Utilization and Demand Recommendations ______61 Clinical Service Levels Recommendations ______61 Medical First Response Recommendations ______61 Fleet and Logistics Recommendations ______62 Medical Direction and Accountability Recommendations ______62 Preparedness Recommendations ______62 Customer and Community Accountability Recommendations ______62 System Finances and Funding Recommendations ______62 Governance, Growth, Organizational Structure, and Leadership Recommendations ______62 Prevention and Community Education Recommendations ______62
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FIGURE 1. MARQUETTE COUNTY, WISCONSIN ...... 4 FIGURE 2. TYPICAL EMS CALL PROCESSING FLOW ...... 11 FIGURE 3. MAP OF SERVICE AREA WITH STATIONS ...... 19 FIGURE 4. CALL DISTRIBUTION MAP ...... 21 FIGURE 5. WESTFIELD STATION MAPPING WITH DRIVE TIME APPLIED (09:59) ...... 22 FIGURE 6. WESTFIELD STATION MAPPING WITH DRIVE TIME APPLIED (19:59) ...... 23 FIGURE 7. MONTELLO STATION MAPPING WITH DRIVE TIME APPLIED (09:59) ...... 24 FIGURE 8. MONTELLO STATION MAPPING WITH DRIVE TIME APPLIED (19:59) ...... 25 FIGURE 9. OXFORD STATION MAPPING WITH DRIVE TIME APPLIED (09:59) ...... 26 FIGURE 10. OXFORD STATION MAPPING WITH DRIVE TIME APPLIED (19:59) ...... 27 FIGURE 11. COMBINED THREE STATIONS STATION MAPPING WITH DRIVE TIME APPLIED (09:59) ...... 28 FIGURE 12. COMBINED THREE STATIONS MAPPING WITH DRIVE TIME APPLIED (19:59) ...... 29 FIGURE 13. COMBINED OXFORD AND MONTELLO MAPPING WITH DEMAND AND DRIVE TIME APPLIED (19:59) CY 2015 ...... 30 FIGURE 14. SAMPLE CONTROL CHART ...... 43 FIGURE 15. MCEMS ADMINISTRATIVE STRUCTURE CHART: ...... 49
TABLE 1: TYPES OF CALLS ______6 TABLE 2. RESPONSE TIME CY 2014 DATA ______18 TABLE 3. MARQUETTE EMS CALL DISTRIBUTION CY 2015 ______20 TABLE 4. RESPONSE TIME % BY STATION ______21 TABLE 5. CHUTE TIME CHART (GOAL 5:00) ______31 TABLE 6. CY 2015 DAILY ACTIVITY & CALL SUMMARY______32 TABLE 7. . STAFFING APPLIED TO CURRENT DEMAND PERFORMANCE CY 2015 ______33 TABLE 8. CALLS PER MONTH CY 2015 ______33 TABLE 9. . AMBULANCE FLEET UTILIZED BY MCEMS ______34 TABLE 10. MODEL PREVENTIVE MAINTENANCE SCHEDULE ______36 TABLE 11. BASE CHARGES AND ALLOWABLE ______54 TABLE 12. PAYER MIX ______55 TABLE 13. TAX CONTRIBUTION ______57 TABLE 14. AREA EMS AGENCIES SUBSIDY PER CAPITA ______57 TABLE 15. FY 2014 FINANCIAL SUMMARY ______58
ATTACHMENTS A. Ambulance Benchmark Summary
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EXECUTIVE SUMMARY
Marquette County Emergency Medical Service (MCEMS) is a division of county government ambulance service located in Montello, Wisconsin. It operates as a “third service,” with a minimum full time staff supported by paid on-call staff. MCEMS is licensed by the Wisconsin State Department of Health as an EMT-Intermediate level ambulance service. Besides Marquette County, MCEMS also provides services to the townships of New Chester and Jackson in Adams County (directly west). A small portion of the northeast section of Marquette County is served by Waushara County EMS under contract.
Marquette County is located in the south central portion of the state. The adjusted service area has a population base of 21,204. Marquette County has one incorporated city and several villages. The county seat is Montello.
Within this calendar year, MCEMS’ service director of 25 years will retire. The organization is currently searching for an assistant director that can assume the service director’s role upon the current director’s retirement. Coupled with the office administrator’s extended leave, administrative functions are difficult to perform in a timely manner. Additionally, the organization’s status as an EMT-Intermediate Level of service is at risk due to a shrinking pool of available volunteer intermediates and paramedics. In its assessment of MCEMS, Fitch and Associates (FITCH) was tasked with developing a multi-year plan for sustainability. The assessment included documenting and reviewing the organizational structure, 9-1-1 call center processes, the EMS responder capabilities, fleet and asset allocations, staffing and management practices, and system costs and billing processes.
Specifically, the FITCH study found: . The system’s operations are in fragile condition with the director and three full-time crew chiefs working in excess of 200% additional hours due to a shrinking pool of qualified staff. . The loss of any one of five key staff members could cause an immediate catastrophic negative change of the service. . Fundamental Emergency Medical Dispatch processes that could improve patient outcomes are not provided by the communications center. . A more formal relationship and active engagement of the medical director will benefit the system. . A three station configuration utilizing paid-on-call staff can provide an acceptable response time. . The service’s fleet and remount policies have served the community well.
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. Marquette’s subsidy per capita benchmarks below other similar counties and County Supervisors should expect this to increase as additional staff (immediate) and increased requirements for paramedics take effect (longer term).
For MCEMS to achieve its goals of maintaining high quality service and adding enhancements, as well as keeping pace with the needs of the county, improvements are needed in the eight process areas reviewed by the Consultant. A total of 48 recommendations have been made that will need to be prioritized for implementation by the system’s leadership for approval by the County.
Key recommendations include:
. Recruit three part-time staff members to fill the scheduled time off for the three chiefs. . Immediately begin cross training someone to perform billing and office duty functions. . Ensure that calls are received by personnel certified in emergency medical dispatch and the pre-arrival instructions are consistently given prior to the ambulance arrival. . Make it a priority to identify and hire an assistant director before June 1, 2016. . Expand and enhance the volunteer staff to drive further improvements. . Consider full-time staff stations at Oxford and Montello in subsequent years. . Consider funding/developing a bridging program for moving EMT-I/99s to Paramedic level. . Continue the migration from a mostly volunteer department towards full time staffing as the availability of community volunteers decrease.
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METHODOLOGY
Marquette County EMS retained Fitch & Associates to conduct a comprehensive review of the MCEMS operating system. FITCH objectively benchmarked current system performance capabilities, as well as compared and contrasted MCEMS’ current practices to industry recognized best practices.
FITCH used a seven-phase approach to accomplish the scope of work. The first phase launched the project. Phases two and three consisted of comprehensive data collection. Phases four through six involved data analysis and benchmarking. The final seventh phase is complete with the presentation of this report. A description of each of the seven phases follows:
. Project Initiation. The FITCH consultant initially met with the EMS Director by phone and subsequently, in person to identify project goals and initiate the project activities. . Materials and Data Collection. The MCEMS Director was forwarded a detailed Information Data Request (IDR) that included key questions to be answered and requests for specific documentation and reports related to every area of the organization. . Onsite Interviews and Direct Observations. FITCH site-visited the organization and conducted interviews with leaders of key functions (process leads), as well as external and internal stakeholders and staff. . Data Compilation and Client Input. All data from onsite interviews and the IDR were compiled and organized for analysis. Emerging questions were directed to MCEMS staff, as appropriate. . Benchmarking and Compliance Assurance. The department was compared with the FITCH 50 EMS System Benchmarks (see Attachment A). In addition, the organization’s local enabling legislation and practices were reviewed. . Define Future State. The report provides brief descriptions of steps necessary to take over the course of the next three years for sustainability. . Reporting Results. The information and analysis summary of the first six phases is compiled in a report to the client.
The seven phases resulted in a comprehensive analysis that draws from both qualitative and quantitative data, addressing the specific needs outlined in the initial scope of work.
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SYSTEM BACKGROUND AND DEMOGRAPHICS
The Community Marquette County is described as a “super rural”1 environment (Figure 1) that also provides EMS to adjacent Adams County. That additional coverage is provided by surrounding area EMS agencies through inter-local agreements. MCEMS also provides mutual aid to assist area providers in Adams and other nearby counties. The EMS service area is approximately 477 square miles, with a population base of approximately 21,204 people. The population density is 457 people per square mile for the total service area.
Figure 1. Marquette County, Wisconsin
1 NFPA 1720 Staffing & Response per population density guide. Any population per square mile under 500 is designated as Rural.
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Marquette County Emergency Medical Services
MCEMS traces its history back to 1960 when the Oxford Fire Department contracted with the Oxford Lions Club to operate the first ambulance in Marquette County. In 1961 the Village board loaned the Lions Club money to purchase a van and equip it as an ambulance. Subsequently, the sheriff’s department purchased station wagons fitted with cots, which functioned as ambulances. Marquette is one of four remaining county-operated EMS systems in Wisconsin. In 1985 MCEMS upgraded their service level from basic to Intermediate/85. Again in 2003, the service upgraded to the EMT-I/99 level. As the county itself has no hospitals, more than 70% of patients are transported to Portage. It is imperative that citizens have advanced life support ambulance service available for their survivability. Rural in nature, the system functions as a fully volunteer system with paid crew chiefs to assure an intermediate level of care is scheduled 24/7 at all three stations. Stations are strategically located to minimize response times.
The organization is staffed with a full-time EMS director employed by Marquette County. A full- time office administrator performs the billing functions and is a certified ambulance coder. The office administrator is also an EMT-I/99 and routinely is on the ambulance running calls. Two stations each have an EMT-I/99 crew chief assigned, while the third station has a Paramedic. The crew chiefs schedule volunteers for the stations. This is a fully volunteer squad, as even the paid chiefs have limited office hours, take on-call hours and routinely respond from home for alarms.
The MCEMS is licensed by the State of Wisconsin as an EMT - Intermediate ambulance service. Each of the three stations holds their own license.
Current scheduled ambulance unit hours are 540 per week, or 28,080 per year. In 2014, MCEMS ambulances responded to 1,308 service requests that resulted in 874 ambulance transports. Fully 100% of the calls were emergency calls received through the 9-1-1 system. The breakdown of call types is shown in Table 1. Overall, the service achieves a Unit Hour Utilization (UHU) level of 0.030, in part due to the rural nature of the service area. Management reports the cost per transport averages $968.29.
In the MCEMS system, emergency calls are those routed through 9-1-1 to the public-safety answering point (PSAP). MCEMS does not perform transfers or scheduled non-emergency calls for the one nursing home and there is no hospital in the County. The PSAP does not differentiate emergency or non-emergency response during the dispatch (EMD) process for 9-1-1. In a properly prioritized EMD PSAP, a mix of emergency vs. non-emergency dispatched calls averages about 55% emergency dispatches. At MCEMS the emergency dispatch rate is 100%. For Advanced Life Support (ALS), the ALS-2 ratio is below national benchmarks at 2%.
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Table 1: Types of Calls CY 2014 % of Tx Total Ambulance Responses 1,308 100% Total Ambulance Transports 874 67% Total Emergency Calls 1,308 100% ALS Assist 0 0% No Transport 373 28% Transports from Emergency Calls 874 67% ALS-1 Emergency 699 79% BLS Emergency 175 19% ALS-2 Emergency 18 2%
The Optimal EMS System
An optimal EMS system is best designed from the patient's perspective. Patients should expect the service to be engaged in illness and injury prevention, health education and early symptom recognition, in addition to responding to emergency and transportation requests. The EMS system should provide a rapid and appropriate response when a caller dials 9-1-1 and routinely provide medical instructions until help arrives.
The 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiac Care focuses on the impact the community has on patient outcome. The revised Chain of Survival emphasizes rapid identification of potential cardiac arrest, followed by immediate delivery of high quality CPR and early defibrillation with an AED.
Communities able to implement a rapid response see a cardiac arrest survival rate approaching 50%. Team-based response, using the community and medical first responders, should be able to deliver rapid defibrillation and high-quality CPR, arriving to the patient’s side within four to six minutes of a 9-1-1 dispatch, with 90% reliability.
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The response time of emergency caregivers is based on the type of community. Population density within central Wisconsin falls under the “Rural” and “Remote” classifications by the National Fire Protection Association Standard 1720.2
The arrival of a transport-capable ambulance with ALS support should occur within nineteen minutes and 59 seconds (19:59) for life-threatening emergencies in rural areas, with not less than 80% reliability.
Patients should be transported either to a hospital of their choice or one that can treat their specific condition. The EMS system should be externally and independently monitored, with participants held accountable for their responsibilities. Finally, the system should deliver good value for the resources invested.
The performance of MCEMS is compared to these optimal system standards in the following section.
2 National Fire Protection Association Standard 1720: Standard for the Organization and Deployment of Fire Suppression Operations, Emergency Medical Operations, and Special Operations to the Public by Volunteer Fire Departments: 2014 Edition.
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EMS DESIGNS, BEST PRACTICES AND BEST PRACTICE SYSTEMS
Milestone documents in the early development of Emergency Medical Services Systems (EMSS) included the National Academy of Sciences-National Research Council White Paper “Accidental Death and Disability: The Neglected Disease of Modern Society,” the Federal Highway Safety Act of 1966, and the Federal Emergency Medical Services Systems Act of 1973. They guided the first 30 years of Emergency Medical Services system growth on the local, regional, and state levels.
These early systems evolved from “neighbor helping neighbor” volunteer groups to highly complex response systems of physician extenders that function as part of the larger healthcare delivery system.
In many areas of the United States, EMS systems are struggling to meet clinical, operational, and financial performance objectives. Ambulance services are primarily funded under a complex and flawed federal reimbursement methodology that does not cover the full cost of operations or the cost of readiness. Studies, including those prepared for the International City and County Management Association (ICMA) and the National Academies of Science Institute of Medicine, (IOM) document the underlying issues.
No single identifiable source for industry standards of practice exists. State EMS regulations reflect minimum performance requirements. In its review, Fitch drew from a number of commonly accepted standards, including those found in the following resources:
. “10 EMS Standards,” currently used to evaluate state EMS systems . “EMS Agenda for the Future,” developed by the U.S. Department of Transportation . “EMS at the Crossroads,” developed by the National Academies of Sciences’ Institute of Medicine 2006 . “EMS In Critical Condition: Meeting the Challenge,” produced by The International City/County Management Association . “Community Guide to Ensure High Performance Emergency Ambulance Service,” published by the American Ambulance Association and the standards developed by the National Academy of Emergency Dispatch . Commission on the Accreditation of Ambulance Services . National Fire Protection Association
In like manner, no single universally best EMS system design model or single “best practice system” can be identified.
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PROCESS AREA SUMMARIES
Every EMS organization is comprised of multiple process areas to address specific functions of the operation. The Consultant team met with the specific process owners and process leads within MCEMS, as well as with community, and local stakeholders. A summary of the best practices and findings for each process is described below. Recommendations for enhancing activities are included, where appropriate.
Specific benchmarks and MCEMS performance in each of the following categories are described:
. 9-1-1/Communications . Customer and Community Accountability . Medical First Response . Prevention and Community Education . Medical Transportation . Organizational Structure and Leadership . Medical Accountability . Ensuring Optimal System Value
The summary of 50 benchmarks can be found in Attachment A – Benchmark Summary. MCEMS clearly documents its achievement of 24 of these 50 objective measures. Eleven measures are partially achieved. Remaining to be accomplished are fifteen more measures.
Community Access and Emergency Communications
Description of Best Practices Best practice EMS systems are organized to facilitate wire-line, cellular, voice over internet protocol (VoIP), automatic crash notification, patient alerting system devices and other public 9- 1-1 access to the Emergency Medical Services System. Voice, video, telemetry, and other data communications conduits are employed, as necessary, to best enhance real-time information management for patient care.
A medically directed system of protocol-based EMD and communications is in place. The call reception and EMS call processes are designed logically and should not delay activation of medical resources. Technology supports the caller being directed to the appropriate Public Safety Answering Point for the geographic location of the call. All 9-1-1 callers should receive International Academies of Emergency Dispatch (IAED) [or similar process] call prioritization and pre-arrival instructions. Automated quality improvement (QI) processes are used to facilitate the report of results to clinical and operations executives in a concise manner.
In best practice EMS systems, data collection facilitates the analysis of key service elements and these data collections are routinely benchmarked and reported. Technology supports interface between 9-1-1, medical dispatch functions, and administrative processes. Radio/cellular linkages between dispatch, field units and medical facilities provide adequate coverage and facilitate both
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voice and data communications. There is interoperability between allied public safety agencies. More than 71% of major cities utilize EMD processes.
Emergency Medical Dispatch is a system that: . Categorizes and prioritizes emergency calls . Predicts patients who require rapid care . Has a goal to provide appropriate and timely pre-hospital response . Allows local effectiveness to be measured when linked with ePCR records
Communications Benchmarks . Public access is available through a single number, preferably enhanced 9-1-1 (E-9-1-1). . A single PSAP exists for the communications system. . The system allows effective connection between PSAP and dispatch points, requiring minimal handoffs for callers. . Certified personnel provide pre-arrival instructions and priority dispatching (EMD) under supervision of a medical director. . Regular data collection allows key service elements to be analyzed. . The system has a technology-supported interface between 9-1-1, dispatching and administrative processes. . GPS/AVL–equipped vehicles enable dispatch to alert the closest unit. . Radio linkages between dispatch, field units, and medical facilities provide adequate coverage and facilitate uninterrupted communications.
Observations and Findings Public Access to EMS Public access to emergency medical services throughout the MCEMS service area is provided via an enhanced 9-1-1 (E-9-1-1) Phase II-compliant system. Requests for service are received by the Marquette County Sherriff’s department, county 9-1-1 center, or PSAP. A secondary PSAP in Adams County refers medical requests for the two townships to the primary PSAP in Marquette County. There is no emergency medical dispatch (EMD) in use in the communications center. PowerPhone training was provided at one time, but users have not been refreshed.
. EMD is not performed. The sheriff’s office would like to do so, but based on costs and training to implement, EMD is not a high priority. . ALL incoming calls to 911 are classified as emergency responses and are dispatched as such. . The county PSAP utilized a Spillman CAD server. There are no plans in the near future to upgrade CADs or change any of the EMD processes. . 50% of the dispatcher’s role serves as a correctional officer with the jail.
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The key rationale for using EMD is to correctly prioritize 9-1-1 calls by consistent use of medical protocols. Dispatch personnel are to stay on the line and provide pre-arrival first aid instructions on critical calls. These are to be routinely monitored through a QI process. The EMD process should be actively supervised by a physician.
The PSAP staff consists of commissioned officers with the Marquette Sheriff’s Office with correctional officer responsibilities in addition to dispatching. The correctional officer roles consume about 50% of their task time.
Figure 2. Typical EMS Call Processing Flow
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. The current call processing times could not be determined. At a minimum, calculations should begin from the time the call is answered by the Telecommunicator (T1) is received to time of dispatch (T4) and then the time the crew is notified (T5). Analysis of the data should determine MCEMS’ ability to meet the 80th percentile of reliability (using the fractile statistical method). . Automatic Vehicle Locating (AVL) is not available through the Spillman CAD, but may be available in a future upgrade.
Computer-Aided Dispatch MCEMS receives emergency dispatches from the Marquette County 9-1-1 Dispatch, a multi- jurisdictional service covering all of the communities in the county for law enforcement, fire, and EMS. Departments and crews are alerted by voice and tone alert pager. The current computer- aided dispatch (CAD) system has no direct interface to link call taking data from the CAD directly to the MCEMS ePCR. Call data and other relevant statistics are not available, but most statistics can be pulled from the ePCR. The Spillman CAD cannot support Automatic Vehicle Locator (AVL) devices in the ambulances. Spillman does provide CAD mapping. The CAD will map each call as it is received; however, accuracy in pinpointing the location is poor. The system was updated to include fire membership numbers, but that, too, has not been updated in several years.
Radio Communications Marquette County PSAP broadcasts over a VHF digital radio system. It is comprised of a nine- tower analog voted simulcast system with microwave links between all towers backed up by a redundancy system with the Columbia County 911 center. Ambulances are equipped with 100 watt dual head analog VHF radios and portables for back up. Cellular phones are on board and medical control discussions are held via cellular.
MCEMS shares the same dispatch radio frequency as ten fire departments and the Department of Natural Resources (DNR) fire and EMS departments on the radio system. This allows for a common call dispatch, units to monitor each other’s response and efficient interoperability for a single call response.
The dispatcher alerts MCEMS crews for an emergency via voice call over the radio frequency as well as tone and voice pagers carried by the crew members. Crews use their portable and mobile radios to communicate with dispatch throughout the rest of the call. The radio communications system works well and is built for future capacity.
CAD Reporting Ideally, a single CAD system should be able to report call statistics on a regular basis. The report should encompass the elements outlined in Figure 2. In addition, the CAD should be able to provide call data in a spreadsheet format, e.g. Microsoft Excel, to facilitate mapping and analysis.
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The sheriff’s officer in charge of the PSAP verified that detailed reports are not available through the CAD.
Community Access and Emergency Communications Recommendations
1. The PSAP should make consistently using and EMD protocol a priority. The CAD should make emergency versus non-emergency response determinations; they should be capable of advising crews upon dispatch. 2. The PSAP should be reporting call processing times and EMD and pre-arrival instruction compliance to MCEMS and the medical director. 3. Add AVL/GPS to ambulances as the Spillman CAD is updated.
Medical First Response
Description of Best Practices Medical first responders in best practice systems are organized appropriately for the communities in which they serve. They function as part of an integrated response system that is guided by state and local legislative authority, and which reflects accepted medical practice. First responders (paid or volunteer) are certified at a minimum EMT-B or Medical First Responder (MFR) level. They are medically supervised by the system medical director, and are included in performance improvement audits/activities. Defined response time standards exist for formal first responders and those response times are reported with those of the system. Early defibrillation capabilities are available for EMS first responders in areas of high-density response areas, such as airports and hotel complexes. When community or first response personnel are involved in patient care, a smooth transition of care is achieved.
Medical First Response (MFR) Benchmarks
. MFRs are part of an integrated response system and are medically supervised by a single system medical director. . MFR-defined response time standards are documented and followed. . MFR agencies, in accordance with the National Fire Protection Association (NFPA) 1710/1720 standard, report fractile response times. . AED capabilities exist on first-line apparatus.
Observations and Findings Medical First Responders Medical first responders play a critical role in life-threatening emergencies and support the Marquette County communities’ EMS efforts as part of the public safety mission. In the vast
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majority of North American cities, this role is funded by local tax dollars as part of the public safety budget. Both involvement of the medical director with first responder agencies, and the engagement of first responders in a system-wide QI process are essential elements of a high- quality EMS.
In Marquette County, the MFR role is provided by six independent agencies. In Adams County, New Chester Fire provides MFR for one of the townships. In Marquette County five fire departments provide MFR services. Not all of Marquette County has MFR available. These services are licensed under MCEMS and will respond to calls when available. Sheriff department cars all have AEDs available, but do not always respond to medical emergencies.
The MCEMS medical director functions as a system medical director. Although no medical direction is required for non-certified responders, the medical director is able to exercise oversight of most responders. MFRs are included in QI of selected calls. They are invited to participate in training offered by MCEMS. The PSAP does not require a medical director at this time.
In the rural MFR environment, there are no suggested response time standards. It is preferred to engage as many response agencies in order to maximize the response throughout the county, at any level and to respond as able to scenes of emergencies.
Medical First Response Recommendations
4. MFRs should be accountable to the MCEMS medical director through QI process involvement. 5. MFR/MCEMS joint training that accommodates the scheduling needs of the volunteer companies. 6. MFR response times should be reported and measured from call receipt until “wheel stop,” on a fractile basis to the tenth of a second, based on NFPA standards.
Ambulance Operations and Clinical Performance Description of Best Practices In a best practice EMS system, a mechanism exists to identify and assure adequate deployment of ground, air and other transportation resources to meet specific standards of quality, to assure timely response, scaled to the nature of event. There is capability to monitor safety and response time issues. Defined response time targets come into play, according to severity of call, and individual response components are measured by using both mean and 80th percentile measures in rural and remote areas.
Defined clinical service levels use current medical research to guide the medical interventions of the system. Changes to improve clinical practice can be introduced rapidly. Ambulances are
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staffed and equipped to meet the identified service requirements. Procurement, maintenance, and logistics processes function to optimize unit availability. Resources are efficiently and effectively deployed to achieve response time performance for projected demand with due regard for taxpayers and end-users. When multiple agencies are involved, a smooth integration and transition of care is achieved.
The system is capable of scaling up day-to-day operations to meet the needs of larger, all-hazards events, based on threat and capabilities assessments of the likeliest events to occur in the state. It is essential that mass casualty responses involve logical expansion and extension of daily practices and not the establishment of new practices reserved for large-scale events.
Medical Transportation Benchmarks . Defined response time standards exist. . Agencies report fractile response times. . Units meet staffing and equipment requirements. . Resources are efficiently and effectively deployed. . There is a smooth integration of first response, air, ground, and hospital services. . The system develops and maintains coordinated disaster plans.
Observations and Findings Medical Transportation This section addresses key components of ambulance service operations and performance, including clinical service levels, resource utilization and demand, fleet and logistics, preparedness, education and training, and quality management.
Clinical Service Levels The State of Wisconsin authorizes ambulance service programs to operate as EMT-Intermediate ambulance services based upon:
State of Wisconsin Department of Health Services Chapter 256 – Emergency Medical Services
Marquette County EMS has been issued three licenses, one for each base of operations (Numbers 6000993, 6600084 and 6600086) to provide Ambulance Services by the Department of Health, State of Wisconsin. The licenses are valid until June 30, 2016.
Crew Configuration Marquette County staffs each ambulance as an Intermediate, Advanced Life Support service unit 24 hours a day, seven days a week, at each location. The crew chief for each station is responsible
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for scheduling staff and to assure there is an EMT-I/99 available for each shift period. In order to maintain ALS coverage, the crew chiefs are being required to schedule themselves with increasing frequency. Recently several EMT-I/99 volunteers have relocated outside the county for personal reasons; there has been no success in replacing the volunteers. Time constraints in sending EMT-Bs to an Intermediate class have been problematic. Classes are held infrequently and at distant locations. EMT, Inc. covers costs, but the time away from family and jobs is problematic.
EMS has been able to maintain an acceptable number of EMT-Basics to cover available shift times at each station.
The three MCEMS crew chiefs are represented by a binding collective bargaining agreement. This agreement is with the Marquette County Deputy Sheriff’s Association. It is a Local of the Wisconsin Professional Police Association, Law Enforcement Employee Relations Division. This agreement is in effect for the 2015 through 2017 years.
Scheduling is all based on an “on-call” schedule. No one stays at the station and there are no facilities for anyone to stay at the station. Staff are scheduled to fill as much time as they can with shifts typically lasting 12 hours. Crew chiefs try to schedule three-person crews as often as possible. Shifts typically run from 0600 to 1800 hours and 1800 hours to 0600 hours. Intermediates are placed on the schedule to work hours they are available. When Intermediates are not available, one of the MCEMS crew chiefs will fill in. The crew chief is expected to work a minimum of 40 hours per week. They are paid around $14.00 an hour. If they take any on-call time, they are compensated at the same on-call rates as everyone else. If they respond to a call, they are in overtime status.
Anyone taking on-call time is compensated at a prescribed rate schedule established by the director.
Clinical Service Levels Recommendations
7. A minimum of three part time staff at EMT-I/99s or paramedics need to be hired to cover extra shifts not filled by volunteer EMT-I/99s. 8. Track times volunteers are not available to create a hybrid schedule increasing paid staff time as funds are available and the need arises.
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Resource Utilization and Demand Description of Best Practices In a best practice EMS system, a mechanism exists to identify and assure adequate deployment of ground and air transportation resources meeting specific standards of quality, to assure timely response scaled to the nature of the event. The systems are capable of monitoring safety and response time issues. Defined response time targets help rank the severity of calls. The individual response components are measured by using both mean and 80th percentile metrics (rural classification).
Observations and Findings An EMS system has three primary responsibilities when it comes to managing its resources: . Cover geography, . Cover call demand, and . Deploy as the coverage and demand change.
Response Time Performance Response times are considered a key benchmark of an EMS system’s performance. In sophisticated EMS systems, response times are measured on a fractile basis with 90% reliability in urban communities and 80% reliability in rural settings. The most commonly recognized benchmark is to place a transport-capable ambulance on the scene of life-threatening emergencies within the following time limits: 8:59 in urban areas; 10:59 in suburban areas; 14:59 in rural areas; and 19:59 in remote rural areas. For non-life-threatening emergencies, the typical urban response time is 11:59 and the typical suburban response time is 14:59. Population densities are established based on National Fire Protection Association (NFPA) 1710 Staffing and Response Guide3.
Based on population density and geographical size and land mass, MCEMS should adopt a best practice response time goal of 19:59 minutes for life-threatening emergency calls in their primary response area. From point of dispatched to arrival at scene, this goal should be measured to the 80th percentile for all emergency responses.
Response Time Reporting Issues The County PSAP CAD does not directly interface with Tri-Tech’s™, electronic patient care reports (ePCR) system. Due to lack of bridging capability, direct download of call times or other related data is not possible. Instead, the EMS office receives a hand written form from the sheriff’s office with hand written times and notes. This process can cause the incorrect entry of times and other pertinent data, making the information suspect and unquantifiable. The times are entered by the
3 NFPA 1710/1720 Fire Service Measures 11/09 NFPA Fire Analysis & Research, Page 15, Table 4.3.2 Staffing & Response Times
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biller into the system. These times do not contain seconds, which creates a margin of error for any calculations of ± 60 seconds.
Table 2. Response Time CY 2014 Data
In Table 2 above, response times for CY 2014 Data; from time of dispatch to arrival at scene is being accomplished within 20 minutes, at the 80th percentile. This included the variable time it takes the volunteer to respond to the station, man the truck and begin to go enroute. Originally, this number was set at five minutes, but as the availability of volunteers within the five-minute time become less available, volunteers further from the station have been recruited.
The maps below will demonstrate that by waiting on volunteers to arrive at the station, it requires three stations to achieve a 19:59 response time 80% of the time. If the crew can respond immediately from the station, two stations can adequately cover the response area in the same response time.
Geographic Coverage Ambulances should be placed within areas with access and close to areas with higher demand. Station placement is often based on demand analysis. In the MCEMS deployment plan, ambulances are “fix based,” also called “static based,” which means each ambulance has a permanent station. There are three fixed EMS station covering the service area.
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Figure 3. Map of service area with stations
Facilities MCEMS operates out of three locations strategically located to maximize response capabilities and in the three largest population centers in Marquette County. Other than the Montello County property, the Oxford and Westfield locations are in partnership with local fire departments. None of the three properties allow for any crew member to stay in station over night or for any extended period of time. It will make sense for future growth and planning for the county to begin looking for property to build EMS stations that will allow for storage, crew quarters and training.
Montello Headquarters 480 Underwood Avenue Montello, Wisconsin 53949
. This is headquarters for MCEMS. . The EMS offices and garaging are attached to the county administrative complex. It is a single story building with a two-bay, back-in garage. Each bay can accommodate one vehicle. A quick response vehicle and one ambulance are parked in the garage. The administrative offices are based here. There is limited parking for staff.
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Westfield Station 1214 E. Third Street Westfield, Wisconsin 53964
. This is located within the Westfield Volunteer Fire Department. . EMS shares garage space with the fire department and parks one ambulance here. There is a small office for the EMS crew chief assigned to this location. There is limited storage and no sleeping facilities available.
Oxford Station W8593 State Hwy 82 Oxford, Wisconsin 53952
. This is located within the Oxford Volunteer Fire Department. EMS shares garage space with the fire department and parks two ambulances here. There is a small office for the EMS crew chief assigned to this location. There is ample storage and no sleeping facilities available.
Mapping Drive Time to Demand Locations No EMS system has control of where emergency calls occur. They do have control over where ambulances are placed and deployed in order to maximize their response times. Table 3 below illustrates how the 9-1-1 call volume was distributed for the 2014 calendar year.
Table 3. Marquette EMS Call Distribution CY 2015
Station Unit Hours Responses Percentage
Montello 8,736 582 39%
Westfield 8,736 411 27%
Oxford 8,736 512 34%
Total 26,208 1505 100%
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Figure 4. Call Distribution Map
Using sophisticated mapping software (MapPoint), the Consultant identified and mapped each emergency response in the target period. The MCEMS station was added to the map. The results are displayed in the maps above.
Next, the Consultant was able to identify calls by station district and to determine response time performance for each district. This process provides the director with a method for monitoring response performance and changes in system demand.
Table 4. Response time % by Station
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With a goal of a 20-minute response time to the scene, the drive time of 09:59 was utilized estimating a ten-minute response to station by crew members and then 10 minutes responding to scene. If the crew was based at the station, then the 20 minute response times correlates to the 20-minute drive time. The chart demonstrates an almost 40% improvement in reaching the patient
Figure 5. Westfield Station Mapping with Drive Time Applied (09:59)
Figure 5 above demonstrates a ten-minute response to the station by crew and a 10-minute drive time to scene for a 20-minute total response time from the Westfield station.
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Figure 6. Westfield Station Mapping With Drive Time Applied (19:59)
Figure 6 above demonstrates an immediate response from the Westfield station at 19:50 minutes. The Westfield station responded to 411 patients representing about 27% of the total call demand.
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Figure 7. Montello Station Mapping with Drive Time Applied (09:59)
Figure 7 above demonstrates a ten-minute response to the station by crew and a ten-minute drive time to the scene for a 20-minute total response time from the Montello station.
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Figure 8. Montello Station Mapping with Drive Time Applied (19:59)
Figure 8 above demonstrates an immediate response from the Montello station at 19:59 minutes. The Montello station responded to 582 patients representing about 39% of the total call demand.
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Figure 9. Oxford Station Mapping with Drive Time Applied (09:59)
Figure 9 above demonstrates a ten-minute response to the station by the crew and a ten-minute drive time to the scene for a 20-minute total response time from the Oxford station.
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Figure 10. Oxford Station Mapping with Drive Time Applied (19:59)
Figure 10 above demonstrates an immediate response from the Oxford station at 19:59minute. The Oxford station responded to 512 patients representing about 39% of the total call demand.
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Figure 11. Combined three Stations Station Mapping with Drive Time Applied (09:59)
Figure 11 above demonstrates the drive time from all three stations combined at 09:59 minutes
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Figure 12. Combined Three Stations Mapping with Drive Time Applied (19:59)
Figure 12 above demonstrates the drive time from all three stations combined at 19:59 minutes
In order to serve the county with a 20-minute response time, from time of dispatch to arrival at scene, it is necessary to run out of three stations using volunteers. The first ten-minutes are consummed by the crew responding to the station, then the remaining ten-minutes’ drive time is depicted in the maps, from each station.
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Figure 13. Combined Oxford and Montello Mapping with Demand and Drive Time Applied (19:59) CY 2015
Figure 13 demonstrates a scenario with paid, on-duty crews based at the Montello and Oxford stations having an immediate response; a 93.38% compliance could be achieved within 19:59.
The move towards hybrid staffing should begin in 2016 and be fully implemented by end of 2020. It may take five years to achieve the desired end result. During this transition time, all three stations should continue to operate. The search for property for full-time stations should begin in as soon as possible. It will be necessary to identify locations in Montello and Oxford. Architectual design and build out should be completed by the end of 2020. Funding for this project may be possible through bonds issued by the county.
Time-On-Task (TOT) Figure 2 provides a matrix of Typical EMS Call Processing Flow. Each segment contributes to the eventual time-on-task calculation. Time-on-task is the amount of time the ambulance and crew is committed to a call until they are available for another call. TOT is not defined within the organization. For one crew, availability may begin upon leaving a destination facility, for another
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it may be entering the service area. A uniform policy should be established defining when a crew is “in service.” A review of the time-on-task components indicates in the MCEMS system, TOT at the 80th percentile represents 117 minutes.
Chute Time Analysis Key metrics T5 to T6 (Figure 2) measure the metric referred to as the “chute” time. This is the time interval from dispatch of the call until the unit begins rolling towards the scene. NFPA 1710 benchmarks this standard for paid on-duty staff at one minute from time of dispatch. For volunteers, there is no benchmark. MCEMS Chute times are calculated based on ePCR data, which does not include time to the seconds. MCEMS Chute Times average seven minutes; or at the 80th percentile 10 minutes, representing the amount of time it takes volunteers to respond to the station. This results in a margin of error ±60 seconds.
Table 5. Chute Time Chart (Goal 5:00)
Capturing all time data accurate to the second in the ePCR or using CAD data to calculate performance would result in a more refined and useful measurement.
Over the past decade, as volunteer availability has waned from a five-minute to ten-minute response to the station, volunteers who live further out from the station have been recruited. This has caused an increase in chute times and subsequent response times.
Unit Hour Utilization UHU is a calculation that measures the amount of time a unit is staffed, on duty, and prepared to respond to a call. This is measured as a percentage and is the total amount of hours a unit is staffed and available for response. A 24-hour unit consumes 8,760 unit hours per year. When compared to transports, the UHU measures the percentage of on-duty time engaged in call activities.
The specific formula used to calculate the UHU for each unit is:
(Number of calls) x (average call duration in hours) UHU= X,XXX hours per year
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Other times that are not included in the UHU calculation include time for training, maintenance, and other preparedness-related functions. Standby services, extrication, trails rescue and public education efforts also are not included in the UHU calculation.
UHU benchmarks in high performance systems range between 0.35 and 0.45. In the urban community, at this rate the system should be generating enough call activity to basically break even.
In the rural environment, it is unrealistic to compare one EMS service’s productivity against that of another. The best way to measure productivity in this scenario is for each service to establish a UHU baseline and track it monthly. The only truly important UHU value for comparison is that of each individual EMS service. UHU should be used to measure changes (+/-) in the efficiency of your organization. Used correctly, it’s a measure that is used as part of a quality cycle. The trends in UHU are much more important than how high or low you can make the number. . MCEMS reports a UHU of 0.030.
Table 6. CY 2015 Daily Activity & Call Summary
Table 6 depicts demand based on day of the week. Over the course of the year, the numbers of calls by day of week are relatively flat and consistent.
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Table 7. . Staffing Applied to Current Demand Performance CY 2015
Table 7 depicts demand by hour of day. This chart is usually produced for each day of the week; however, demand by hour of day was more or less the same for each day of the week so only one chart is displayed.
Table 8. Calls per month CY 2015
Resource Utilization and Demand Recommendations
9. Track call volume and response time calculations by station. 10. Request the PSAP to provide response times to include the seconds and load into the tri-tech system. 11. Perform response time calculations based on CAD records. 12. Adopt a response time performance for emergency responses of 19:59 minutes measured on a fractile basis at the 80th percentile for all calls. 13. Chute times goals should be measured and plotted. 14. Continue to track demand annually, as it relates to ambulance/station placement. 15. Identify property for future station locations. Engage a design firm and let out bids for targeted completion by end of 2020. 16. Consider county-issued bonds for funding the construction of the stations. Marquette County Emergency Medical Service Page 33 ©Fitch & Associates, LLC EMS Assessment 19 April 2016
Fleet and Logistics The fleet is one of the most important resources of an EMS system and a significant non- personnel expense. Making sound purchasing decisions and conducting frontline and preventative maintenance is critical to reducing lost unit hours and keeping ambulances in service and available for assignments.
The MCEMS fleet is unified and consistent. The fleet consists of five vehicles, four Type III modular ambulances and a support vehicle. Unit odometer readings range from 11,500 miles to 95,000 miles. The total ambulance fleet age ranges from 2009 to 2015 model years or an average of 4 years. The fleet age is well proportioned and for the purposes of capital planning on a distinct schedule based on age and miles as retained by most EMS organizations. Well- maintained fleets should be reaching 250,000 miles prior to replacement or five years, whichever comes first. At MCEMS, a chassis ages out before it reaches maximum miles.
Table 9. . Ambulance Fleet Utilized by MCEMS # Unit ID Type Year Make Model Conversion License # Mileage Age Valuation 1 88 III 2009 Ford E450 Excellance 7058 95,000 7 $ 88,000 2 81 III 2011 Ford E450 Excellance 13322 91,000 5 $ 89,000 3 83 III 2013 Ford E450 Excellance 47130 41,000 3 $ 98,000 4 80 III 2015 Ford E450 Excellance 10106 11,500 1 $ 94,000 5 Med-1 SUV 2013 Chev Tahoe None 86106 12,000 3 $ 35,000
Best Practice EMS systems have fleets that represent 150% to 200% of peak demand for urban systems and 125% to 150% for rural systems. Under MCEMS’ present schedule, the system in- service peak is three units. At 125% this would be four ambulances. The MCEMS fleet conforms to benchmark fleet capacity.
Quality Control Driving System MCEMS would benefit from the use of a monitoring system such as a “Dash Cam” or other “black box” recording technology that provides behavioral feedback and accountability for emergency response vehicle operators. When implemented effectively, these types of systems have reduced accident rates dramatically, lowered maintenance costs by as much as 10% to 20%, and can extend the life of parts (e.g., brake pads). There are several monitoring products on the market that can provide this information. MCEMS should evaluate the use of this technology.
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Patient Stretchers The stretchers in use by MCEMS are relatively new and in good working order. They are the Stryker Power Cots that help reduce back injuries and facilitate easy loading. This is a valuable best practice.
Preventive Maintenance Emergency vehicles typically are driven long and hard. Best practice preventive maintenance programs keep vehicles on the road and out of the shop. Maintenance is also critical for matching timeframes for capital replacement schedules.
Cost per mile is an important tool for monitoring maintenance effectiveness. It should include all costs associated with the operation of a vehicle. This includes maintenance labor, parts, and fuel. Tracking these costs should begin when the vehicle is acquired and should be measured consistently over the lifespan of the vehicle. MCEMS reports the ambulance fleet mileage for CY2015 at 64,800 miles. Maintenance, including fuel, labor, and parts for same time period was $32,256. This provides a fleet cost per mile of $0.50. The EMS director is responsible for managing maintenance of the fleet and performs some minor maintenance as needed.
National benchmark costs for ambulance maintenance is $0.50 per mile. The fleet costs per mile are within benchmark standards. There is reported to have been no critical failures within the past five years, indicating that keeping fleet maintenance within benchmark standards reduces liability of critical failures. Critical failures occur when maintenance is inadequate or incomplete. It is not uncommon for expensive repairs to be deferred, driving the cost/mile down while subjecting the vehicle to higher than standard critical failures. This is not the case in Marquette County. The tables and recommendations below reinforce industry benchmark standards.
Maintenance Practices Although preventive maintenance (PM) is scheduled in accordance with manufacturer recommendations for each vehicle, PM may be delayed for various reasons. A PM routine generally consists of an oil and filter change, as prescribed by manufacturer. A common measure of fleet performance that has a direct impact on operational effectiveness is the number of vehicle critical failures per 100,000 miles. The median for The Coalition of Advanced EMS Systems (CAEMS) most recent national study is 2.00 vehicle failures per 100,000 miles. MCEMS management can demonstrate over 300,000 miles without a critical failure.
. At minimum, a multi-point DOT level safety inspection is recommended to be conducted every time a vehicle is serviced and the completed check sheet kept with the vehicle’s file.
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Table 10. Model Preventive Maintenance Schedule
Service Mileage Hourly Service Points Level Interval Interval
Check lights, signals, warning systems, fluid levels, tire pressure, AC & Daily N/A N/A heating systems, wipers, brake pedal travel, tire condition & monitor engine condition. Change oil & filters, check suspension, belts, alternator, tire wear, & A 5,000 200 load test battery. Check suspension & differential, fuel filter, brake rotors & pads.
B 10,000 400 All A items, plus replace belts, fuel filters, air filters, transmission fluid.
All A & B items, plus replace A/C compressor & dryers, hoses, oil bypass C 30,000 1,200 lines, repack bearings, replace shock absorbers.
D 100,000 4,000 All, A, B, & C items, plus replace water pump & radiator.
Best practice programs tend to check vehicles every 5,000 miles or 200 engine hours and have a graduated inspection and replacement schedule as the vehicle increases in miles. By taking a comprehensive approach, fleet management can catch potential maintenance problems before they cause vehicle failures.
When an outsourced vendor is utilized, the PM should follow a prescribed check sheet that is signed and dated by the vendor. Vendors must be monitored to assure the completion of the check sheet. If litigation occurs as a result of a vehicle mishap, maintenance records will prove to be valuable. These check sheets should be filed according to vehicle and maintained throughout the lifespan of each vehicle to evaluate cost effectiveness. This practice also mitigates liability risk, should litigation occur.
Cost per mile should include all labor, parts, and fuel consumed by each vehicle. Mileages must be recorded monthly and a running average should be established for comparison each month. Vehicles with consistently higher averages should be replaced. Although the Consultant was able to identify cost per mile of the fleet, best practice would be to be able to perform this for each vehicle, every month.
Rationale for Preventative Maintenance Schedule Ford Motor Company defines extended idling as follows:
. Over 10 minutes per hour of normal driving . Frequent low speed operation . Sustained heavy traffic less than 25 MPH
– One hour of idle time, is equal to approximately 25 miles of driving
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If any light- or medium-duty diesel-powered vehicle falls into the above categories, it is classified under Severe Service Operations and thus the following maintenance intervals are suggested in the Owner’s Manual: . Oil Filter: 5,000 miles, 200 engine hours, 250 gallons of fuel or 3 months (whichever comes first) . Fuel Filters: 10,000 miles, 400 engine hours or 6 months (whichever comes first)
Example: Each day a certain vehicle averages 50 miles driven and 6 hours of idle time. Here’s how its maintenance schedule would look, if based simply on miles driven: . 5,000 miles recommended interval divided by 50 miles driven per day would result in a scheduled oil change every 100 days
Factoring in the idle hours on those 100 days: . Six hours of idle time per day at an estimated 25 miles per idle hour (from above; one hour of idle time is equal to approximately 25 miles of driving) results in 15,000 simulated miles.
Conclusion: After 100 days the engine oil actually has 20,000 miles of wear! If this vehicle were to have scheduled preventative maintenance, based on engine hours instead of miles driven, the interval would change to approximately 30 days.
Fleet Replacement Planning
Description of Best Practices Ambulances should be considered for replacement based on two distinct factors: age or miles (or hours), whichever comes first. Light duty modular (Type 3) ambulances, when properly maintained, should last five years, 250,000 miles or 10,000 hours. Medium duty ambulances, when properly maintained, should have a usable life of seven years, 350,000 miles or 14,000 hours. Throughout the EMS industry, the current trend is to use gasoline versus diesel engines. This is because gasoline engines are easier to work on, cost less in maintenance and fuel, and have less down time.
Observations and Findings One of the previously mentioned benchmarks is fleet composition. A fleet comprised of all the same vehicle type and manufacturer is preferred for these reasons:
. Parts are easier to stock. . Maintenance staff becomes familiar with the way a truck is built and how to repair it, which results in efficiency and quality work.
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. Cabinetry layout in the rear can be specified for uniformity, helping to improve medic efficiency.
Ambulance vehicle conversions (build out of the patient care areas) are available from one ambulance manufacturer, Excellance. Visual inspection by Fitch revealed the fleet to be in “good” condition, overall. The MCEMS fleet follows best practices regarding selection and replacement practices.
Remounting Remounting a patient care module instead of purchasing a new ambulance has valuable advantages. In a fast-paced urban environment, the miles may mount up on a chassis before it ages out at five years. Remounting typically costs about 75% of the cost of a new ambulance. But this option only can be accomplished with a light duty or medium duty truck chassis. In communities where capital budgets are tight, the savings of performing a remount versus purchasing a new vehicle may make the difference between replacing an ambulance versus not keeping a chassis that is incurring a rising cost per miles and significant downtime issues. If remounting an ambulance is the chosen option, it’s best to obtain a bid from the original manufacturer and have them perform the work. The problems commonly encountered with low bid remounters is not worth the savings.
MCEMS, for consistency and value, has selected to remount the ambulance boxes multiple times. For example, Unit 81 is on its third chassis under the modular patient compartment. In concert with Excellance’s 25 year modular structure warranty, this make good use of the initial investment and capitalizes on the re-mountable concept. When a unit is scheduled for remount, it is sent back to the Excellance factory in Alabama for the work to be accomplished. This includes the latest technology and upgrades that are going into current models under production. Typical re-mount cost is around $90,000 which includes a new Ford gas engine, chassis and all upgrades to the modular unit. This is an industry best practice.
Following a vehicle replacement schedule allows for capital expense planning as well as replacing units before they become failure liabilities.
Fleet and Logistics Recommendations
17. Continue maintaining the power cot stretchers. 18. Track vehicle collisions to determine preventability to improve driver safer. 19. Track fleet critical failures to monitor maintenance program. 20. Consider purchasing driver monitoring technology for each vehicle in the fleet. 21. Continue the fleet preventative maintenance program. 22. Continue the remounting of the patient care module onto new chassis, by using the original manufacturer to perform the remount.
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Preparedness MCEMS should be prepared for large-scale community disasters. The September 11, 2001 terrorist attack on New York City and several other large-scale natural disasters in the United States have stimulated increased governmental funding for all facets of emergency preparedness. Additionally, there has been a rapid increase of active shooter episodes in smaller communities. MCEMS preparedness efforts appear to be in line with ambulance industry norms. Staff preparedness training should be a priority to ensure that they have basic safety and security knowledge of the communities they serve. Records indicate that MCEMS staff has been certified in National Incident Management System (NIMS) Incident Command System 100 and 700 levels. Crew chiefs also maintain level 300. Haz-Mat training up to the awareness levels should also be available for crew chiefs.
EMS systems should have all-hazards preparedness approach, combined with knowledge of the unique risk factors faced by the communities served. By weighing likely and less likely risks, it’s possible to strike a balance in preparedness efforts. Clearly, EMS systems must maintain focus on day-to-day operations, while considering system enhancement for the far less frequent events they encounter.
The 2014 Ebola and 2016 Zika Virus outbreak in the United States focused attention on infectious disease control. MCEMS should use this opportunity to revisit their infection control and post- exposure procedures. The reality for any EMS is that other diseases easier to acquire in the line of duty exist. Adequate plans include having a trained, designated infection control officer, vaccination history documentation for all employees, and infectious disease training that is provided on an annual basis. MCEMS should insure that adequate supplies of personal protective equipment (eye protection, gowns, gloves, shoe covers, and surgical masks) are on hand and should provide annual fit testing for N-95 masks that may be issued to employees. Cleaning procedures and cleaning supplies should be reviewed to be sure they meet the needs of the service. Finally, post-exposure reporting and follow-up procedures should be updated to ensure compliance with federal guidelines and state department of health regulations, as well as with the hospitals that may receive patients with communicable diseases. Also many states are enacting legislation regarding infectious disease control and the roles of responders. The Centers for Disease Control provides guidance and information resources that are highly valuable: http://www.cdc.gov/quarantine/specificlawsregulations.html
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Preparedness Recommendations
23. Conduct exercises several times a year to keep caregivers’ skills and knowledge fresh so that they are always prepared to operate in a disaster environment. 24. Consider joint training with other first responder agencies such as emergency management, other ambulance services, fire and police, as well as PSAPs at defined intervals. 25. Review and update infection control plans, training and procedures regularly. 26. Haz-Mat training at the awareness level should be provided to all staff. 27. Train in active shooter response and determine the level of support of EMS in case EMS arrives before law enforcement.
Medical Direction and Accountability Description of Best Practices
Medical Accountability Benchmarks . Single point of physician medical direction is in place for the entire system. . Written agreement (job description) for medical direction exists. . Specialized medical director training/certification is in place. . Medical director establishes local care standards that reflect current national standards of practice. . The physician facilitates proactive, interactive, and retroactive medical direction. . ePCR/QI data is accessible and transparent for MD review. . Clinical education/development is effective. . Clinical education is efficient.
Observation and Findings Dr. James Gariti, M.D., is the long-time MCEMS Medical Director (MD). He will be retiring later in 2016. Replacing Dr. Gariti may be Dr. Jennifer Bahr, MD. She is an active ED physician with Divine Savior Hospital in Portage. The relationship with Dr. Gariti has been, at best an informal relationship with MCEMS. Unlike Dr. Gariti, Dr. Bahr should be compensated for her time.
The medical director should provide services for the MFRs and EMS. The medical director should provide review of the patient care protocols, perform some patient chart reviews and be present several times a year for drills and training. Although the director and crew chiefs are responsible for training, the medical director should be participative. The medical director must credential each paramedic in the service to the State before they can function as part of the caregiver team.
Electronic Patient Care Reporting The ePCR is a point of care data entry tool for EMS crews. The information about the patient’s condition, assessment, and interventions is documented by the caregiver at the patient’s side
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using a hand-held device. This information should be electronically linked with the dispatch information to develop a record of the entire event as well as interfaced with the billing system for transparency.
MCEMS currently utilizes Tri-tech’s ePCR computer program that integrates with the Tri-tech billing program. All reports are completed on the ToughBook CF-31 laptop computer with a solid state hard drive. All ePCRs are generated on the ToughBooks and uploaded to the main sever via wireless network.
Data Collection The following section discusses technology utilization including ePCR and CAD related issues.
Appropriate technology should be completely utilized by integrating data collected by patient care reports, billing and PSAP computer aided dispatch (CAD) into a single consolidated information resource. Marquette County PSAP CAD will not support direct ePCR interface. The ToughBook laptops will interface with the Tri-Tech Response billing platform. Still, there is a lot of redundancy required possibly resulting in transitional errors due to necessary manual entries. Manual input of dispatch information is required.
Ideally the ePCR reporting package should be able to provide administration with measurements of system and clinical performance on demand.
Education and Quality Management Initial Training
MCEMS employs EMT-Bs, EMT-I/99s and Paramedics. Staff are expected to apply with one of the licenses to work. From time to time, classes of initial training or bridging programs are offered to enhance the staff skill levels. Presently, the EMT-I/99 levels are undergoing transition nationwide. The National Registry for EMTs no longer recognizes this level of certification, while Wisconsin still has regulations pertaining to them. While the EMT-I/99 scope of practice is as close to a paramedic as is available, bridging to become a licensed paramedic may be necessary in the future. The bridging program consists of about 400 hours of classroom plus clinical experience. A nearby community college offers the bridge program and could be offered locally with enough interest. It would be best for the community to offer bridging for the local EMT-I/99 staff before the agency goes out and hires very many paramedics from outside.
Observations and Findings MCEMS provides certification training and CEU programs for EMTs, Intermediates and paramedics. No initial training for licensure is provided. Initial level training programs can be
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obtained at Madison College or other locations. Caregivers must then maintain their initial training licensure.
. All required CEUs are provided by crew chiefs or director. Up to $300 for additional CEU may be provided. . Mandatory refresher courses are paid for by agency. . Training and CEUs are tracked through a module in the Tri-Tech computer system. The system easily tracks time and programs by individual student and provides alerts prior to a certification expiring. . Several staff members hold instructor credentials for some of the training programs.
Driver Training Emergency vehicle driver certification training is a best practice for every staff member who drives an emergency vehicle specifically. The emergency driver program should include both classroom and practical driving exercises to ensure that the drivers are competent to manage the inherent risks of operating EMS and other emergency units. This training should be conducted during new hire orientation. Scheduled refresher courses to ensure driver proficiency should occur annually, or as needed for remediation.
Emergency vehicle driver proficiency and awareness is critically important for two reasons: EMS accidents are the leading cause of death for EMS providers, and poor driving habits result in increased wear and tear on both the drivers and vehicles. Annual refresher training is beneficial for maintaining skills and keeping crews conscious about their performance and the maintenance of the vehicles. An important measure of driver proficiency is the number of vehicle collisions per 100,000 miles. The CAEMS benchmark participants report a median of 1.13 collisions.
MCEMS had one collision involving a deer in the past 24 months. It did not disable the ambulance.
Quality Management The quality management processes at MCEMS include medical director input and were found to be reliable. The crew chiefs and the director review 100% of the ePCRs. They are reviewed again by the administrative person as they are being coded and processed for billing.
The following are examples and recommended components of a quality program. The Sample Control Chart (Figure 13) is a useful statistical process tool for QI.
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Figure 14. Sample Control Chart
SCA ROSC @ ED
100.0%
90.0%
80.0%
70.0%
60.0%
50.0%
40.0%
30.0% UCL 0.29
CL 0.21 20.0%
LCL 0.12 10.0%
0.0% 7-Jan 7-Feb 7-Mar 7-Apr 7-May 7-Jun 7-Jul 7-Aug 7-Sep 7-Oct 7-Nov 7-Dec Date/Time/Period
Key Performance Indicators – These are based on call requests. Upon review of the Tri-Tech CAD data, it is common to find that call types fall into four categories: respiratory, cardiac, traumatic injuries and miscellaneous. By establishing performance measures for the first three categories and then doing targeted studies on the miscellaneous call types in category four, the system can provide continuous feedback of the EMS system’s clinical performance.
Targeted Case Studies – Each month, targeted reviews on certain call types (e.g., Refusals, CHF, Advanced Airways and 12-Lead applications, etc.) provide a deeper look at clinical performance. This is also an effective way to target key call types or the miscellaneous category of call types. The results of these reviews can be tied directly into in-service training, making it a pertinent and data driven educational exchange. This capability can allow follow up later with another targeted review to see if things have changed and additionally, allow a more robust approach to meeting the content areas required for recertification. Sentential Event Review – Event-driven reviews round out the final piece of a sound quality management program. This is traditional quality assurance protocol and practice, which includes sentinel events, complaints, and specifics such as airway insertion, Glasgow Coma Score < 8, IV failures, etc. These activities should account for a small amount of overall time commitment.
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Making a transition to system-focused quality management and away from simply recording clinical errors can be accomplished, in part, with regular quality meetings that follow an agenda structure similar to the following.
Review Key Performance Indicator (KPI) data – Each meeting should begin with a review of the EMS system’s performance scorecard. Are all processes in statistical control? Are there any statistical variances worthy of exploration? What are the results of improvement efforts?
Updates on targeted reviews – As targeted reviews are conducted each month, updates on the progress, new data, and findings should be included in regular meetings. What are the results? Are any system or process changes indicated? How can the data be deployed most effectively through education?
New Directions – Based on the results of KPI data, targeted reviews, or other indicators, the director should check for areas requiring further exploration or that would benefit from a change in course. This may include staff discussion of whether the performance measurement system in place is capturing critical data adequately.
QI Update – The last order of business includes a summation of any complaints or individual call reviews conducted. This should be a small portion of the total meeting time and is done in the spirit of improving processes and systems with an emphasis on achieving best performance targets. It is very helpful to establish a ground rule of eliminating individual finger pointing that encourages open communication facilitates problem solving.
Implementing a quality approach similar to the one described will provide MCEMS and the medical director with a much more in-depth perspective on the clinical quality of the system. This approach also can be expanded department-wide for addressing operational aspects of service delivery.
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Medical Direction and Accountability Recommendations 28. The medical director should be contracted with specific goals and benchmarks. This position should have a compensation factor applied based on time required. 29. Include demand analysis (average, 80th percentile, and maximum), key performance indicators, and individual/system skill performance in any ePCR reporting package. 30. Consider implementing a formal, phased field training and evaluation program for all new volunteers that includes patient contacts and chart reviews. 31. Develop a paramedic assist class for EMTs covering the equipment and skills used by the paramedics. 32. Develop a key performance indicator scorecard to be used on a monthly basis so that data can be used to improve the patient outcomes. 33. To maintain modern practice standards, distribute and maintain an effective quality improvement program. 34. Document and chart outcomes such as IV attempts and airway placements, etc. 35. Contact local community college to schedule a bridge program from EMT-I/99 to Paramedic
Customer and Community Accountability Description of Best Practices A dramatic shift is occurring in healthcare reimbursement with government payers. It is important for healthcare organizations to demonstrate patient satisfaction with the services provided. Organizations that are unable to demonstrate accountability could receive reduced reimbursement, or possibly, no reimbursement at all. Organizations that are solidly committed to quality and good recordkeeping - and which are able to consistently demonstrate patient satisfaction - will experience no such dilemma.
Customer/Community Accountability Benchmarks . Legislative authority to provide service and written service agreements are in place. . Units and crews have a professional appearance. . Formal mechanisms exist to address patient and community concerns. . Independent measurement and reporting of system performance is utilized. . Internal customer issues are addressed routinely.
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Observations and Findings
Patient Satisfaction Currently, MCEMS does not conduct any patient satisfaction surveys. Best practice EMS organizations solicit feedback from their customers regarding patient satisfaction. As outlined in the Affordable Care Act (ACA), future reimbursement amounts are calculated based on determining the satisfaction of the care provided. Without a survey tool, the service cannot demonstrate patient satisfaction.
These surveys could be conducted by mailing letters to a randomly selected sampling of patients. The survey should be printed on a postage paid return post card with instructions. A 30% return would constitute a quality sampling. Survey results can be shared with caregivers reinforcing the services they provide.
Typical patient survey queries: . Ratings for impression of EMS crew . General patient demographics . Ratings of ambulance and the quality of the ride . Did caregivers meet the needs of the patient? . Tell what is important to you when you dial 9-1-1
Customer and Community Accountability Recommendations 37. Initiate a patient satisfaction survey and share the results with staff and community leaders. 38. Provide an annual report to elected officials and community stakeholders. 39. Log internal and external complaints and incidents for tracking and resolution purposes.
Prevention and Community Education Description of Best Practices
Prevention and Community Education Benchmarks . System personnel provide positive role models. . Programs are targeted to “at risk” populations. . Formal and effective programs with defined goals exist. . Targeted objectives are measured and met.
Observations and Findings MCEMS personnel present a positive image in the community. Caregivers maintain a professional image. Uniforms observed were clean and in good order. The public views the staff as helpful, professional, and trustworthy.
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Standby Services MCEMS provides some standby services, both paid and gratis. Standby services are a good opportunity for new volunteers to take the lead and organize.
Community Education MCEMS has extensive involvement in community education. A number of caregivers have instructor certifications and work within the organization teaching community programs such as CPR. As an EMS organization, MCEMS provides support for some community education/prevention programs. There does not seem to be any specific community program that MCEMS, as an organization, leads to promote community awareness/prevention. Community education does require time commitments on the part of the organization and volunteers. Given the small-town nature of the organization, if there was a champion for community education, volunteers would likely step up to represent the organization. Examples of EMS based community programs include:
. Hands-only CPR training . AED Public Access Defibrillator Program (PAD) . CPR training for every high school junior . Citizen Emergency Response Team (CERT) training, focusing on staff in every school . Child seat installation and donation program
Prevention and Community Education Recommendations
40. Management should fine tune standby services staffing to match levels of need with each program, and associated costs should be determined. 41. MCEMS should identify and adopt a formal community awareness/intervention program.
Governance, Growth, Organizational Structure and Leadership
Description of Best Practices In best practice EMS systems, a single lead agency is legislatively charged with the comprehensive leadership, development, and regulation of the Emergency Medical Service System.
Organizational governance, structure, and relationships are well defined. Human resources are developed and otherwise valued. Internal processes are designed to facilitate achievement of performance, with due regard for effective development, involvement and motivation of
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personnel at multiple levels within the organization. The agency assures ongoing needs assessment for areas of personnel shortage, trends in personnel utilization, and generalized health or safety issues. The agency has either documented actions to address human resources needs or, alternatively, has documented that no significant workforce needs or provider agency management issues exist as a result of the needs assessment.
MCEMS has a clear mission and vision. Leaders have established measurable program goals and outcome-based, time-specific, quantifiable, and measurable objectives that guide system effectiveness, performance, and growth. Clinical outcomes and patient experience are clear drivers for the organization. Now is the time for next stage business planning and program development. Operational and clinical data should be used to guide the decision process. Comprehensive annual reports on the status of the EMS system, including the effectiveness of all subsystems routinely report information system data and performance measures. A structured performance/quality improvement (QI) system exists and addresses administrative as well as clinical issues. The EMS lead agency maintains clear procedures for enforcing personnel compliance with laws, regulations, and policies pertaining to provider licensure/certification.
Organizational Structure and Leadership Benchmarks . A lead agency is identified and coordinates system activities. . Organizational governance, structure, and relationships are well defined. . Human resources are developed and otherwise valued. . Business planning and measurement processes are defined and utilized. . Operational and clinical data guides the decision process
Observations and Findings Each of the following sections describes the findings related to governance, growth, organizational structure, human relations, and leadership.
Governance and Regulatory Compliance In general, state EMS legislation aims to establish criteria for emergency medical providers at all levels across the state of Wisconsin. MCEMS is one of four county-operated EMS services in Wisconsin. Traditionally, regulations focus on basic guidelines for the licensing of ambulances, fleet and equipment standards, certification and continuing education requirements, and medical direction.
MCEMS has the necessary licenses (one for each station) to operate at the state level as an EMT- Intermediate Ambulance Service and is in good standing with the regulatory organization.
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Organizational Structure and Human Resources EMS management team structures vary from organization to organization and are typically based on system model, coverage area, and call volume. Traditionally, an organization the size of MCEMS will have a management team that includes a director, administrative support, and lead designations on each shift. Existing staff commonly shares additional responsibilities such as overseeing the fleet, scheduling, training, etc. The titles and specific responsibilities vary.
MCEMS is a county based governmental entity. Oversight is provided by a seventeen-member elected board of supervisors, with operations managed by an EMS Director.
Organizational charts provide an understanding of the reporting relationships. Having a formal organizational chart clarifies the reporting structure to the staff and other departments.
Figure 15. MCEMS Administrative Structure Chart:
EXECUTIVE LEADERSHIP The Marquette Board of Supervisors are the elected authority providing oversight for all county departments, including EMS. Purchasing, budgeting, human resources, communications are all interactive within other county departments ultimately under the Board. The Supervisors hire an EMS director to carry out day to day actual leadership assignments. For the past 25 years, the director has not changed.
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OPERATIONAL LEADERSHIP The director is tasked to be a multi-dimensional leader and is one member of a two person office. The operational management of MCEMS is made up of three crew chiefs that operate 24/7 and are assigned to an ambulance station. Besides field supervision, each crew chief is assigned additional administrative responsibilities, such as chart reviews, supplies and inventory, training, and new hire orientation and most importantly, maintaining the shift calendar.
The crew chiefs all report that they must schedule themselves to work shift positions when unable to fill a spot for an EMT-I. In 2015, it appeared that all three crew chiefs had worked in excess of 200% additional hours than scheduled. In interviews conducted by FITCH, all three chiefs indicated that this seems to be increasing, as they lose volunteers for various reasons. Although the crew chief is able to remain untethered to the EMS station, they cannot roam too far or leave the community, when they are on the schedule, which is most of the time.
Volunteers Volunteers are the heartbeat of organizations such as MCEMS. The organization started out with a robust staff of volunteers. However over time, as in every other community in America, volunteers are volunteering less. These individuals would work a variety of shifts, run calls, and are key members of the team, while trying to blend work, family and other activities. Over time as the organization gained response area and the call volume increased, the scheduling of volunteers has become more difficult. With no hospital in the County and long response and transport times, maintaining an ALS ambulance service is paramount. Concern grows that there may not be an EMT-I/99 or paramedic available to man the ambulances 24/7. Three crew chiefs were hired as full time employees, one for each station. Volunteers are compensated for their time based on the call. EMT-Bs are readily available and cover most of the scheduled time required.
Paying hourly wages to crew chiefs was the first step in securing ALS coverage. Over the past year, the crew chiefs as well as the director and administrative assistant have had to schedule more than twice their regular hours as paid on call. For example, the Montello crew chief worked her 160 hours a month and then was assigned an additional 286 hours of on call time. The Westfield crew chief was scheduled for 160 hours of regular hours and then was scheduled an additional 356 hours of paid on call for a total of 516 hours in one month. A month contains 720 hours, meaning this crew chief was working or on call for 24 hours a day for 72% of the month. The director, in addition to his work shift, took an additional 160 hours of on call for the Oxford ambulance. Undoubtedly, there is a significant staffing crisis requiring the paid staff to work inordinate hours to maintain ALS coverage for the county. If a crew chief applied for medical leave or left the organization, it would necessitate the closure of a station.
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If 140 paid hours a month were added to each station (420 hours) at a part-time rate of pay of $14.00 per hour, would add close to $6,500 (hourly + 7.7% taxes) a month of additional personnel costs to the budget. This would only reflect an increase of $3.67 per capita for the year.
Human Resources The human resources component at MCEMS lies at the county level, but is supported by the EMS leadership. It includes many mandatory components such as time and a half overtime paid to crew chiefs after 40 hours, there are definable job descriptions for each position and employee benefits are administered in a professional manner. It is important that HR practices are complete and compliant; however, the office does not have a Compliance Manual.
EMT, Inc. EMT, Inc. is a 501(c) (3) not-for-profit organization formed by the EMS work force and their families. They conduct numerous very successful fund raising programs in the community to supplement EMS for equipment, supplies and training. Their most profitable program is a letter writing campaign to the community asking for donations. Money from EMT, Inc. is used to purchase large ticket items such as AEDs, jackets and provide scholarships for training programs.
Governance, Growth, Organizational Structure, and Leadership Recommendations
42. The collaboration with EMT, Inc. is a powerful fund raising tool. As the need for tax dollars
increase, may reduce the willingness of some citizens to donate.
43. There should be a Compliance Manual created to guide administrative staff in the following of
legal guidelines and processes.
44. 140 hours of Part time EMT-I/99 or paramedic time should be hired for each station district. 45.
Paid at a part time hourly rate, should provide some relief for the crew chief’s after hours
obligations
46. Track open shifts for trends and begin a hybrid staffing model.
System Finances and Funding
Description of Best Practices In best practice systems, the governing body has identified and appropriated sufficient infrastructure funding from tax levies, insurance recoveries and other non-lapsing funding sources for the EMS system to function in a manner consistent with its legislated mandates. Unit Hour Utilization (UHU) is measured and resources are deployed in a manner to achieve efficiency and effectiveness. Cost per unit hour, per transport and cost per capita are measured and the
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metrics document good value for money. Financial systems accurately reflect system revenues and document both direct and indirect costs.
Financial data is derived routinely from the EMS data, insurers, emergency department, hospital discharge, death certificate, and rehabilitation data and, along with data on general EMS infrastructure costs and is used to assess the cost/benefit aspects of the system. A method exists to investigate, diagnose, and intervene when problems are identified.
Ensuring Optimal System Value Benchmarks . Clinical and customer satisfaction outcomes are enhanced by the EMS system. . Unit Hour Utilization (UHU) is measured and hours are deployed in a manner to achieve efficiency and effectiveness. . Cost per unit hour and transport demonstrate good value. . Financial systems accurately reflect system revenues and both direct and indirect costs. . Revenues are collected professionally and in compliance with federal regulations. . Costs by service line are verified, controlled and represent good value. . Capital asset planning supports the organizational mission. . Local tax subsidies are minimized.
Observations and Findings This section focuses on two areas: reimbursement and system finance. A brief overview of funding is provided. Summaries of the findings are discussed in more detail in each of the following sections.
Funding for MCEMS services is secured from two primary sources—user fees and a tax subsidy. An EMS mill levy, exempt from state-mandated cap limits funds shortfalls from the EMS budget. Secondary sources such as training fees and a contract with Adams County also provides some additional funding,
There are five major categories of payers for ambulance services: Medicare, Medicaid, private insurance, contract accounts, and self-pay patients. Medicare and Medicaid are fixed-fee payers and both, on average, pay less than the fully allocated costs of ambulance services. Medicaid pays significantly less than Medicare in Wisconsin. Contract accounts are those negotiated with other municipalities for the provision of ambulance coverage.
Typically, patients are responsible for co-insurance, deductibles, or the full cost when they have no insurance coverage to reimburse for ambulance services. Nationwide, only a small percentage of billed charges are recovered from self-pay patients (2%). This leaves the insurance companies (29%) to make up for the underfunded governmental programs, indigent care, and low percentage of patient payments.
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The ambulance industry mimics the rest of the healthcare industry by including the costs of uncompensated care in its commercial rates. While there is a limit to the amount that can be charged and reasonably reimbursed by insurance companies, even subsidized ambulance services will continue to do so, as they have few other options.
Billing and Reimbursement Section 4531 (b) (2) of the Balanced Budget Act of 1997 added Section 1834 (l) to the Social Security Act (the Act), which mandated the implementation of a national Ambulance Fee Schedule (FS) effective for Medicare Part B ambulance services claims with dates of service on or after April 1, 2002. The Ambulance Fee Schedule applies to all ambulance services. Section 1834 (l) of the Act also required mandatory assignment for all ambulance services, which means that the provider or supplier will be paid the Medicare allowed amount as payment in full for these services. In addition, the provider or supplier may bill or collect only any unmet Part B deductible and coinsurance amounts from the beneficiary.
The federal government and healthcare systems are linking compensation with quality measures. This is in place for hospitals and physicians and is being implemented for skilled nursing facilities and home healthcare. It is only a matter of time before quality measures will determine reimbursement levels for ambulance services. Many of the recommendations in this report are in preparation for value-based reimbursement – specifically the quality improvement and customer service components.
Table 11 below charts the retail user fees charged and by procedure and how much the government funded programs allow based on procedure code. Tax payers enjoy a discounted base rate when using the services.
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Table 11. Base Charges and Allowable Description Code Charge MCARE MCAID BLS Emergency - Resident A0429 $600.00 346.31 151.84 BLS Emergency - Non Resident A0429 $650.00 $411.24 $180.31 ALS 1 Emergency - Resident A0427 $700.00 $595.21 $260.97 ALS 1 Emergency -Non Resident A0427 $750.00 $10.74 $5.56 ALS 2 Emergency - Resident A0433 $800.00 $10.74 $5.56 ALS 2 Emergency - Non Resident A0433 $850.00 $10.74 $5.56 On Scene BLS - Resident A0998 $200.00 $0.00 $0.00 On Scene BLS - Non-Resident A0998 $300.00 $0.00 $0.00 On Scene ALS - Resident A0998 $400.00 $0.00 $0.00 On Scene ALS - Non Resident A0998 $500.00 $0.00 $0.00 Transport Mileage - Resident A0425 $14.50 $10.74 $5.56 Transport Mileage - Non Resident A0425 $15.00 $10.74 $5.56 Additional Charges A0999 Varies $0.00 $0.00 ** - MCARE pays $10.74/mile for 1st 7 miles, then pays $7.10/mile.
Revenues and Collection Processes The administrative assistant has been to ambulance specific billing and reimbursement training. She is a certified ambulance biller and coder. MCEMS conducts billing and collection services in- house. This means the Administrative Assistant and the Director are responsible for data input, coding of claims and applying charges. Using the Amazon Billing by Tri-Tech, which is server based and backed up on multiple platforms including off site. Patient care reports (ePCRs) are generated using Tri-techs Field Data program associated with the Toughbook computers and then uploaded into the billing system every day. All standard reports are available.
All transports are billed as emergency since they are all scene responses and originate from a 911 call center.
The key measure for determining the effectiveness of a collection agency is focused on the percent of billed charges collected. MCEMS is able to collect 57.9% (FY 2014) of the total billed charges. This is on target with industry gross collection rates and is reflective of good process and procedures for obtaining reimbursement, and a favorable payer mix (which entity pays the bill, i.e., Medicare, Medicaid, commercial insurance).
Another indicator is the net collection rate where the total charges are reduced by contractual allowances. The contractual allowances are those amounts that the service is precluded from receiving. For example, the service has to accept what Medicare allows as payment in full and this amount is significantly below the retail patient charges. The gap is larger for Medicaid
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recipients where the Medicaid reimburses a small fraction of the charged amount. At MCEMS, Medicare and Medicaid contractual allowances represent 37% of the total amount billed. Bad debt and uncompensated care represents 5.1% of the total amount billed, which is better than the industry benchmark standard of 15%.
Patient Payer Mix (Table 9 below) is comparable to other 9-1-1 ambulance services across the country.
Table 12. Payer Mix Revenue Sources CY 2014 Self-pay 2% Commercial Insurance 29% Medicare 51% Medicaid 18%
The final indicator is the amount of time it takes to collect and close an account. This is measured from the date of service until the account is considered satisfied in full. It may include a contractual allowance being applied, a payment by a third party source, and/or payment from the patient. This is called an account’s “days in A/R”. Medicare usually pays about 14 days after receiving a claim. Some HMOs pay claims at 45 days after receipt, the time allowed by law in some states. Veterans Administration contracts are notorious for prolonged payments.
The following time parameters constitute benchmarks for medical billing and collections: . 30 days or less for a High performing Ambulance Billing Department. . 40-50 days for an Average performing Ambulance Billing Department. . 60 days or more for a Below Average Ambulance Billing Department.
Combined accounts receivable has a “Days in A/R” rating at 66 days, an accounts receivables rating which is little high by industry standards for a similar patient mix and service base. A/R over 120 days is another valuable measure. This is derived by simply dividing the total amount of receivables against the value of receivables over 120 days.
. A/R over 120 days at less than 12% is considered good performance. . A/R over 120 days between 12% and 25% represent average performance. . A/R over 120 days at 25% or greater should re-evaluate their processes
MCEMS has an A/R over 120 days rate of 36.7%. This rate is more than twice the rate it should be, and 57% of the over 120 days old is in the over 180 days category. An effort should be made to reduce the 0ver 120 days and especially the over 180 days to keep the AR manageable. Anything not active should basically just be sent off to outside collections or written off as uncollectable.
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Mileage charges can typically generate a substantial amount of revenue. The MCEMS average transport mileage is 23.3 miles for FY 2014.
From a high level review of the reimbursement and billing process, the organization and staff involved are doing a better than average job. Typically with services of this size, the consultant does not recommend to perform billing and collection services in house. At MCEMS, the billing benchmarks are mostly being met and the staff have a good handle on how to perform this function correctly, timely and lawfully. If at such time a major change of personnel occurs with the key staff people, we would recommend outsourcing this function to a qualified third party.
System Cost and Finance Historically, MCEMS has been able to meet expenses and set some cash reserves aside with the help of three different tax revenue sources and a good outside billing company maximizing user fee collections. Over time, the organization implemented Advanced Life Support care levels, increased staffing; however, when compared to national benchmarks, the cost per transport is $968.29. The total wage and benefit line items represent 80% of the expenditures. This is typical of hybrid/volunteer based operations of this size.
MCEMS follows the Marquette County general ledger and financial reporting template. Fiscal year is the calendar year.
Observations and Findings MCEMS recorded 2014 gross billing at $1,093,666. Close to 37% of MCEMS’ billings are reduced by lawful contractual obligations (Medicare and Medicaid). Billing operations was able to recover 80.0% of net billings, which is above industry standards.
Taxing Authority Marquette Board of County Supervisors have the authority to make up any operational shortfalls with the use of general fund tax dollars. Tax dollars typically cover the cost of standing by or availability. With low call volumes, the cost of availability is expensive. Over the years the tax contribution to EMS has varied slightly. In the past three years, the subsidy has remained relatively flat. The cost of availability to the citizens of Marquette County is $18 a year or $1.51 a month per person. This is exceedingly low by measures of other area communities as noted at Table 14 below.
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Table 13. Tax Contribution Year Tax Dollars 2011 $ 167,159 2012 $ 129,716 2013 $ 262,335 2014 $ 279,488 2015 (est.) $ 275,120
Other Wisconsin communities around Marquette County provide paid full time ambulance staffing. Their revenue, call volume and geographical service area are similar to Marquette County. The difference is, each of those communities has a higher tax base to support the costs of availability.
Table 14. Area EMS Agencies Subsidy per Capita Community Tax/Capita Marquette $ 18.12 *Waushara Contract $ 23.00 **Adams Contract $ 14.00 Waushara $ 42.43 Portage $ 37.37 ***Springville (Adams) $ 20.00 ****Dells Delton $ 32.50 *Marquette pays Waushara to service NE corner of county **Adams pays Marquette for western two townships ***Spring City in Adams County pays Curtis Ambulance for service ****Dells/Denton charges to outsource their services
Based on the data above in Table 14, Marquette tax payers should be able to pay a larger per capita subsidy in order to assure ALS coverage as well as an improved response time to emergencies.
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Table 15. FY 2014 Financial Summary Financial Summary CY 2014 Gross Revenue billed (+) $1,093,666 Contractual deductions (-) $403,180 Net patient Fees (=) $690,486 Charity Care/Bad Debt (-) $143,517 Net Operations cash (=) $546,969 Tax Contribution (+) $279,488 Adams County (+) $27,800 Training (+) $7,500 Total operations funds (=) $861,757 Total Operational Expenses $847,986
System Finances and Funding Recommendations
47. Send accounts with no activity that are over 120 days to collections or bad debt. 48. Make sure all user charges exceed the CMS allowable fees. 49. Consider an increase in the subsidy to pay for additional paid EMT-I/99 or paramedics’ hours for sustainability of ALS services.
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THE FUTURE
THE WAY FORWARD
We have made multiple recommendations to strengthen the EMS program in Marquette County. Unfortunately, there are no easy answers to issues confronting this organization. The status quo, in our view, is not sustainable over time and is not a valid option. The alternative is to make a significant investment to implement the recommendations outlined throughout the report accepting the losses associated with the required improvements.
Another option is to consider an alternative system design, but the complexity of doing so does not seem warranted for MCEMS to achieve the improvements discussed herein. There are over 20 common models of ambulance service delivery. The most common include: . Exclusive franchise (private) . Non-exclusive franchise . Entirely volunteer . Hospital based . Volunteer . Fire service based (paid) . EMS/third government service . Not-for-profit community based . Police operated
Ambulance service is medically (physician) driven and is, therefore, primarily a healthcare service that is delivered in a public safety environment. Key elements and guiding principles for system design should be considered by the County. These include: . Ensuring performance accountability . External oversight . Full cost accounting and disclosure . Design features that ensure efficiency over time, . Performance sustainability being central to the right to continue to serve
In our view, an optimal EMS system is best designed from the patient's perspective. Patients should expect that the service will be engaged in community awareness including prevention, health education, and early symptom recognition, in addition to responding to emergency and transportation requests. The EMS system should provide a rapid and appropriate response when a caller dials 9-1-1 and routinely provide medical instructions until help arrives. Medical first responders should be able to deliver rapid defibrillation, arriving within ten to twelve minutes with 80% reliability in rural areas.
Standards, such as NFPA 1710 and the Commission of Ambulance Accreditation, suggest an eight-minute response of ALS; however, current studies suggests proper first response of ten to
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twelve minutes can allow for the arrival of ALS within 19:59 in rural areas on life-threatening emergencies with 80% reliability from the time the EMS center receives the call.
Patients should be transported to a hospital that can treat their specific condition, not just the closest receiving facility, or the hospital with which the service is affiliated. The EMS system should be externally and independently monitored with participants held accountable for their responsibilities. Finally, the system should deliver good value for the resources invested.
STATUS QUO IS NOT AN OPTION The status quo is unsustainable. If MCEMS does not change its current mode of staffing, the system is at risk for having to shut down an ambulance station or reverting back to a Basic Life Support (BLS) service, which will neither serve patients or taxpayers well. There simply are not enough volunteer EMT-I/99s and paramedics to fully staff three stations without causing an undue hardship on the crew chiefs and director. As EMT-I/99s move away from the area, there is no one to replace them. The service must continue to benchmark their activities and trend their results.
STATUS QUO IMPROVED A system design change is not recommended. A county-operated third service should serve the community best. With the changing of the medical director and the EMS Director in 2016, the service is at risk of not being able to maintain the high level of dedication and work effort exhibited by the current director. The Board of County Supervisors will need to receive regular updates on the status of the recommendations and the key benchmarks as outlined in this report.
The harsh reality is that additional funding is required to maintain this program. We estimate that the annual cost for the increased staffing level will approximate $90,000. Additional funds to implement the other recommendations will need to be budgeted over time to bring MCEMS into line with the performance of other EMS systems of similar size and structure.
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SUMMARY OF RECOMMENDATIONS
Community Access and Emergency Communications Recommendations
1. The PSAP should make consistently using and EMD protocol a priority. The CAD should make emergency versus non-emergency response determinations; they should be capable of advising crews upon dispatch. 2. The PSAP should be reporting call processing times and EMD and pre-arrival instruction compliance to MCEMS and the medical director. 3. Add AVL/GPS to ambulances as the Spillman CAD is updated.
Medical First Response Recommendations 4. MFRs should be accountable to the MCEMS medical director through QI process involvement. 5. MFR/MCEMS joint training that accommodates the scheduling needs of the volunteer companies. 6. MFR response times should be reported and measured from call receipt until “wheel stop,” on a fractile basis to the tenth of a second, based on NFPA standards.
Clinical Service Levels Recommendations 7. A minimum of three part time staff at EMT-I/99s or paramedics need to be hired to cover extra shifts not filled by volunteer EMT-I/99s. 8. Track times volunteers are not available to create a hybrid schedule increasing paid staff time as funds are available and the need arises.
Resource Utilization and Demand Recommendations 9. Track call volume and response time calculations by station. 10. Request the PSAP to provide response times to include the seconds and load into the tri-tech system. 11. Perform response time calculations based on CAD records. 12. Adopt a response time performance for emergency responses of 19:59 minutes measured on a fractile basis at the 80th percentile for all calls. 13. Chute times goals should be measured and plotted. 14. Continue to track demand annually, as it relates to ambulance/station placement. 15. Identify property for future station locations. Engage a design firm and let out bids for targeted completion by end of 2020. 16. Consider county-issued bonds for funding the construction of the stations.
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Fleet and Logistics Recommendations 17. Continue maintaining the power cot stretchers. 18. Track vehicle collisions to determine preventability to improve driver safer. 19. Track fleet critical failures to monitor maintenance program. 20. Consider purchasing driver monitoring technology for each vehicle in the fleet. 21. Continue the fleet preventative maintenance program. 22. Continue the remounting of the patient care module onto new chassis, by using the original manufacturer to perform the remount.
Preparedness Recommendations 23. Conduct exercises several times a year to keep caregivers’ skills and knowledge fresh so that they are always prepared to operate in a disaster environment. 24. Consider joint training with other first responder agencies such as emergency management, other ambulance services, fire and police, as well as PSAPs at defined intervals. 25. Review and update infection control plans, training and procedures regularly. 26. Haz-Mat training at the awareness level should be provided to all staff. 27. Train in active shooter response and determine the level of support of EMS in case EMS arrives before law enforcement.
Medical Direction and Accountability Recommendations 28. The medical director should be contracted with specific goals and benchmarks. This position should have a compensation factor applied based on time required. 29. Include demand analysis (average, 80th percentile, and maximum), key performance indicators, and individual/system skill performance in any ePCR reporting package. 30. Consider implementing a formal, phased field training and evaluation program for all new volunteers that includes patient contacts and chart reviews. 31. Develop a paramedic assist class for EMTs covering the equipment and skills used by the paramedics. 32. Develop a key performance indicator scorecard to be used on a monthly basis so that data can be used to improve the patient outcomes. 33. To maintain modern practice standards, distribute and maintain an effective quality improvement program. 34. Document and chart outcomes such as IV attempts and airway placements, etc. 35. Contact local community college to schedule a bridge program from EMT-I/99 to Paramedic
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Customer and Community Accountability Recommendations 36. Initiate a patient satisfaction survey and share the results with staff and community leaders. 37. Provide an annual report to elected officials and community stakeholders. 38. Log internal and external complaints and incidents for tracking and resolution purposes.
Prevention and Community Education Recommendations 39. Management should fine tune standby services staffing to match levels of need with each program, and associated costs should be determined. 40. MCEMS should identify and adopt a formal community awareness/intervention program.
Governance, Growth, Organizational Structure, and Leadership Recommendations 41. The collaboration with EMT, Inc. is a powerful fund raising tool. As the need for tax dollars increase, may reduce the willingness of some citizens to donate. 42. There should be a Compliance Manual created to guide administrative staff in the following of legal guidelines and processes. 43. 140 hours of Part time EMT-I/99 or paramedic time should be hired for each station district. 44. Paid at a part time hourly rate, should provide some relief for the crew chief’s after hours obligations 45. Track open shifts for trends and begin a hybrid staffing model.
System Finances and Funding Recommendations 46. Send accounts with no activity that are over 120 days to collections or bad debt. 47. Make sure all user charges exceed the CMS allowable fees. 48. Consider an increase in the subsidy to pay for additional paid EMT-I/99 or paramedics’ hours for sustainability of ALS services.
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Attachment A
Ambulance Benchmark Summary
Marquette County Emergency Medical Service Page 64 ©Fitch & Associates, LLC EMS Assessment 19 April 2016
Ambulance Benchmark Summary
Presented to
Marquette County, Wisconsin Emergency Medical Services
April 19, 2016
Prepared by
Marquette CountyEmergency Medical Service Attachment A - Page 1 ©Fitch & Associates, LLC EMS Assessment 19 April 2016
System Components Benchmarks Overview
Communications Benchmarks— Comments Public access through a single number, D preferably enhanced 9-1-1 Coordinated PSAPs exist for the system D Single PSAP, coordinated secondary from Adams County Certified personnel provide pre-arrival instructions and priority dispatching (EMD) ND No EMD. Previously trained in and this function is fully medically PowerPhone but not maintained. supervised Data collection which allows for key service ND PSAP advises no reports available elements to be analyzed for EMSs Technology supports interface between ND Spillman CAD will not support 9-1-1, dispatching & administrative interfaces with EMS Processes Radio linkages between dispatch, field units Multiple repeaters allow for good & medical facilities provide adequate D coverage coverage and facilitate communications
Medical First Response Benchmarks— First Responders are part of a coordinated PD MFRs where available coordinated response system and medically supervised and medically supervised by a single system medical director Defined response time standards exist for ND No response time standards. first responders First response agencies report/meet ND No response time standards. fractile response times AED capabilities on all first line apparatus D AEDs available on units that participate & S.O. cars Smooth transition of care is achieved D Key D=Documented, ND=Not Documented PD= Partially Documented
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Medical Transportation Benchmarks- Defined response time standards exist. ND No response time requirements. Agency reports/meets fractile response ND Fractile response times not times reported. Units meet staffing and equipment D In compliance with State law & requirements medical Control Resources are efficiently and effectively PD Fixed station deployment, but seem deployed to be in primary population localities There is a smooth integration of first D Agencies integrate well response, air, ground and hospital services Develop/maintain coordinated disaster PD Practiced disaster plan in place. plans Need additional training & practice
Medical Accountability Benchmarks— Single point of physician medical direction PD Single MD reviews operations but for entire system not supervise PSAP Written agreement (job description) for ND medical direction exists Specialized medical director D Active ED physician training/certification Physician is effective in establishing local D care standards that reflect current national standards of practice Proactive, interactive and retroactive PD Current MD not so active. New MD medical direction is facilitated by the will be more engaged. activities of the medical director PCR/QI data transparency for MD review D Web-based, online Clinical Education/Development D Active training programs by crew Effectiveness chiefs & director Clinical Education Efficiency D Key D=Documented, ND=Not Documented PD= Partially Documented
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Customer/Community Accountability Benchmarks— Legislative authority to provide service and D Licensure & authority to provide written service agreements are in place services are present & current Units and crews have a professional D Units & crews look sharp & clean appearance Formal mechanisms exist to address patient ND No mechanism exists and community concerns Independent measurement and reporting of PD Ability to measure and report exists system performance are utilized Internal customer issues are routinely PD Good communications with chiefs addressed and staff
Prevention and Community Education Benchmarks— System personnel provide positive role D Local staff provide good image for models community Programs are targeted to “at risk” ND No “at risk” programs exist populations Formal and effective programs with defined ND No specific programs. goals exist Targeted objectives are measured and met ND No specific objectives.
Ensuring Optimal System Value Benchmarks— Clinical outcomes are enhanced by the D Director utilizes outcomes for system training Amb Response Utilization and transport ND Flat static scheduling vs. Utilization (UHU) is measured and hours are effectiveness or demand deployed in a manner to achieve efficiency and effectiveness Ambulance cost per unit hour & transport D Cost per transport and UHU is document good value within benchmark standards Service agreements represent good value PD Difficult to evaluate Non-emergency ambulance effective & ND Services not provided efficient Non-Ambulance but medically necessary ND Services not provided (MAV) services are effective and efficient System facilitates appropriate medical D access Financial systems accurately reflect system D revenues and both direct and indirect costs Revenues are collected professionally and in D In-house process works well. compliance with regulations Tax subsidies when required are minimized PD Very low per capita participation Key D=Documented, ND=Not Documented PD= Partially Documented
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Organizational Structure and Leadership Benchmarks— A lead agency is identified and coordinates D MCEMS is the lead agency system activities Organizational structure and relationships D are well defined Human resources are developed and PD Needs written compliance manual otherwise valued Business planning and measurement PD Needs to conduct future business processes are defined and utilized planning Operational and clinical data informs/guides D the decision process A structured and effective performance D based quality improvement (QI) system exists Key D=Documented, ND=Not Documented PD= Partially Documented
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