Improving Operational Performance The Theoretical Performance Model

Improving OperationalPerformance

The Theoretical Performance Model

Presented by

Jonathan D. Washko, BS-EMSA, NREMT-PDirector of Deployment – REMSA

President – Washko & Associates, LLC

EMS Performance Improvement Consulting

An EMS Fact…

Understand that all the training, equipment, personnel, supplies, drugs,

protocols, hardware, vehicles, technology, maintenance, QI systems

etc, etc, etc don’t mean a thing if…

An EMS Fact…

Understand that all the training, equipment, personnel, supplies, drugs,

protocols, hardware, vehicles, technology, maintenance, QI systems

etc, etc, etc don’t mean a thing if…

We Can’t get to the Patient in/on Time

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

Homeostasis & The EMS Success Triad

The Constant Balancing of 3 Key Elements– Patient Care

– Employee Well-Being

– Financial Success (however you define it)Pat

ient Car

e

Employee Wellbeing

Econ

omic S

tability

SuccessTriad


Patient Care– Response Times– Clinical Performance– Customer Service

Pat

ient Car

eSuccess

Triad


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

Pat

ient Car

e

Employee Wellbeing

SuccessTriad


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

atie

nt Car

e

Employee Wellbeing

Econ

omic S

tability

SuccessTriad

Production Model EMS Theory

QUESTION:

Is EMS a Service Industry or Production Industry?


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


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


Quality Services from Quality Products

So what Widgets (or products) do HPEMS Systems Produce?

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

The Quality Unit Hour Concept

TheQuality

Unit Hour

Human Resources

Pu

blic E

du

cation C

on

tro

l Cen

ter

Trai

ning

& E

du

Operations Finance

Supply / Logistics Data Analytics

QI / CQI /

PI

Flee

t Mai

nt.

Safety & Risk

IT / Technology

PR

/Mar

keti

ng

The Quality Unit HourManufacturing / Production Cycle

Based on Supply & Demand


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

It’s never safe to assume so any questions before we move on?

The HPEMS Theoretical Performance Model

Patient Care

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Employee Well-being / SatisfactionP

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uctivity / U

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rofitab

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Geospatial / Unit Hour Deployment Plan Most AggressiveLeast Aggressive

Response Time Goal

Performance Comfort Theshold

Sta

tion

Bas

ed E

MS

HP

EM

S /

SS

M

The Triad Tradeoff

Best Care Best Profit

CONTRACTUAL DANGER ZONE

Unit Hour Reduction Zone

Triad H

omeostasis

PerformanceImprovement

Zone

UHU Syndrome

Copyright 2006 by Washko & Associates, LLC - All Rights Reserved

Union Formation Zone

HPEMS System Operational Maturity

Young MatureMiddle Aged

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

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

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UHU Syndrome




Understanding The HPEMS Theoretical Performance Model - Variables

Response Time Reliability / Performance


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

Patient Care

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Response Time Goal

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UHU Syndrome





Patient Care


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

Patient Care

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Tim

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Pro

du

ctivity / Un

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tilization

/ Pro

fitability

Response Time Goal

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HP

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SS

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UHU Syndrome





Productivity / UHU / Profitability


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

Patient Care

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Tim

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bili

ty /

Per

form

ance


rod

uctivity / U

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rofitab

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Response Time Goal

Sta

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HP

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UHU Syndrome





Employee Well-being


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?

The Homeostatic Balancing of 3 Key Elements– Patient Care

– Employee Well-Being

– Financial Success (however you define it - Productivity)

Pat

ient Car

e

Employee WellbeingEmployee Wellbeing

Econ

omic S

tability

SuccessTriad

These Elements Should Look Familiar

Understanding The HPEMS Theoretical Performance Model - Zones

Patient Care

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rofitab

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Response Time Goal


Sta

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MS

HP

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SS

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The Triad Tradeoff




Triad H

omeostasis


Zone

UHU Syndrome






Patient Care

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uctivity / U

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n / P

rofitab

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Response Time Goal

Sta

tion

Bas

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MS

HP

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SS

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UHU Syndrome







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)


Patient Care

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Response Time Goal

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HP

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UHU Syndrome





Contractual Danger Zone


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)


Patient Care

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Response Time Goal


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UHU Syndrome





Performance Comfort Threshold


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)


Patient Care

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Response Time Goal


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HP

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Zone

UHU Syndrome





Performance Improvement Zone


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


Patient Care

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Response Time Goal


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Triad H

omeostasis


Zone

UHU Syndrome





Triad Homeostasis


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)


Patient Care

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Response Time Goal


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The Triad Tradeoff




Triad H

omeostasis


Zone

UHU Syndrome





UH Reduction Zone / Triad Tradeoff


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


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.


Patient Care

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Employee Well-being / Satisfaction

Pro

du

ctivity / Un

it Ho

ur U

tilization

/ Pro

fitability


Response Time Goal


Sta

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HP

EM

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SS

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The Triad Tradeoff




Triad H

omeostasis


Zone

UHU Syndrome





Deployment Aggression Zone


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

Understanding The HPEMS Theoretical Performance Model - Discussion

Patient Care

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The Triad Tradeoff




Triad H

omeostasis


Zone

UHU Syndrome





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 (don’t $kimp)• Open Minded Management Team Capable of Change!


Strategies for Performance Improvement…– Simple Stuff (low hanging fruit – can do tomorrow)

• Data Integrity & Accuracy– Check data and dispatch practices / procedures to ensure

accuracy…analysis 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


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 today’s 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!


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 accordingly…yes 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


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


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



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 KPI’s (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 ;-)


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


Strategies for Improving Performance– Advanced Stuff (takes lots of time, patience & consistency)

• Implement & USE Bleeding Edge Technology– Don’t $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 Zoll’s Resource Planner & Crew Scheduler, eCore’s

NetScheduler Pro, ADP’s 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


Performance Improvement Pitfalls & Tips

Closed minded management incapable of change– Without a good solid team you’re 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 improve…isn’t 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, let’s take a lesson from the Japanese business approach

Don’t $kimp on your employees or their families– Without them, you’re dead in the water

– Spend the extra bucks to make their office more livable especially in an aggressive deployment model system


Find the mix of performance improvements that work best for you…not 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


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 doing…and 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 (it’s why it’s the same color)– Remember hasty Greed Kills EMS Systems

– Slow and steady wins the race


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 again…and this can be painful…especially 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!

Summary / Review / Questions

Contact Information– REMSA

• Phone: 775-858-5700 x140• Email: [email protected]• Website: www.remsa-cf.com

– Washko & Associates, LLC.• Phone: 804-347-3337 / 775-626-4459• Email: [email protected]• Website: www.washkoassoc.com

Improving Operational Performance The Theoretical Performance Model

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