Journal of Emergency Medical Services- JEMS, September 2013 Issue
By David M. Williams, PHD
Published on jems.com (http://www.jems.com)
Austin, Texas is on the rise. It’s the 11th most populous city in
America, and it’s one of the fastest growing metro areas in the country.
Featured on virtually every top-10 list, Austin is known as a hub for
high technology, education, government and being the live music capital
of the world. The capital city is also home to the nationally respected
Austin-Travis County EMS (ATCEMS) System. But there might be trouble in
the capital of the Lone Star State. Local press reports from the past 24
months have raised concerns about the system’s performance and
sustainability, and some stakeholders are calling for significant
change. Is Austin’s EMS system in distress or broken?
Quick Assessment
According to the International City/County Management Association’s
(ICMA) report EMS in Critical Condition:
Meeting the Challenge, an EMS
service is in distress if it meets any of the following six signs.1
1.
Media or council investigations: The Austin-American Statesman and
local media regularly report on issues with the Austin-Travis County
EMS department, including stories on problems between Travis County and
Austin about the interlocal EMS agreement funding and the results of
City Auditor reports that are critical of the department’s safety and
billing practices.2–4 The Austin Public Safety Commission has advised
the Austin City Council to request a full department audit.5
2.
Response time troubles: Fiscal year 2013 first-quarter performance
reports to the ATCEMS Advisory Board show urban response time
compliance for Priority 1 calls under 10 minutes at 91.24%; suburban
compliance at less than 12 minutes was 75.09%.6
3.
Internal issues: A November proposition resulted in voters
approving an amendment of the city charter to grant uniformed, certified
EMS employees collective bargaining rights, as well as stronger
arbitration rights for hiring and firing disputes and the department’s
commanders (field supervisors) sued the department over overtime pay.7,8
4.
Turf battles: Tiffs between agencies have been minor, but media reports present relations between Austin-Travis County EMS and the County Emergency Services
departments as stressed. Stakeholders’ proposals that the county pull
out of the EMS system or that EMS be merged into the fire department
are reported.9–11
5.
Lack of accountability or transparency: County administrators have
expressed concerns about performance outside the city and with
reporting reliability.10 Limited performance data is publically
accessible, but it’s not easily accessible and is reported only
quarterly.
6.
Financial distress: In 2012, the Austin-American Statesman
reported the EMS department was to overrun its budget for the first time
in 12 years by an estimated $910,000, and the City Auditor released a
report on the department’s billing operations that identified several
issues including not appropriately handling cash and other payments and
failing to bill Medicaid for an estimated $150,000–$345,000.4,12
Given that ATCEMS meets all of the ICMA signs of distress, it’s easy
to understand why Austin Public Safety Commission Vice Chair and Texas
Monthly founder Michael Levy has described the system as “broken” and
expressed concern about its leadership and sustainability.
The Method
Local stakeholder and media attention on the EMS system focuses on
the pieces of the puzzle that frequently result in a negative assessment
of the ATCEMS department. Still, these assessments haven’t taken a look
at the macro level, and instead remain focused on individual processes
or issues. Local stakeholders also haven’t attempted to apply reasonably
accepted industry criteria to evaluate the current state of the system.
This review attempts to follow a systematic assessment and present the
findings in objective framework to understand the current state of the
Austin-Travis County EMS system.
There are no universally accepted criteria for assessing EMS system
quality. Most consultant reviews pull together evidence from firsthand
experience and best practice from position papers, federal studies and
consensus reports to develop a framework. This review mirrors that
method and uses two primary sources: the American Ambulance Association
(AAA) EMS Structured for Quality guide developed for communities to
effectively contract for high-performance ambulance service and a paper
published in the peer-reviewed journal Prehospital Emergency Care by
physicians from the U.S. Metropolitan Municipalities EMS Medical
Directors Consortium on evidenced-based performance measures.13,14
System Description
For the purpose of this report, ATCEMS is the main focus of analysis.
Due to the climate in the EMS system at the time of research for this
article, the author decided to focus on publicly accessible information.
The majority of the information to follow was pulled from city and
county documents, performance reports, and firsthand experience and
knowledge of the EMS system. City and county elected officials and
department leaders, labor representatives and oversight members also
provided context and background about the state of the EMS system.
It’s acknowledged the 9-1-1 communications center and transport
entity are only components of a complete EMS system, and success also
depends on partners, such as medical first-response agencies and air
medical providers. The following describes the full EMS system serving
Austin and Travis County.
ATCEMS includes volunteer and paid medical first-response
organizations, a municipal emergency-only transport provider, private
interfacility transport providers and a public helicopter.
Medical first response is provided by a spectrum of organizations
around the county, including corporate response groups, volunteer and
combination fire districts, and the Austin Fire Department. MFR patient
care is primarily delivered at the EMT-basic level.
ATCEMS is the exclusive provider of 9-1-1 ground response and
transport in Travis County.
ATCEMS is a municipal third-service agency
within the city of Austin and is jointly funded by the city and the
county. ATCEMS is an all-ALS system and primarily uses a fixed-station
deployment model.
The EMS department was founded by city ordinance in 1976 as the
exclusive provider of emergency and non-emergency ambulance service in
the city. Prior to 1976, a private service had an exclusive franchise to
provide ambulance services. In 1980, the non-
emergency business was transferred to an exclusive private franchise provider.15
The Framework: Five Hallmarks
The AAA EMS Structured for Quality guide describes five hallmarks to
ensure high-performance emergency ambulance service:
1) hold the
emergency ambulance service accountable,
2) establish an independent
oversight entity,
3) account for all service costs,
4) require system
features that ensure economic efficiency, and
5) ensure long-term
high-performance service.
The following applies this framework to the
Austin-Travis County EMS system.
Transport Accountability
Accountability includes monitoring clinical results and response time
compliance, customer feedback, and evidence-based protocols. Austin is
no different than most metropolitan EMS systems, and its performance
accountability is reflective of most government EMS systems. Performance
measurement occurs for several purposes and is reported in a number of
venues.
Measures aren’t publicly available in a single, easily
accessible place.
Austin’s budget requires certain key performance indicators (KPIs)
are measured and reports the data in a system known as the ePerformance
Measures. The data is accessible publically—but not easily—from the
city’s website. The measures are tied to the budget process and aren’t
changed frequently.
Measures aren’t updated in real-time and the reason
why they aren’t isn’t clear.
Response times are an indicator for the Austin ePerformance Measures
and for the Travis County interlocal agreement. Only the city compliance
is reported in the ePerformance system, and there’s no publically
reported county data. Reports to the ATCEMS Advisory Board include
response-time compliance to an urban goal of 9 minutes 59 seconds and a
suburban goal of 11 minutes 59 seconds.
There appears to be no penalty
for failure to achieve the response-time goal.
Out-of-hospital cardiac arrest survival has been a singular
evidence-based measure since the 1980s. ATCEMS reports a 12.1% survival
rate for the 2012 fiscal year in the Austin ePerformance system.16
Additional measures are internally tracked, consistent with the
recommendations from “Evidence-Based Performance Measures for Emergency
Medical Services Systems: A model for expanded EMS benchmarking.”14
ATCEMS Advisory Board minutes show time series charts of data on EMS
call to door interval time for ST-segment elevated myocardial infarction
(STEMI), cerebrovascular attack (CVA) and trauma. No industry standard
performance goal exists, but each measure shows a mean of less than 40
minutes.
There’s no evidence that the EMS department surveys feedback from
customers and reports the results. The EMS System's standards of care
are developed through the Office of the Medical Director and are
available online. Protocols appear to be evidence-based and reflective
of industry standards and there’s no indication that medical equipment
isn’t current.
Independent Oversight
Independent oversight can occur through boards or committees charged
with direct performance oversight, external accrediting organizations
(e.g., National Academies of Emergency Dispatch) or physician oversight.
Boards and commissions: ATCEMS falls under the authority of two
oversight groups: the ATCEMS Board and the Austin Public Safety
Commission.
The ATCEMS Advisory Board was originally defined by city ordinance
and then further described in the EMS interlocal agreement between
Travis County and the city of Austin. The Board’s aim is to monitor the
performance of the whole system, not just the EMS department, and make
recommendations to the city council and county commissioners related to
EMS delivery. The Board receives performance reports from leaders in the
EMS department, helicopter service and the Office of the Medical
Director. Medical first response is not included.
The Board doesn’t have the authority to provide administrative
control over any of the entities. Members are appointed by city council
members and county commissioners, and include representation from
consumer groups including neighborhood associations and two large
hospital networks. The Board meets only quarterly, and its materials are
accessible on the Austin website.
The Austin Public Safety Commission has a broader charge to provide
budget and policy guidance to the Austin City Council related to the
three public safety departments—EMS, fire and police—serving the city.
It includes members from the community appointed by city council
members. The Commission doesn’t receive standard reporting from the EMS
department, and EMS agenda items are more topic-specific. The Board,
which meets monthly, doesn’t have the authority to provide
administrative control over any of the entities.
The Advisory Board and Public Safety Commission are external
oversight bodies charged with reporting recommendations to elected
officials. Neither has authority to direct the activities of any entity
in the EMS system, and
there’s no direct penalty for not acting on a
recommendation or concern that has been raised. Absence of defined
performance dashboard makes it difficult for the bodies to monitor
performance reliability.
Accrediting bodies: The Austin-Travis County EMS medical
communications center is accredited by the National Academies of
Emergency Dispatch (NAED) as an Accredited Center of Excellence. It
received initial accreditation in 2000 and was the first ACE center in
Texas. Travis County’s STAR Flight. rescue helicopter program was
accredited in 2000 by the Commission on Accreditation of Medical
Transport Systems (CAMTS). ATCEMS was awarded accreditation by the
Commission for the Accreditation of Ambulance Services (CAAS) in July.17
One of the two non-emergency franchise companies—Acadian
Ambulance–Texas—is also accredited by CAAS.
Accreditation is a valuable process and provides standardized,
industry recognized criteria and external evaluation. It ensures that an
organization meets minimum standards for key structures and processes.
The NAED’s accreditation includes confirmation of process reliability,
but CAMTS and CAAS don’t assure performance reliability.
Physician medical oversight: Medical first response organizations and
the ATCEMS 9-1-1 transport provider fall under the clinical oversight
of the Office of the Medical Director. One of the EMS system associate
medical directors is the medical director for STAR Flight. The private
franchise providers have independent medical direction.
Accounting for All Service Costs
Often, EMS providers get squeamish when discussing the dollars and
cents of their system. Public officials and citizens are often rather
uninformed about EMS economics and whether their community is receiving a
good value for their investment.
It can be difficult to quantify the true cost of operations for
public entities because governmental accounting may not identify all of
the actual costs of delivering service. This is especially true when
departments benefit from shared services like public relations, legal,
fleet or human resources. The numbers described below are sourced from
publically accessible, self-reported data.
The ATCEMS budget is $56,058,891, which includes the communication
center and the Office of the Medical Director, but not non-emergency
transport.18 Based on the county’s current Census population estimate of
1.063 million, that’s
a cost per capita of $52.68. A benchmark study in
2010 including
21 North American cities reported a median cost per
capita of $42.43.19 The majority of the cities participating in the
benchmark study deliver both emergency and non-emergency transport
service.
ATCEMS delivers only emergency transport service, meaning
addition of the non-emergency transport costs would increase the cost
per capita further. ATCEMS is also significantly subsidized through tax
dollars; the department’s 2013 budget goal is to recover $18 million in
user revenue, which is a third (32%) of the overall 2013 budget.
To put this in context, consider another Texas metro area—Ft. Worth.
MedStar Mobile Healthcare covers a smaller geographic area (421 square
miles vs. 1,022 square miles), but it serves a similar population and
has a similar EMS incident volume. MedStar had a 2012–2013 budget of
$33,118,507, which was funded almost completely through non-tax subsidy
revenue.20 MedStar also achieves comparable clinical and operational
outcomes.
Austin has been recognized as a heavily tax-funded EMS system for 30
years. EMS System
Consultant Jack Stout once described Austin as an old
Jaguar car he had a love/hate relationship with: “It was capable of
combining superb performance with real luxury, but maintaining that
performance required a high-capacity dollar injection system.”21 He also
compared it on more than one occasion with high-performance EMS system
models in Tulsa, Okla., and Kansas City, Mo., challenging that,
with the
ATCEMS budget, he could serve both the emergency and non-emergency
transport volume and still pay every patient $50 back.22,23 Consultant
Frank Heyman also noted the high cost of the EMS service in a 1985
benchmark report, but commented that “no one in the Austin area seems to
think that is a significant factor.”15
Economic Efficiency
Several factors influence the economic efficiency of an EMS system,
including covering multiple contiguous jurisdictions, providing
emergency and non-emergency ambulance services, matching the supply of
ambulance and caregivers to the predictable call demand, and having the
right resources to do the job.
One element of efficiency comes from the economies of scale present
in a larger service. Economies of scale are savings that can come from
covering a larger region, which means more resources to provide coverage
and response while sharing costs. ATCEMS is currently the exclusive
provider of 9-1-1 ambulance service to Travis County. If the county, or
one of the smaller cities, were to pull out of the system, economies of
scale would be lessened for all parties.
Economies of scale can further be enhanced if the EMS organization
provides both emergency and non-emergency services, further increasing
the resources and diversifying the payer mix. ATCEMS doesn’t benefit in
this case. Non-emergency ambulance service in Austin is provided through
two companies—American Medical Response and Acadian Ambulance
Service—that hold franchises with Austin, serving 42,572 responses
(transports were not reported).24,25 The franchise process is unique
because Austin is a closed system requiring city council approval for a
provider to enter the market. Franchise providers then compete with
minimal restriction or regulation. Franchise providers are required to
be made available for disaster needs but aren’t called on to support or
back up the 9-1-1 volume.
How a system deploys its resources and matches it to predictable call
patterns can also significantly improve efficiency.26
ATCEMS primarily
uses a fixed-station deployment model with some peak-load units.
Ambulances perform move-ups as demand and coverage require, but it isn’t
a dynamic deployment system. This
limits the efficiencies of managing
demand and reduces the flexibility to move resources. Lots of waste and
crew fatigue is created by returning units to assigned stations vs. the
next station requiring coverage.
Long-term High Performance
Sustainable high performance is described in “Hallmark 5” of EMS
Structured for Quality as a service that includes a continuous
improvement system that enhances performance without always requiring
added cost.13 If the EMS system is unable to perform, then are mechanisms in place to use lateral benchmarking to confirm if the system
remains a value and there’s a process to replace an unsuccessful
provider?
ATCEMS has a business analysis and research function reporting to the
EMS director and a traditional clinical quality improvement function in
its professional practices and standards division.27 The Office of the
Medical Director staffs a performance management and research
coordinator.28 From published reporting, data is measured in such areas
as response times, cardiac arrest, STEMI and stroke. Data is presented
in a mix of aggregate summary statistics and time-series charting, but
there doesn’t appear to be regular application of statistical process
control.
Quality is one of the department’s pillars; there’s no
reference to an improvement methodology for enhancing process
performance in use in the system.28
Similar to other communities with municipal EMS departments,
there
isn’t a process to routinely benchmark performance and confirm if the
system remains a value to the community. The city doesn’t have a
performance-based contract with its own department and, although the
county has some performance expectations in the EMS Interlocal
Agreement, they aren’t equivalent to the expectations in a traditional
performance-based contract. There’s also no process to consider
replacing the provider and doing so could be very disruptive.
Summary of the Hallmarks
Applying the AAA’s five hallmarks to ATCEMS reveals several quality
factors are in place, and there are opportunities for improvement and
development that may enhance the sustainability and results of the
organization.
Limitations & Discussion
Use of the five hallmarks and evidence-based performance measures as a
framework for evaluating an EMS system enables a high-level view and
degree of objectivity. Stakeholders on the ground may struggle with this
analysis because it doesn’t provide the whole story, nor does it
provide analysis of organizational culture, workforce morale,
operational process reliability, inter-agency relations or community
relations. The overview does support answering the opening question of
whether the EMS system is in distress (yes) or “broken” (no), but it
does not evaluate every issue.
A contributing factor not discussed is the role of elected officials.
In speaking with current elected officials for the county and city,
there’s universal concern that the EMS system isn’t where they desire it
to be. But there isn’t consensus on what’s wrong or how to repair it.
Cost and reliability are common themes. This is made more complicated by
conflicting lobbying from across the local EMS and fire community and
ongoing press attention. Added to the noise is a pending Travis County
judge election in November, which has included focus on EMS service in
the county and proposals for system change.29,30
Local perception of ATCEMS’ national reputation is also a challenge.
Local stakeholders believed the system was a national model or best
practice of EMS service. The strong positive national reputation is
true, but
many are surprised that the system has also been used as a
benchmark for high cost and low efficiency since its inception.
Two very real concerns include that
1) elected officials will feel
the pull to act and will make significant change to the system without
understanding what the community needs or what the system is capable of
doing, affecting access, cost and quality, and
2) the continuing
scrutiny and issues identified will erode confidence in the EMS
department leadership forcing a change.
Conclusion
Using the ICMA six signs as a diagnostic, one could conclude the
Austin-Travis County EMS system is in distress. The EMS system’s current
performance, structure and funding do make it stable. Stakeholders may
not be comfortable with the current outcomes, but the system is not
“broken” and could be repaired. Doing so would require laser focus on
shared outcomes, heavy emphasis on engagement and communication, and a
collaborative action plan to change. The will and resources are present
to achieve the aim if there’s community interest and strong leadership
to do so. jems
David M. Williams, PhD, is the founder of TrueSimple Improvement (
www.truesimple.com)
and collaborates on Urban EMS System Design projects with Washko &
Associates. He works in healthcare, education and ambulance service
systems as an improvement advisor. He is on the faculty of the Institute
for Healthcare Improvement and an alumnus of Leadership Austin. He
serves on the board of a local federally qualified health center system
and has lived and worked in Austin, Texas, for 15 years.
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