U.S.
Department of Health and Human Services
Health Resources and Services Administration
Office of Rural Health Policy
This document was prepared under HRSA contract
# 250-03-0022, U.S. Department of Health and Human Services, Health
Resources and Services Administration, Office of Rural Health Policy.
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Contents
Foreword
Introduction
What is the Rural and Frontier
EMS Agenda for the Future?
Community Assessment and Planning
Introduction and
Background
Key Recommendations from the
Rural & Frontier EMS Agenda for the Future
Specific Tasks
Integration and Regionalization
Introduction and Background
Key Recommendations from the
Rural & Frontier EMS Agenda for the Future
Specific Tasks
Quality and Performance Improvement
Introduction and Background
Resources for Quality
Improvement Project Development
Key Recommendations from the
Rural & Frontier EMS Agenda for the Future
Specific Tasks
Conclusion
Contact Us:
APPENDIX A: About the Rural &
Frontier EMS Agenda for the Future
APPENDIX B: Acknowledgements
APPENDIX C: REMSTTAC Stakeholders
Foreword
The Rural and Frontier EMS Agenda for the Future,
published in 2004, was a landmark document that focused attention
on the issues specific to the survival and improvement of EMS in
rural America. Much of what is included in the document is aimed
at policy makers at various levels of government. However, it also
contains many practical ideas and concepts that can, and should,
be implemented at the local EMS agency level.
This serves as a companion document to the report
and identifies some of the tasks that can be started in almost any
rural and frontier EMS agency. We recognize that taking on additional
tasks as a volunteer overseeing a rural agency may seem impossible.
However, the action items listed in each section are, in most cases,
small steps that can be accomplished over time.
We hope that each of you will choose at least one of these tasks
to tackle in your community. By completing these activities you
will make a difference to your agency, your community and your patients.
Marcia K. Brand, Ph.D. |
Nels D. Sanddal, Director |
Associate Administrator
for Rural Health, HRSA |
Rural EMS and Trauma
Technical Assistance Center |
Rural and Frontier EMS
Agenda for the Future: A Service Chief's Guide to Creating Community
Support of Excellence in EMS
INTRODUCTION
"Rural America is unique and requires unique
solutions."
-David Sniff, National Rural Health Association
Ensuring access to high-quality EMS services is
growing more and more difficult for EMS ambulance agencies in rural
areas around the country. Many rural EMS agencies are finding that
it is:
- challenging to understand and successfully
respond to changing reimbursement policies, regulation, and community
needs,
- hard to recruit and retain quality staff (paid
or volunteer),
- complicated to keep up with changing technology,
- challenging to meet the needs of an increasingly
elderly population, and
- difficult to "make ends meet" financially.
In order to succeed in the future, rural EMS agencies
must galvanize community support, develop strong partnerships and
collaboration, and utilize new systems to measure performance and
enhance quality. Achieving any of these goals is difficult; succeeding
in all three areas seems like an overwhelming task. However, there
are resources to help rural EMS agencies address these challenges.
One such resource is the recently published report, the Rural and
Frontier EMS Agenda for the Future. This guide summarizes some of
the key elements of the Rural and Frontier EMS Agenda for the Future,
and describes the changing health care environment so that rural
EMS services can best position themselves to succeed in the future.
What is the Rural and Frontier EMS Agenda
for the Future?
The Rural and Frontier EMS Agenda for the Future
is a 2004 report that describes an optimal future for rural EMS
and describes changes that would be required for rural EMS to achieve
that vision. Several associations worked together to complete the
report and invited hundreds of EMS professionals and other interested
people to submit comments regarding the current rural EMS system,
and to suggest important systems changes that must occur for rural
EMS to remain viable.
The partner organizations that decided to undertake
the project were the National Association of State EMS Officials,
the National Organization of State Offices of Rural Health, and
the National Rural Health Association. With funding from the U.S.
Department of Health and Human Services Health Resources and Services
Administration, Office of Rural Health Policy, these organizations
set up a Web site to accept comments from any interested parties
and also sponsored a 1-day meeting that was attended by over 100
individuals who represented ambulance services, other health care
providers, and numerous associations and government agencies. A
final report was published in October of 2004 (read more about the
development of the "Agenda" Appendix A).
The partners had several purposes when they decided
to undertake this project. First, they wanted to lay out a policy
agenda for political leaders and rural EMS advocates. They wanted
to provide guidance to influence policy makers whose decisions can
have an impact on the future of rural EMS. However, the partners
also believed that the Rural and Frontier EMS Agenda for the
Future could serve as a guide for local and State EMS agencies,
and their communities, in developing realistic plans for the future
based on available resources. Ultimately, sound local decision-making
will ensure the ongoing success of EMS in any community. With that
in mind, A Service Chief's Guide to Creating Community Support of
Excellence serves as a companion document to the Rural and Frontier
EMS Agenda for the Future and is created specifically to provide
information, tools and resources to rural EMS leaders and their
partners. Specifically, this guide will help EMS agencies address
issues around the topics of:
- Community Assessment and Planning. A
deliberate planning process involving broad representation from
the community (including representatives of health care, education,
public safety, business, government, citizen consumers, and other
"stakeholders") should be used to guide system decisions in rural
communities. EMS is generally poorly understood in rural areas.
EMS agencies cannot afford to plan for the future without involving
the community (which should help develop community support). The
planning process should examine at the current situation, a "visioning"
process to describe what the community would like EMS to become
in the future, and an honest dialogue regarding the type of system
the community is willing to support in the long term. Most rural
and frontier EMS systems are currently under-funded. Expansion
and upgrading of existing systems without solidifying community
commitment to funding could result in deeper financial hardships.
- Integration and regionalization. Historically,
these words have had a negative flavor in rural areas, but it
is important that rural EMS providers embrace these concepts.
Integration does not mean that a local EMS system has to become
a part of a larger organization and lose its independence. But
in today's environment, EMS must collaborate closely with local
health care systems, public health, and public safety. EMS agencies
may also want to form closer connections with other "sectors"
in the community. Regionally, EMS needs to think about its role
in the continuum of health care delivery. Centers for Medicare
and Medicaid Services and other Federal agencies have already
begun demonstration programs to base reimbursement on quality.
In rural areas, measures that demonstrate quality across the entire
spectrum of care, including EMS, will be selected for "pay for
performance" systems in the coming years. This includes such things
as participation in programs that improve outcomes for such issues
as trauma, cardiac, burns, and stroke. Being part of an organized
and pre-planned system has measurable benefits to those in need
of services.
- Quality and Performance Improvement.
As mentioned above, Medicare and other payors/purchasers of health
care services are moving toward systems where payment is based,
in part, on performance in accordance with standardized quality
measures. Regulators may follow the trend in years to come, by
requiring that regulated agencies demonstrate that quality improvement
systems are in place. Patients deserve to be treated by organizations
that are committed to reducing errors and providing the highest
possible quality services. Quality Improvement and Performance
Improvement (QI/PI) systems are dependent on processes to gather
and analyze data and methods to use this information to improve
systems performance.
This guide provides information about existing
resources and tools that are available to local EMS leaders who
undertake community planning and establish strong QI/PI efforts.
The information is designed to help keep rural EMS services viable
next year and well into the future. To survive, however, there is
another important role for rural EMS, and that is the role of advocacy.
An unfortunate byproduct of the lack of understanding of rural EMS
is that oftentimes it is overlooked when policy decisions are made,
or poor policy decisions are made on behalf of rural services. It
is important that rural EMS be a strong and vocal advocate, and
to educate the general public and policy makers at a local, State,
and national level about the importance of a quality EMS system
in rural areas. In this guide you will find information that will
help you, as a local EMS leader, use strategies and techniques to
advocate on behalf of your system.
The remainder of this guide is broken into the
three general focus areas summarized above: community assessment
and planning, integration and regionalization, and quality and performance
improvement. Each of the three sections is further broken down into
three discrete parts, an introduction and background statement,
a list of specific key associated recommendations from the
Rural and Frontier EMS Agenda for the Future that support
the section, and a brief list of specific action items that
might be implemented to move a rural EMS system closer to the attainment
of at least some of Rural and Frontier EMS Agenda for the Future's
recommendations. Many rural EMS agencies will have already completed
some of the tasks. Target those tasks and activities that make the
most sense for your service. There is also a brief guide to advocacy
at the end of this document. Advocacy is the word used to describe
involvement of an agency in the political process. To be successful
you have to do more than simply go about your business and provide
good service; it is also imperative that you work with decision-makers
to help them understand rural EMS needs and issues. This advocacy
guide will provide some ideas about ways to get involved in the
political process (see Appendix B). That process may seem intimidating
or even mysterious to some. If you are among those, don't worry.
This guide will take away some of that mystery and show you some
simple ways to get involved, and help position your service for
success.
COMMUNITY ASSESSMENT AND PLANNING
Introduction and Background
"
Despite the last 30 years of experience
and intense media profile, EMS remains mostly a mystery to the
public. They know we will show up when they call 9-1-1, but the
public knows very little about who we are, how we are organized
and funded, and quality in the system." - Tom Judge, CCT-P,
Executive Director, LifeFlight of Maine
Comprehensive advanced life support (ALS) services
are difficult to establish and maintain in systems with low call
volumes, because of the high fixed costs associated with ALS services
and the challenge of being able to recruit, retain, and adequately
reimburse highly-trained paramedics. As a result, the more remote
a rural area, the less likely one is to find advanced life support
(ALS) levels of EMS available in that area. However, even in rural
areas many residents may expect that ALS care is readily available.
In areas where EMS is heavily dependent on volunteers, and services
are limited to basic life support (BLS), the general public may
be surprised to learn that paramedic care is unavailable.
In rural areas, many of which have a limited (and
perhaps shrinking) resource base, community support of EMS should
not be taken for granted. If EMS is to sustain community support,
it is critical that the community understand the challenges EMS
faces. Rather than shying away from community scrutiny, EMS should
help communities accurately understand the services they provide,
other service options that exist, and the cost of the options. This
education needs to start at a basic level. Indeed, many people outside
of health care do not even realize that different types of EMTs
(basic, intermediate, and paramedic) exist. The community needs
to understand the costs of maintaining EMS in both financial and
human resources so they can make an informed decision about the
level of service that is possible. Rural EMS services should promote
a community-based EMS assessment and planning process and encourage
community decision makers to determine the type and level of EMS
they desire and the means to fund the system. You need to ask, "How
can we add value to our present system?"
A number of community EMS assessment and planning
programs have been developed for rural areas in the United States.
Two State EMS offices have developed community technical assistance
team processes, and in these States expert teams visit communities
to assist in the process of community assessment. Another process
was developed by a not-for-profit agency with funding support from
the Federal Office of Rural Health Policy. The Critical Illness
and Trauma Foundation (Bozeman, Montana) offers their "EMS
Community Planning and Integration Guide" online at http://www.citmt.org/Training.htm#Community%20Planning.
This process includes a system self-assessment as well as perception
surveys conducted with a variety of community sectors (health care,
public safety, school system, media, government, etc.). Regardless
of the approach you decide on, you will probably need some outside
help. Your EMS Office, State Office of Rural Health or the Rural
EMS and Trauma Technical Assistance Center (REMSTTAC) may be able
to help you find resources to provide assistance with the assessment
process.
Key Recommendations from the Rural &
Frontier EMS Agenda for the Future
- Develop a national template for community EMS
system assessment and informed self-determination processes to
help communities determine and be accountable for their own EMS
type, level, and investment (Ch. 8).
- Fund processes for community EMS system assessment
and informed self-determination. Consider regional and statewide
resources (e.g. aeromedical services) in implementing these processes
(Ch. 8).
- Foster the development of a culture of volunteerism
and community service through local schools in partnership with
community agencies (Ch. 5).
- A national EMS service leadership and service
management training model should be developed and shared with
all State, territorial and tribal governments. This model should
include successful practices in EMS volunteer and paid human resources
management (Ch. 5).
- Conduct an ongoing assessment by rural/frontier
EMS agencies and local hospitals of their resources and needs
and search for common educational opportunities (Ch. 7).
- Emphasize optimal interdisciplinary care of
the ill or injured patient, including complex event management
such as cardiac arrest and multiple casualty incidents (Ch. 7).
Specific Tasks
- Establish a local planning group that consists
of EMS stakeholders, local political/policy leaders, medical community
leaders, and public health leaders to develop an EMS system development
plan at the community level. This group can become the catalyst
for the implementation of a focused effort to identify future
directions in the development of your local EMS system. You may
want to choose a facilitator for this group. Oftentimes you can
find trained facilitators in your area. County extension agents
are often a good resource for this activity, particularly if they
utilize the tools available through REMSTTAC.
- Ensure that your agency is represented at regional
and statewide activities in EMS system development. This would
include attending key meetings, monitoring Internet information
resources such as list serves, and maintaining an awareness of
opportunities that may be helpful to your local efforts in EMS
development and planning.
- Assign individual liaisons to key partners
in the local EMS system. The liaisons should be responsible for
developing relationships with those components of the community
that can support your EMS mission. By having these liaison relationships
in place, your partners can learn more about the needs of EMS
as well as giving EMS providers an opportunity to understand the
web of relationships necessary to support health care in rural
communities.
INTEGRATION AND REGIONALIZATION
Introduction and Background
"Rural and frontier EMS providers must
be well integrated with their public safety partners in this era
of domestic preparedness in order to operate more effectively
in disaster situations. But EMS providers must learn to integrate
as well with community health, medical, and nursing partners if
they are to bring the level and type of care to the community
that it expects and are to continue to operate at all. Our survival
depends upon it." - Kevin McGinnis, MPS, WEMT-P, Program
Advisor, National Association of State EMS Officials and Crew
Chief, Winthrop Ambulance Service (Maine)
In many rural areas populations are aging. Older
populations mean that the need for all types of health care services
increases. However, at the same time many rural communities are
finding it hard to maintain current health care services because
of declining rates of reimbursement, challenges in recruiting and
retaining health care professionals, and a declining tax base as
a result of shrinking population. As other resources dwindle, communities
may increasingly call on EMS providers not only for traditional
emergency services but also for a range of informal care, evaluation,
and advice. These services are often provided in "no transport"
situations, which may be the reason that isolated communities often
have "no transport" rates much higher than the State average.
These locally developed solutions to fill a gap in the community's
health needs have been called "EMS-based community health services"
or "community paramedicine." In some cases these "no
transport models" of care may impose additional burden on rural
and frontier EMS systems due to loss of revenue. In other cases
such care models may provide opportunities to bolster human resources
by establishing paid positions at local hospitals.
How can rural EMS respond to this growing demand
for both traditional and non-traditional EMS services? Many experts
believe the key to rural EMS' survival and success will depend on
the ability of EMS providers to successfully link with partners
including nearby EMS providers, local public safety, and especially
the health care system.
EMS should be able to draw upon fire department,
emergency management, law enforcement, and public works resources
(as well as resources from nearby EMS) as needed, based on the presence
of mutual aid agreements. If such agreements are not in place, EMS
agencies should contact their State Bioterrorism Hospital Preparedness
Program (BHPP) or their Department of Emergency Management for assistance.
Each State has a BHPP, funded through the Health Resources and Services
Administration, and each State program is tasked with providing
technical assistance to local EMS to develop such mutual aid agreements.
Information is available at http://www.hrsa.gov/bioterrorism/.
Rural and frontier EMS should also work closely
with medical oversight to ensure that they are part of teams representing
the continuum of care to enhance triage, transport and treatment
decisions that make effective use of local resources and ensure
a disposition in the patient's best interest. Many States have State
trauma programs and within those programs, regional trauma teams
or councils exist that work to enhance trauma care in their regions.
Other local and State teams are working to enhance the continuum
of care for stroke, heart attack, and other acute medical conditions
that require emergency treatment. Sources of information on these
programs are State Quality Improvement Organizations (http://www.cms.hhs.gov/QualityImprovementOrgs/)
or State FLEX programs (http://tasc.ruralhealth.hrsa.gov/).
Strong medical oversight is a key part of the development of such
initiatives. However, little formal training exists for rural practitioners
who are often trained in family practice or general internal medicine,
to become well versed in providing medical direction for EMS. Currently,
a collaboration led by the Critical Illness and Trauma Foundation
is migrating the NHTSA medical director training program to an interactive
Web-based format (http://www.citmt.org/training.htm).
Regional approaches to consider are many. The
most common regional cooperatives are Quality Improvement-based
systems. In Kansas, the State FLEX program has funded the development
of three such regional QI initiatives. In each case, a regional
EMS provider has worked with smaller EMS agencies in the area to
develop a common run form and to collect and analyze run form data
from these agencies. The regional agency then brings all participating
EMS units together on a regular basis to share information, explore
best practices in care among the sharing agencies, and promote adoption
of these best practices region-wide. EMS should involve emergency
department and other hospital personnel in this process, as they
may have valuable insight into the quality of care based on their
observations of EMS when they arrive with a transported patient.
In some cases EMS services have partnered with local physicians,
and together they have worked with specialists in regional referral
centers to develop standard protocols among the specialists in the
referral centers.
EMS agencies in a region may also wish to form
a collaboration to pursue a joint purchasing arrangement that will
allow them to purchase equipment and supplies at lower prices, and
to rotate stock regionally to ensure that supplies do not have to
be discarded due to non-use prior to expiration dates. One example
of such a buying co-op is the North Central EMS Cooperative (NCEMC),
another network: the Western EMS Network (WEMSN) is forming to similarly
serve western States. State EMS offices (www.nasemso.org)
and State Offices of Rural Health (www.nosorh.org)
are places to search for information on such programs.
Formalized agreements between nearby EMS services
may also allow the integration of paid staff into units that have
essentially relied on volunteer service. It may seem like a stretch
for small basic life support (BLS) units to consider moving to a
model that includes paid staff. However, the nature of volunteerism
is changing in rural America. It is becoming more difficult to recruit
young volunteers who themselves are willing to spend time away from
their jobs, families, and other pursuits to volunteer for the demanding
job of EMT. Finding volunteer staff to work during standard business
hours can prove very difficult, as employers can be reticent to
allow employees to leave work when they realize that long transports
to a distant medical center may mean that an employee is away from
the job for hours at a time. There are examples of services that
have brought paid staff into their organizations and created ALS
systems in environments that historically were based on BLS services.
However, this usually entails integration of several local EMS units,
a political and operational process that is, admittedly, very difficult
to achieve. We are not suggesting that an ALS system is needed in
each area. That decision should be part of the community planning
process described in the first section and supported by historical
EMS response data. A well-trained BLS system with strong relationships
to area health care organizations may be the right solution for
many rural areas, but even these systems will likely need to move
toward a model with paid staff.
This goal might also be accomplished through integration
of EMS and a local hospital, another process that might sound intimidating...to
both sides! Different cultures among EMS and hospitals has often
meant that there is an important, yet uneasy, relationship between
the two. However, integration can have important benefits. Integration
may be defined as close collaboration or sharing of resources. Integration
can provide services access to new resources. Integration provides
EMTs the chance to work in other prehospital and in-hospital settings.
Another potential benefit is the chance to generate new revenues
for the ambulance service. For example, some EMS units owned and
operated by Critical Access Hospitals receive cost-based reimbursement
for Medicare and Medicaid patients. Analyses have shown that cost-based
reimbursement for emergency services can result in significant additional
Medicare and Medicaid revenue. For more information about cost-based
reimbursement, contact your State FLEX program. State program contacts
for the FLEX program can be found at http://tasc.ruralhealth.hrsa.gov/.
Key Recommendations from the Rural &
Frontier EMS Agenda for the Future
- Encourage EMS-based community health service
program development through the funding of pilots, cataloguing
of existing successful practices, exploration of opportunities
for expanded EMS scopes of practice, and ongoing reimbursement
for the provision of such services (Ch. 1)
- Federal, State, and local programs addressing
all-hazards planning, and addressing the specific needs of special
rural populations, should include EMS as a categorical component.
Statewide and border State networks of formal regional EMS mutual
aid agreements, including EMS licensee recognition, should be
established (Ch. 1).
- The Indian Health Service should integrate
tribal EMS-based community health service and Community Health
Representative programming, and consider the use of both tribal
and non-tribal sources of care (Ch. 1).
- Facilitate the use of subscription services
as a part of the overall funding of the EMS safety net infrastructure,
in cooperation with State insurance authorities (Ch. 4).
- Form, and fund through county, regional, State,
or Federal tax dollars, rural/frontier EMS operational or service
contracting networks in those areas where they provide economies
of scale, improved access to EMS care, improved quality and/or
increased tax payer value (Ch. 4).
- Implement EMS based community health programs
and services through an interdisciplinary approach involving EMS
operational and medical oversight components and primary care
professionals (Ch. 6)
- Development of State/regional stockpiling,
and sharing of expensive training devices such as mannequins and
patient simulators (Ch. 7).
- Among local, State, Federal, and national EMS
and public health agencies (and other agencies with prevention
roles), cooperatively develop and fund community health advocacy
roles and prevention programs for rural/frontier EMS personnel
that are mutually beneficial (Ch. 9).
- Provide formal Emergency Medical Dispatch to
every caller seeking EMS (Ch. 10).
- States should establish formal plans for roadside
call-box, satellite, and/or cellular networks to effectively cover
all rural/frontier primary roads (Ch. 10).
- EMS leaders should continue to develop ongoing
paths of communication with State and Federal telecommunications
interoperability and Intelligent Transportation Systems industry
planning entities (Ch. 11).
- EMS-based community health services pilots
and programs should have a physician supervised evaluation system
(Ch. 14).
Specific Tasks
- Review and update existing mutual aid agreements
with neighboring services. Consider including "administrative/planning"
mutual aid in these agreements that will institutionalize an expectation
of routine communication with neighboring services and institutions.
By developing a culture of cooperation and communication, agencies
concerned with providing health care in rural communities can
develop into strong regional consortiums.
- Identify specific needs and opportunities within
your own agency and look for resources outside of your agency
that may be able to provide resources to address these needs.
Approach these agencies and ask for their input and assistance.
This can become the basis upon which strong regional relationships
can be built. In most communities, resources exist that aren't
used due to the fact that someone just never asked. Be the one
to ask!
- Invite local elected officials and policy makers
to attend your organization's meetings on a regular basis. Seek
opportunities to provide reports of your ongoing activities and
needs at county commission meetings, local service organizations,
etc.
QUALITY AND PERFORMANCE
IMPROVEMENT
Introduction and Background
You have to remind yourself
sometimes
.your arrival at the end of the driveway is a significant
event in the lives of those who call for help. It is not just
another call. It is a moment likely to be incorporated into family
lore as "the day the ambulance came."
You try to act accordingly.
To meet the expectations. To simply - help. You won't always live
up to the hype. "What we're going to do
" I was
saying, when the woman on the couch interrupted me.
"Oh, I know,"
she said, "I've seen Paramedics [TV show]." This
is like telling your Little Leaguer you expect him to yank a Randy
Johnson fastball over the left-field wall. We are basic-level
emergency medical technicians. We have skills, but they are basic.
We can't always match what you see on TV
.- from Population
485, by Michael Perry (writer and volunteer firefighter/EMT)
It is true that public expectations of EMS are
high. Often times in rural areas, the expectations may be unrealistic.
But EMS providers, whether individual prehospital care providers
(EMT-B, EMT-I, EMT-P) or the service providers themselves, are all
interested in meeting expectations, and in helping to the best of
their abilities. Also, it must be stated that high quality prehospital
care does not relate to the level of care provided (ALS & BLS).
Basic life support services can provide high quality care. EMS providers
do strive to continuously improve the quality of services they provide
to their patients and to enhance their overall system performance.
It is central to the mission of EMS to provide the best care possible.
However, traditional methods used within health care and sometimes
in EMS to enhance quality (often referred to as "quality assurance")
are limited in their ability to truly make advances in improving
the quality of services delivered. It is thus important for EMS
to begin to adopt new methods to enhance quality. It is something
patients will expect and demand, and in the future, the ability
of EMS providers to document the quality of care they provide may
influence their levels of reimbursement. Purchasers of care, like
the Medicare program, have already begun basing payments to some
types of health care providers on the basis of "pay for performance."
In such systems, providers must demonstrate their involvement in
Quality Improvement (QI) efforts, or even demonstrate actual improvement
in quality on the basis of some predefined set of measures.
QI systems can be simple or complex. If your system
is just beginning a QI program, start simple. Determine several
areas where you believe your system could show improvement. Select
a clinical area, and perhaps also a non-clinical area (form completion,
recruitment progress, billing efficiency, etc.) and discuss the
issue.
First, discuss how you can measure the issue. If you want to improve
some aspect of timeliness, for example, describe how you can measure
the current "baseline" level of performance and how you
can measure improvement. Then, set a target for performance that
describes how much you want to improve. For instance, you might
want to improve the time from when a dispatch call is received to
when the ambulance leaves the station. If it currently takes 20
minutes and you think that could be improved, set a target for improvement,
such as: "We will decrease the time from dispatch call to time
the ambulance leaves the station by 30%". Your goal would be
to have a 16-minute response time. You then have to make plans on
how you can improve your performance to reach your goal. Perhaps
you have read about a process another ambulance service used to
improve their response time, and you decide to try that approach.
Or you could simply ask other area ambulance services for ideas.
One way to generate these ideas is by creating
a "benchmarking" system. This is accomplished when a group
of health care providers agree to share information through a systematic
process so that everyone in the group can see who does something
particularly well. The group of providers agrees to measure the
same process, and to share the resulting data amongst themselves.
Providers that may be struggling with a particular activity can
ask those services that seem to be doing well for advice and assistance,
thus allowing everyone to benefit from this mutual effort. Several
State Flex programs have used Federal funding to support the development
of benchmarking systems. In Kansas, for instance, the Flex program
provided start-up grants to three groups of ambulance services that
came together to do benchmarking. In each instance, one ambulance
service took the lead in discussions among a number of area EMS
providers about creating a common run form, focusing on certain
elements that were measured by the run form, and sharing the information
among one another through reports and monthly meetings when the
services got together to share lessons learned and "best practices."
These networks also provided computers to each ambulance service
so that they could enter the data into a computer, which made the
comparisons among the services easier to accomplish.
Another place to get ideas on performance improvement
is from hospitals where you transport patients. Have you ever sought
input from Emergency Department staff in the hospitals where you
transport? They might be a valuable source of information. State
Rural Hospital Flexibility Program (FLEX) programs are encouraged
to support this type of integration and collaboration, so you should
contact your State FLEX program to see if they may have resources
or assistance that could help you develop this type of process.
Of course, once a service has gathered ideas on
ways to improve a process, they should implement those changes.
It is ideal to implement one change at a time so you can measure
the impact of the change. Implement one change and then continue
to evaluate the issue, and after 1 or 2 months determine if the
change made a difference. If it did, you might be satisfied with
that and move on to look at other measures. Or perhaps you are still
not satisfied and think you could enhance performance even more.
Perhaps you institute another change and once again measure progress
in that area of concern.
Don't continue to evaluate the same parts of your
service forever. Choose one or two areas and show that you can make
improvements. Then move on to another area. Put together teams that
can oversee the process. These teams can include internal staff,
but as we discussed above, consider other resources - other ambulance
services, hospital personnel, perhaps even community members (who
represent the patient perspective). Of course, it is critical to
involve the service medical director in this process.
Resources for QI Project Development
Of course, taking on QI projects takes time and
resources. You may feel you don't have sufficient staff to take
on this added responsibility. If that is the case, please realize
there are many resources available to help you move forward. As
mentioned before, FLEX programs often have (or are aware of) resources
that can help develop these projects. There are also organizations
in each State, funded by the Medicare program, to help health care
providers develop QI programs. These organizations are known as
Quality Improvement Organizations, or QIOs (find your QIO online
at http://www.cms.hhs.gov/QualityImprovementOrgs/).
Each State QIO is different, so your QIO may, or may not, have resources
that are pertinent to EMS.
You may also be able to identify volunteers within
your communities who can help. A great recruiting tool is to provide
opportunities for area youth to learn about EMS. Would you consider
asking the local high school if they would like to offer an internship(s)
to a student to help your service develop a QI program? Approaching
a larger ambulance service in the area to see if they would be interested
in helping with program development is another way to not only establish
a QI program, but promote cooperation and regionalization as well.
Many hospitals have well developed QI programs.
Do you believe an area hospital might be willing to help you? You
might find assistance from a small local hospital, or perhaps a
tertiary facility further away. You may feel that you don't have
a good working relationship with these facilities, but we urge you
to take the step, to start talking with these hospitals. Caring
for patients who arrive through the ER is of critical importance
to hospitals, and they are very interested in working to ensure
that the continuity of care from one provider to the next is as
good as it can be. Your area hospitals, if they are like most, will
be happy to begin talking with you about creating joint QI opportunities.
For instance, a collaboration between area EMS, community hospitals
and cardiac specialists in a referral center might come together
to help determine how to improve the entire continuum of care for
a heart attack patient who lives in your community, from the time
he/she places a 9-1-1 call to the time they receive treatment in
the tertiary facility. A project of this type was initiated by the
Minneapolis Heart Hospital. Working with community ER physicians
and area EMS providers, they were able to improve system "hand
offs" and communication and significantly reduce the amount
of time it took to get transported patients onto the operating table
for life-saving angioplasty.
Key Recommendations from the Rural & Frontier
EMS Agenda for the Future
- Make data that are collected through information
systems at State and Federal levels available for community based
assessment and research, and provide tools to promote community-based
research (Ch. 2).
- Compensate EMS medical directors for the EMS
medical oversight services that are provided. The level of compensation
should be equivalent to the level of compensation the physician
would experience (for the equivalent hours) in their normal clinical
practice (Ch. 6).
- Require that EMS medical directors be physicians,
but encourage the use of physician extenders and regionalized
arrangements of medical oversight to increase the EMS medical
oversight resources in rural/frontier areas (Ch. 6).
- EMS medical directors must actively participate
in local, regional, and State EMS program planning and implementation.
States must seek out and include rural/frontier medical directors
for these purposes (Ch. 6).
- Encourage EMS-based community health service
program development through the funding of pilots, cataloguing
of existing successful practices, exploration of opportunities
for expanded EMS scopes of practice, and ongoing reimbursement
for the provision of such services (Ch. 1).
- Implement EMS-based community health programs
and services through an interdisciplinary approach involving EMS
operational and medical oversight components and primary care
professionals (Ch. 6).
- EMS-based community health services pilots
and programs should have a physician supervised evaluation system
(Ch. 14).
- Fund the availability of training and tool
kits to encourage effective local service/system quality improvement
processes (Ch. 14).
- Implement and maintain a local EMS information
system at every local EMS service/agency. Maintain data on every
EMS event in a manner that is timely and able to drive the quality
of the EMS system service and patient care delivery (Ch. 13).
- As needed, share costs and resources required
to implement and maintain an EMS information system among multiple
systems to achieve an economy of scale (Ch. 13).
- EMS systems must provide analyzed and descriptive
information on service and patient care delivery that they provide
to their EMS personnel, administration, and community (Ch. 13).
- EMS-based community health services pilots
and programs should have a physician supervised evaluation system
(Ch. 14).
Specific Tasks
- Contact your State/regional EMS office to locate
data collection resources that may already be available to your
agency. Many States are working to establish and enhance their
statewide data collection systems and resources may be readily
available that can provide an appropriate capability for your
agency.
- Consider developing a relationship with the
local high school or community college to gain assistance in developing
a data gathering system that works for your community and area
providers. Many institutions of this nature look for opportunities
to place students in "real life" situations and provide local
technical assistance in the development of data collection systems.
- Develop a "quality improvement" team within
your service to identify areas of potential improvement in both
patient care and administrative areas of service. Empower the
team to look into all aspects of service operation and develop
a plan to implement a quality improvement plan of action.
Conclusion
We hope that you have found this document useful
and practical. Hopefully, it has stimulated your thinking about
how your service might be improved or solidified, how you might
better engage the public or how you might work with other agencies.
We look forward to receiving your comments and thoughts on how we
might improve this document in subsequent editions.
Contact REMSTTAC:
Thank you for using the Rural and Frontier
EMS Agenda for the Future: A Service Chief's Guide to Create
Community Support of Excellence in EMS. We're interested in
your feedback on the use and utility of this product. If you have
comments or suggestions for improvement, please contact us at:
Health Resources and Services Administration,
Office of Rural Health Policy
5600 Fishers Lane, Room 9A-55
Rockville, MD 20857
Phone 301-443-0835
Fax 301-443-2803
http://ruralhealth.hrsa.gov/
REMSTTAC
300 North Willson Avenue
Suite 802-H
Bozeman, MT 59715
Phone 406-587-6370
Toll Free 866-587-6370
Fax 406-585-2741
info@remsttac.org
http://www.ruralhealth.hrsa.gov/ruralems
APPENDIX A: ABOUT THE Rural and Frontier
EMS Agenda for the Future
In 1996 the National Highway Traffic Safety Administration
brought together a broad set of experts and advocates to create
the EMS Agenda for the Future. This document was supposed to set
out a broad vision for the future of EMS. However, because rural
America presents such a unique set of challenges to the provision
of Emergency Medical Services, the National Rural Health Association,
the National Association of State EMS Directors, the National Organization
of State Offices of Rural Health and the Federal Office of Rural
Health Policy came together in 2003 and 2004 to target the national
goals outlined in this report that were most critical to rural communities.
These partner organizations were responsible for the publication
of the Rural and Frontier EMS Agenda for the Future.
Their goal was to inspire and inform a number
of different audiences. For rural advocates it was to serve as a
policy blueprint for the future. For political leaders, it was designed
to outline what needs to be done, and what needs to be funded, to
ensure that quality EMS care is available in even the most remote,
frontier communities. And for rural communities nationwide, the
partners hoped that the new document would serve as a tool for what
communities could do with available resources and how they could
plan to sustain and enhance EMS services in the future.
The Rural and Frontier EMS Agenda for the
Future was built on the same format as the 1996 EMS Agenda for the
Future. It proposed continued development of 14 key EMS attributes:
- Integration of Health Services
- EMS Research
- Legislation and Regulation
- System Finance
- Human Resources
- Medical Oversight
- Education Systems
- Public Education
- Prevention
- Public Access
- Communication Systems
- Clinical Care and Transportation Decisions/Resources
- Information Systems
- Evaluation
A process for developing the document began in
2003. Volunteer writing and editorial teams helped in the direction
of a draft document that was posted to the NRHA web site in fall
2003. From January to June of 2004 over 235 individuals from over
100 organizations provided comments about versions of the document
that were routinely posted to the Web site. These included about
100 individuals including local ambulance directors, State EMS officials,
State rural health officials, and a range of policy experts provided
input during a 1-day session preceding the May 2005 National Rural
Health Association Annual Rural Health Conference. The document
was first released to the public in October 2004 at the annual meeting
of the National Association of State EMS Directors (now the National
Association of State EMS Officials).
Fulfilling the vision identified in the
Rural and Frontier EMS Agenda for the Future requires the application
of significant Federal, States and local resources as well as committed
leadership at all levels. Because significant policy and funding
decisions at Federal and State levels are critical to future success
of rural EMS, the Rural and Frontier EMS Agenda for the Future focused,
in large part, on those policy makers. However, the project partners
also recognize that action at the local level is just as important,
if not more important, to the future of EMS in rural communities.
We recognize that rural and frontier EMS providers are acutely aware
of the challenges they face. As such, this new "Service Chief's
Guide" has been created in hopes of arming local EMS providers
with information about possible future directions for rural EMS
system development to ensure their survival, advancement, and growth.
It is meant to serve as a companion document to the Rural and Frontier
EMS Agenda for the Future, and we encourage rural EMS leaders to
learn about and use that original document. It is available for
free download at http://www.citmt.org/download/rfemsagenda.pdf
APPENDIX B: ACKNOWLEDGEMENTS
This service chief's guide was made possible by
funds provided by ORHP and the Rural Emergency Medical Services
and Trauma Technical Assistance Center (REMSTTAC) and the Kansas
Department of Health and Environment. Special thanks for producing
this guide go to Chris Tilden from the Kansas Department of Health
and Environment, Office of Local and Rural Health and to REMSTTAC
staff Nels Sanddal, Director; Heather Soucy, Program Support Specialist;
Joe Hansen, Assistant Director and Teri Sanddal, Associate Director;
and members of the Service Chief's Guide Workgroup at REMSTTAC.
Nels D. Sanddal, B.S., Co-chair
Director
Rural Emergency Medical Services and Trauma Technical Assistance
Center
Chris Tilden, PhD, Co-chair
Interim Director
Kansas Department of Health & Environment
Contributors and Reviewers:
Dennis Berens
Director
National Organization of State Offices of Rural Health
Nebraska Office of Rural Health
Dean Cole
EMS/CISM Program Administrator
Nebraska Health and Human Services System
EMS Program and Public Health Assurance Division
D. Randy Kuykendall, MLS, NREMT-P
Chief, Emergency Medical and Trauma Services Section
Colorado Department of Public Health and Environment
Health Facilities and Emergency Medical Services Division
Fergus Laughridge
EMS Coordinator/ Program Manager
Nevada State Health Division - EMS
Bureau of Licensure and Certification
Kevin K. McGinnis, MPS, EMT-P
Program Advisor
National Association of State EMS Directors
Mary Sheridan
Director
State Offices of Rural Health
Idaho Department of Health and Welfare
Ron Seedorf
Outreach Coordinator
Colorado Rural Health Center
APPENDIX C: REMSTTAC STAKEHOLDERS GROUP
Jane Ball, Executive Director
EMSC National Resource Center
Trauma-EMS Technical Assistance Center
Eli Briggs, Policy and State Affairs Manager
National Rural Health Association
Government Affairs Office
Bethany Cummings
Rural Affairs Ad Hoc Committee
National Association of EMS Physicians
Drew Dawson, Chief, EMS Division
National Highway Traffic Safety Administration
Tom Esposito, Medical Director
Rural EMS and Trauma Technical Assistance Center
Loyola University Medical Center
Blanca Fuertes, Past Project Officer
U.S. Department of Health and Human Services
Health Resources and Services Administration
Office of Rural Health Policy
Tommy Loyaconno, Representative
National Association of Emergency Medical Technicians
Christian L. Hanna, Rural Site Director
Children's Safety Network
National Children's Center for Rural Agricultural Health and Safety
Bob Heath, EMS Education Coordinator
Nevada State Health Division
Marilyn Jarvis, Assistant Director for Continuing
Education
Burns Telecommunications Center
Montana State University
Doug Kupas
Rural Affairs Ad Hoc Committee
National Association of EMS Physicians
Fergus Laughridge, Program Manager
Nevada State Health Division
EMS Bureau of Licensure and Certification
Tami Lichtenberg, Program Manager
Technical Assistance and Services Center
Rural Health Resource Center
Patrick Malone, Director
Initiative for Rural Emergency Medical Services
University of Vermont
N. Clay Mann, Professor, Associate Director of
Research
Intermountain Injury Control Research Center
University of Utah
Evan Mayfield, CDC Public Health Advisor
New York Department of Health
Charity Moore, Research Assistant
Cecil G. Sheps Center for Health Services Research
University of North Carolina at Chapel Hill
Carol Miller, Executive Director
Frontier Education Center
National Clearinghouse for Frontier Communities
Daniel Patterson, AHRQ-NRSA Post-Doctoral Research
Fellow
Cecil G. Sheps Center for Health Services Research
University of North Carolina at Chapel Hill
Davis Patterson, Research Associate
WWAMI Center for Health Workforce Studies
University of Washington
Ana Maria Puente, Project Officer
U.S. Department of Health and Human Services
Health Resources and Services Administration
Office of Rural Health Policy
Kristine Sande, Project Director
Rural Assistance Center
University of North Dakota Center for Rural Health
Dan Summers, Director of Education
Center for Rural Emergency Medicine
West Virginia University
Chris Tilden, Interim Director
Kansas Department of Health and Environment
Office of Local and Rural Health
Robert K. Waddell II, Secretary /Treasurer
National Association of EMS Educators
Bill White, President
National Native American EMS Association
Gary Wingrove, Program Development
Technical Assistance and Services Center
Rural Health Resource Center
Jill Zabel, Healthcare Consulting
Wipfli LLP
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