Questions You Can Ask to Learn About Your System

01 Jan Questions You Can Ask to Learn About Your System

The Dallas Morning News (2016, Sept) reported half to two-thirds of city general funds are for police, fire, and EMS. With significant tax dollar investments, elected officials, community leaders, and the media want to be good stewards. Still, they are frequently not equipped with the knowledge or data to determine if their services are built to get results and where there are opportunities for improvement.

Here are twelve questions local leaders can use to learn about their communities. Each should generate ideas for more learning and improvement.

1. Who do you serve and how? There are many stakeholders an EMS system is designed to serve: Critical patients, taxpayers, EMTs and paramedics, etc (Stout, 1986/January). Who are your key stakeholders? Is there an order of attention? How do you serve the needs of each?
2. What are your constraints? Most communities have a limited set of requirements to satisfy. What are the Federal, State, and local rules, regulations, and ordinances you must follow? Are there other requirements from grants, contracts, or accreditation that you have entered into? Knowing the minimum requirements helps you meet them. It also aids you to see where you can change. 
3. Clinical Outcomes. EMS systems clinically impact a narrow set of clinical conditions: myocardial infarction, pulmonary edema, bronchospasm, status epilepticus, diabetes, and trauma (Myers et al., 2008). NHS England developed measures (Siriwardena, 2008). What is the clinical performance of your system in evidence-based clinical conditions? Pull your data for the last 24 months and develop a run chart for each measure. How are you doing? Do you know how you compare with the best? 
4. Response Time Compliance and Emergency Response. The limited relationship between ambulance response times and clinical outcomes is well documented (Pons, 2005; Blackwell, 2009). Only 6.9 percent of patients receive a potentially life-saving intervention by EMS, yet 86 percent are responded to with lights and sirens (Jarvis et al., 2021), creating unnecessary risk to providers and the community. What are the numbers in your community? What can you do to reduce lights and sirens response? How can you limit ambulance response time standards not tied to clinical outcomes?
5. Over Utilization. Two out of three patients transported by ambulance are discharged from the emergency department (Burt et al, 2005). The Scottish Ambulance Service aided half of its callers over the phone or in the field (Scottish Ambulance Service, 2022/December). HHS estimated 15 percent of EMS-transported Medicare patients could be cared for better by other means (DOT/HHS, 2013). What percentage of EMS calls does your system transport? What percentage could be served without transport to the emergency department?
6. Living Wages and Pay Parity. The median wage for EMTs and Paramedics is $35,470 and $46,770 (US Bureau of Labor and Statistics), or $17 to $22.5 per hour. What is a livable wage for your community? Is EMS compensation equal or better? Do your police, firefighters, and EMS providers have equal compensation? How does EMS compare with other local allied health professions?  
7. Workforce Safety. The injury rate for EMS workers is higher than most professions and several times higher than the national average (Maguire 2005, 2013, 2014). What is your community’s injury rate? What are you doing to reduce injuries?
8. Patient Harm. Medical systems harm patients. Do you miss things (e.g., deterioration, pain)? Do you do things you shouldn’t (e.g., spinal movement restriction, leave at home)? Sampling tools support understanding the harm risk (Howard, 2018). What is your service’s harm rate? Do you know? What are you doing to reduce harm potential?
9. Health Equity. Every person deserves equal care and outcomes. COVID revealed inequity in healthcare systems (Nundy et al., 2022), with data showing unacceptable variation when stratifying by gender, people of color, and socioeconomic factors. What does your community’s data show? What can you do to close gaps in equitable care and service? How does your staff match the diversity of your community?
10. Waste. Berwick and Hackbarth (2012) estimate at least 20 percent of healthcare expenditures are waste. Rework, errors, process variation, unneeded movement, inventory, staffing and overtime, not working to your license, mismatching supply and demand. Do you know where waste lives in your system? What could you do with those funds if you could reduce the waste?
11. Risks. The COVID pandemic was an abrupt introduction to disruptive events. Staffing is now creating swift changes. What other possible future scenarios (Schwartz, 1996) could be disruptive to your community? Reimbursement reductions, worker expectations, universal coverage, reduction in transport, disasters, etc. What potentially disruptive scenarios do you need to understand to best prepare for your community?
12. By What Method? To improve, leaders need a shared method. A method to learn about the system, make changes, and appreciate the results. Were you able to achieve your 2022 strategic objectives? What is your method for improving your system to get enhanced performance? 

This list is not exhaustive. These are questions leaders find useful in understanding their community and their EMS systems. Many can be used for fire and police services, too. What other questions might add to your learning? 

How can you use these questions? Pick one question each month and discuss it as part of your team’s development. Start anywhere. Collect any available data to support the discussion and display it visually in charts or graphs. What does it tell you? What questions do you have? Where can you make changes to get a better result?

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David M. Williams, Ph.D., works with community and ambulance leaders globally to understand and improve EMS systems.

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