Improving Operational Performance The Theoretical Performance Model

1
Improving OperationalPerformance The
Theoretical Performance Model

• Presented by
• Jonathan D. Washko, BS-EMSA, NREMT-P
• Director of Deployment REMSA
• President Washko Associates, LLC
• EMS Performance Improvement Consulting

2
An EMS Fact

• Understand that all the training, equipment,
  personnel, supplies, drugs, protocols, hardware,
  vehicles, technology, maintenance, QI systems
  etc, etc, etc dont mean a thing if

3
An EMS Fact

• Understand that all the training, equipment,
  personnel, supplies, drugs, protocols, hardware,
  vehicles, technology, maintenance, QI systems
  etc, etc, etc dont mean a thing if

We Cant get to the Patient in/on Time
4
Session Overview

• Homeostasis The EMS Success Triad
• Production Model EMS Theory The Quality Unit
  Hour Concept
• Understanding The Theoretical Performance Model
• The Variables of Performance Improvement
• Strategies / Best Practices for Performance
  Improvement
• Performance Improvement Pitfalls Tips
• Summary / Review / Questions

5
Homeostasis The EMS Success Triad

• The Constant Balancing of 3 Key Elements
• Patient Care
• Employee Well-Being
• Financial Success (however you define it)

Success Triad
Patient Care
Economic Stability
Employee Wellbeing
6
Homeostasis The EMS Success Triad

• Patient Care
• Response Times
• Clinical Performance
• Customer Service

Success Triad
Patient Care
7
Homeostasis The EMS Success Triad

• Employee Well-Being
• Retention
• Health / Safety / Welfare
• Satisfaction
• Schedules
• Work Environments
• Compensation
• Recruitment
• Family

Success Triad
Patient Care
Employee Wellbeing
8
Homeostasis The EMS Success Triad

• Financial Success
• A/R Billing Practices
• EMS Delivery Model System Design
• Operational Efficiency Effectiveness
• Employee Compensation
• Safety Risk Management
• Systems Engineering
• Profitability
• Subsidy Needs

Success Triad
Patient Care
Economic Stability
Employee Wellbeing
9
Production Model EMS Theory

• QUESTION
• Is EMS a Service Industry or Production Industry?

10
Production Model EMS Theory
High Performance EMS Systems Believe That EMS
is a Production Industry that provides its
customers with a level of Quality Service as an
end result of a Quality Product
11
Production Model EMS Theory

• Quality Services from Quality Products
• Examples
• Radio / Boom Box. The quality of the sound,
  reception, etc. (Service) is based on the quality
  of the Radio (Product)
• Televisions. The quality of the picture provided
  (Service) is based on the quality of the TV
  (Product)
• Etc, etc, etc

12
Production Model EMS Theory
Quality Services from Quality Products So what
Widgets (or products) do HPEMS Systems Produce?
13
A Quality Unit Hour

• A Quality Unit Hour is an ambulance that is
  available to the EMS System for one hour that
  responds to properly triaged calls for service,
  is produced within a CQI environment that uses
  modern technology to collect and assess accurate
  data, is fully staffed, fully trained, fully
  maintained, fully stocked, properly placed in
  location and time, properly funded and safely
  operates within an educated population

14
The Quality Unit Hour Concept
Patient Care Employee Wellbeing
Financial Stability
Public Education
Control Center
Training Edu
Human Resources
Operations
Finance
The Quality Unit Hour
Supply / Logistics
Data Analytics
Safety Risk
QI / CQI / PI
Fleet Maint.
IT / Technology
PR/Marketing
15
Production Model EMS Theory
The Quality Unit Hour Manufacturing / Production
Cycle Based on Supply Demand
16
Improving Performance

• Assumes you understand the EMS Success Triad
• Assumes you understand and/or operate under the
  Production Model EMS Premise
• Assumes you understand the Quality Unit Hour
  Concept

Its never safe to assume so any questions before
we move on?
17
The HPEMS Theoretical Performance Model
18
Understanding The HPEMS Theoretical Performance
Model

• The HPEMS-TPM is a graphical representation of
  how HPEMS systems can progress over time in
  relation to the EMS Success Triad based on
  changing key deployment and performance
  variables. This enables visualization of great
  and not so great performance and the positive and
  negative tradeoffs associated with changing these
  performance variables.

It also allows for a visual representation of
HPEMS Homeostasis which is an achievable but
difficult band in the TPM to reach and then
maintain
19
Understanding The HPEMS Theoretical Performance
Model

• Empirically Driven Common Denominator Model
  Based on Years of HPEMS Exposure and Experiences
• Variables (Color Coded)
• Response Time Reliability / Performance
• Patient Care
• Productivity / Unit Hour Utilization /
  Profitability
• Employee Well-being
• Zones
• Union Formation Zone
• Contractual Danger Zone
• Performance Comfort Threshold
• Performance Improvement Zone
• Triad Homeostasis
• Unit Hour Reduction Zone / The Triad Tradeoff

20
Understanding The HPEMS Theoretical Performance
Model - Variables
Response Time Reliability / Performance
21
Understanding The HPEMS Theoretical Performance
Model - Variables

• Response Time Reliability / Performance
• Depicts response time reliability based on
  fractile measurement
• The further up the matrix the higher the
  performance, the lower on the matrix, the lower
  the performance
• Response Time Goal depicts contractual or self
  imposed response time reliability standard
• UHU Syndrome represents what can happen to many
  HPEMS systems when productivity drops too low

22
Understanding The HPEMS Theoretical Performance
Model - Variables
Patient Care
23
Understanding The HPEMS Theoretical Performance
Model - Variables

• Patient Care
• Can represent many different aspects of patient
  care
• Survival rates / outcomes
• Customer Service Satisfaction
• Assumes patient care is proportional to response
  times and employee well-being
• The further up the matrix the better the patient
  outcome, the lower on the matrix, the lower the
  patient outcome

24
Understanding The HPEMS Theoretical Performance
Model - Variables
Productivity / UHU / Profitability
25
Understanding The HPEMS Theoretical Performance
Model - Variables

• Productivity / UHU / Profitability
• Represents the typical productivity curves seen
  as HPEMS systems mature
• Assumes profitability improves as performance and
  productivity increases
• The further up the matrix the higher the
  performance, the lower on the matrix, the lower
  the performance
• Profit Departure
• When productivity hits a level of diminishing
  returns based on poor performance outcomes

26
Understanding The HPEMS Theoretical Performance
Model - Variables
Employee Well-being
27
Understanding The HPEMS Theoretical Performance
Model - Variables

• Employee Well-being
• Represents employee satisfaction
• Turnover rates
• Health / safety / welfare
• Employee happiness
• Good employee satisfaction survey scores
• The further up the matrix the higher the
  satisfaction / less turnover, the lower on the
  matrix, the lower the satisfaction / higher
  turnover rates
• Employees are the foundation of your organization
• Note that employee satisfaction is the first to
  go as systems attain higher performance.why?

28
These Elements Should Look Familiar

• The Homeostatic Balancing of 3 Key Elements
• Patient Care
• Employee Well-Being
• Financial Success (however you define it -
  Productivity)

Success Triad
Patient Care
Economic Stability
Employee Wellbeing
29
Understanding The HPEMS Theoretical Performance
Model - Zones
30
Understanding The HPEMS Theoretical Performance
Model - Zones
Union Formation Zone
31
Understanding The HPEMS Theoretical Performance
Model - Zones

• Union Formation Zone
• Represents areas where HPEMS systems have
  typically unionized, mostly due to poor
  management communication / employee education or
  area specific cultural issues
• Key Union Formation Areas
• Beginning of a HPEMS System (largest change)
• When attempting to improve performance by holding
  employees accountable for avoidable mistakes
  without balancing employee needs / understanding
• Dramatic increase in productivity (employee
  workload) after performance improvement steps
  taken
• When Job security is threatened (real or assumed)

32
Understanding The HPEMS Theoretical Performance
Model - Zones
Contractual Danger Zone
33
Understanding The HPEMS Theoretical Performance
Model - Zones

• Contractual Danger Zone
• Represents an area where experienced operators
  shy away from when managing response time
  performance
• Typically ½ to 1 percentage point above the
  minimal contractual requirement
• Less experienced operators will sometimes try to
  manage their response times within this region,
  however they typically burn out their management
  teams and/or problems will begin to arise in
  operator trustworthiness / integrity
• Primary reason an operator manages in this zone
  is due to poor financial performance (for a
  variety of reasons)

34
Understanding The HPEMS Theoretical Performance
Model - Zones
Performance Comfort Threshold
35
Understanding The HPEMS Theoretical Performance
Model - Zones

• Performance Comfort Threshold
• Represents an area where most experienced
  operators manage response time performance to
• Typically 1 to 2 percentage point above the
  minimal contractual requirement
• Less experienced operators may get frozen in the
  left side of this zone not understanding that
  performance can be improved (What we will be
  discussing today)
• Some performance based contract systems force
  their operators to live either on the left or
  right in this zone and are sometimes have
  disincentives to operate in the middle (at Triad
  Homeostasis), however some do receive performance
  bonuses for operating in the middle (through
  performance penalty forgiveness)

36
Understanding The HPEMS Theoretical Performance
Model - Zones
Performance Improvement Zone
37
Understanding The HPEMS Theoretical Performance
Model - Zones

• Performance Improvement Zone
• Represents an area where experienced operators
  improve systemic system performance
• Can increase compliance upwards of 3 or 4
  percentage points based on approach that works
  for their particular system and / or contractual
  need without the need for additional unit hours
• Takes time and patience to achieve and most
  successful systems wait to reap the financial
  rewards of this zone until the systems needed to
  manage improvement are in place, tested and are
  habitual
• I believe the dollar pay-off for this is not as
  great as the patient care and employee well-being
  payoff (contrary to what many may believe),
  however there are financial rewards if taken
  advantage of

38
Understanding The HPEMS Theoretical Performance
Model - Zones
Triad Homeostasis
39
Understanding The HPEMS Theoretical Performance
Model - Zones

• Triad Homeostasis
• The HPEMS Sweet Spot!
• Where maximum response time reliability, best
  patient care outcomes and almost best
  employee-wellbeing collide
• Purely due to the aggressive geospatial
  deployment methodologies needed to achieve this
  level of performance, employee well-being begins
  to wane
• Notice that maximal financial performance is not
  yet achieved in this zone as they are typically
  competing (based on contractual requirements)
  although financial performance can come quicker
  if an agency chooses to do so
• May bring into question the need for
  first-responder services for certain geographic
  areas within a service area as typically
  Ambulances will beat First Responder Services on
  scene (upwards of 60 to 70 of the time and
  sometimes higher)

40
Understanding The HPEMS Theoretical Performance
Model - Zones
UH Reduction Zone / Triad Tradeoff
41
Understanding The HPEMS Theoretical Performance
Model - Zones

• Unit Hour Reduction Zone / The Triad Tradeoff
• Where profitability or availability of system
  funds will increase due to the lowering of unit
  hours
• Lower Unit Hours come from an increase in
  production / UHU
• Increased production / UHU comes from lowering
  response time reliability back into the
  Performance Comfort Threshold region
• The Tradeoff
• Patient care begins to drop from slower response
  times
• Employee well-being will drop from increased
  workload demands
• Other problems may arise if Performance
  Improvement Systems fail or apathy invades an
  operation

42
Understanding The HPEMS Theoretical Performance
Model - Zones

• Unit Hour Reduction Zone / The Triad Tradeoff
• Additional Facts
• Based on the make / model of your HPEMS system,
  the dollars and/or unit hours may be used for
  other things
• Acceptance of increasing call volume on a
  marginal cost basis
• Better servicing of outlying (rural) service
  areas
• Increasing contiguous service area size on a
  marginal cost basis
• Attempting to shore up employee well-being though
  increased compensation, benefits, appreciation
  programs, etc.

43
Understanding The HPEMS Theoretical Performance
Model - Zones
Deployment Aggression Zone
44
Understanding The HPEMS Theoretical Performance
Model - Zones

• Deployment Aggression Zone
• Defines (on a sliding scale) the impact of
  deployment tactics based on aggressiveness and
  approach.
• A key and necessary element in Performance
  Improvement
• Your success to performance improvement is
  directly correlated to how you do your deployment
  model
• Least aggressive static models are on the far
  left side of the scale
• Most aggressive dynamic pure SSM models are on
  the far right side of the scale
• Everything in between is some form or mix of
  these two extremes

45
Understanding The HPEMS Theoretical Performance
Model - Discussion
46
The Performance Improvement Zone

• The Performance Improvement Variables
• Simple Stuff (low hanging fruit can do
  tomorrow)
• Data Integrity Accuracy (is it)
• Measurement / Reporting Systems (are they
  accurate)
• Underlying Technology Systems (causing problems
  with data)
• Chute Times (dispatch unit) Clock Start to
  Physically En Route
• Open Minded Management Team Capable of Change!
• Intermediate Stuff (takes more time but can
  happen quick)
• Educate entire team on HPEMS SSM (VERY
  important!!!)
• Temporal Supply Demand Matching (do they?)
• Deployment Plan Aggressiveness Approach (simple
  or complex)
• Open Minded Management Team Capable of Change!
• Advanced Stuff (takes lots of time, patience
  consistency)
• Fix controllable response errors
• Implement USE Granular Accountability
  Reliability Tracking Systems, find the problem
  areas and fix them
• Implement USE Real-time Situational Awareness
  Systems (based on data driven and human driven
  intelligence) to adjust as needed
• Implement USE Bleeding Edge Technology (dont
  kimp)
• Open Minded Management Team Capable of Change!

47
The Performance Improvement Zone

• Strategies for Performance Improvement
• Simple Stuff (low hanging fruit can do
  tomorrow)
• Data Integrity Accuracy
• Check data and dispatch practices / procedures to
  ensure accuracyanalysis is only as good as the
  data it is performed on
• Reconcile missing data points (especially Call
  Lat / Long)
• Perform internal audits of every late call to
  ensure they are in fact late (audit clock start
  and stop times)
• Measurement / Reporting Systems
• Make sure your data reporting systems used to
  measure response time performance are accurate
  and meet contractual obligations or internal
  standards

48
The Performance Improvement Zone

• Strategies for Performance Improvement
• Simple Stuff (low hanging fruit can do
  tomorrow)
• Underlying Technology Systems
• Check CAD to CAD interfaces, Atomic Clock
  Synchronizations and CAD system itself to ensure
  proper data collection accuracy call processing
  efficiency
• GIS systems are an integral part of todays
  response systems. Ensure an up to date
  geo-database and attempt to achieve 100 accurate
  geo-validation of addresses (also check response
  zones)
• Chute Times (dispatch unit)
• Measure, monitor report on chute time
  performance at the granular (employee) level
• Work to mitigate remediate problems
• Open Minded Management Team Capable of Change!

49
The Performance Improvement Zone

• Strategies for Performance Improvement
• Intermediate Stuff (takes more time but can
  happen quick)
• Educate entire team on HPEMS SSM (VERY
  important!!!)
• A common denominator of ALL successful HPEMS
  operators
• Provide advanced courses for management and
  supervisors
• Provide basic courses for the rest of the crowd
  (including field)
• Temporal Supply Demand Matching (do they?)
• Plot your Unit Hour supply against your Demand.
  Do they match? If not, adjust schedules and unit
  hour supply accordinglyyes it may be time for a
  shift bid
• Be sure to incorporate call task time into the
  model as longer call task times require more
  resources (most demand models assume 1 call takes
  1 hour)
• Investigate why task times are long and mitigate
  if possible
• Measure Control Lost Unit Hours.
  Non-productive unit hours are commonly at the
  root of many performance problems

50
The Performance Improvement Zone

• Strategies for Performance Improvement
• Intermediate Stuff (takes more time but can
  happen quick)
• Deployment Plan Aggressiveness Approach
• Aggressive Deployment Models
• Hourly demand focused posting plans
• Strategic prioritized redeployment of resources
  after each call is assigned to a unit
• Short post roaming distances, post to post moves,
  chute time tolerances
• Typically use street corner posts only (quicker
  chute times)
• Less Aggressive Deployment Models
• Hour grouping of demand based plans
• Strategic prioritized redeployment of resources
  after each call is assigned to a unit
• Longer post roaming distances, post to post
  moves, chute time tolerances
• Typically use some stations intermixed with
  street corner posts

51
The Performance Improvement Zone

• Strategies for Performance Improvement
• Intermediate Stuff (takes more time but can
  happen quick)
• Deployment Plan Aggressiveness Approach
• Least aggressive Deployment Plans
• Typically one plan for all hours / all days, may
  or may not be demand based (typically
  geographically based)
• Strategic prioritized redeployment of resources
  after each call is assigned to a unit is less
  aggressive and dominant
• Longer post roaming distances, post to post moves
  and chute time tolerances usually apply
• Typically use more stations then street corner
  posts
• Open Minded Management Team Capable of Change!

52
The Performance Improvement Zone

• Strategies for Improving Performance
• Advanced Stuff (takes lots of time, patience
  consistency)
• Fix controllable response errors
• ACCURATELY perform root cause analysis of all
  late calls
• Categorize into controllable and non-controllable
  errors at the granular (employee) level
• Fix controllable errors as causes unveil
  themselves / patterns arise (and they will!)
• Implement USE Granular Accountability
  Reliability Tracking Systems, find the problem
  areas and fix them
• Measure and monitor KPIs (key performance
  indicators)
• Design reporting systems so that data can be
  drilled down into so problem areas can be easily
  identified
• Trend history and use this to help predict future
  events, then act upon prediction models before
  problems arise (a novel concept for many of us
  EMS folks -)

53
The Performance Improvement Zone

• Strategies for Improving Performance
• Advanced Stuff (takes lots of time, patience
  consistency)
• Implement USE Real-time Situational Awareness
  Systems (based on data driven and human driven
  intelligence) to adjust as needed
• PULSE Process / After Action Reviews
• Daily meeting of management key players
• Based on military After Action Review process
• Assess Late Calls, System Performance, Scheduling
• Gain information about your system and act on it
  to improve performance
• Many broken systems and sub-systems will become
  evident the more you look.you just have to look!
• Manage headcount by anticipating losses, properly
  calculating requirements and FTE weights and
  hiring ahead of the curve

54
The Performance Improvement Zone

• Strategies for Improving Performance
• Advanced Stuff (takes lots of time, patience
  consistency)
• Implement USE Bleeding Edge Technology
• Dont kimp go see the vendors outside!!!!!!
• AVL/GIS/In Vehicle Mapping systems that work are
  worth their weight in gold
• Deployment tools like MARVLIS, SIREN, MUM (and
  others) are taking the guess work out of
  deployment plans with scary, dead on accuracy
• Scheduling tools like Zolls Resource Planner
  Crew Scheduler, eCores NetScheduler Pro, ADPs
  HR/Scheduling/Payroll suites and others are
  taking supply chain management online and are
  making it an easier and a much more efficient /
  accurate process
• Electronic charting is opening up new horizons
  for billing DSO, clinical research and call
  processing time minimization
• Operational intelligence systems such as
  FirstWatch and Microsoft Office Live provide
  easy, customizable and real-time data dashboards
  used for benchmarking process improvement
• Open Minded Management Team Capable of Change!

55
Performance Improvement Pitfalls Tips

• Closed minded management incapable of change
• Without a good solid team youre dead in the
  water. I recommend not moving forward until you
  have one
• Assume Nothing Question Everything
• Even your most trusted team-mates should be
  questioning their own expertise and always
  attempting to improveisnt this how we grow and
  learn
• Hasty Greed Kills EMS Systems!
• A balanced EMS Success Triad is just that
  BALANCED. Short term profiteering will lead to a
  long term death, lets take a lesson from the
  Japanese business approach
• Dont kimp on your employees or their families
• Without them, youre dead in the water
• Spend the extra bucks to make their office more
  livable especially in an aggressive deployment
  model system

56
Performance Improvement Pitfalls Tips

• Find the mix of performance improvements that
  work best for younot all will and not all are
  necessary
• Taking an EMS system to the profit / performance
  edge and keeping it there will give you grey hair
  (it has me). Do yourself, employees and patients
  a favor, only use what you have to
• Many performance improvements are strongly based
  on technology so hire only the best IT folks and
  pay them as such
• Often times EMS systems skimp in this area and
  end up paying dearly for it in the end
• You must be consistent and unwavering in using
  newly developed tools, systems approaches for
  the long haul
• Many systems are able to obtain the holy grail
  (triad homeostasis) but keeping it is the most
  difficult thing you will ever do

57
Performance Improvement Pitfalls Tips

• Use caution in the union formation zone
• Unless you like unions, you need to listen to
  your employees, compensate them appropriately,
  take care of their families and most importantly
  do your best to educate them on why you are doing
  what you are doingand all should turn out well
• During your performance improvement, stay in tune
  with your employees and meet often with them
• Really this should be done all the time but is
  really important when trying to move mountains
• Increased productivity / UHU / profitability is
  possible within the performance improvement zone
  if necessary but use caution (its why its the
  same color)
• Remember hasty Greed Kills EMS Systems
• Slow and steady wins the race

58
Performance Improvement Pitfalls Tips

• Avoid the Contractual Danger Zone like the plague
• Living in this zone will burn you up, places
  patients, employees and contracts in jeopardy and
  eventually may lead you down a path you never
  want to be in (survival mode)
• The Theoretical Performance Model is Cyclical
• Unfortunately, many HPEMS systems are based on 5
  to 7 year operational cycles and then go out to
  bid. A new operations contractor will have to
  learn how to walk all over againand this can be
  painfulespecially for the employees and patients
• Unfortunately, cycles also happen within bid
  periods within the same operations contractor.
  This typically happens when the present team
  masters its domain and the parent company moves
  them to fix another system, leaving huge
  experience holes which starts the cycle all over
  again
• THEREFORE - DO SUCCESSION PLANNING TRAINING!

59
Summary / Review / Questions

• Contact Information
• REMSA
• Phone [phone] x140
• Email jwashko_at_remsa-cf.com
• Website www.remsa-cf.com
• Washko Associates, LLC.
• Phone [phone]
• Email jw_at_washkoassoc.com
• Website www.washkoassoc.com