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How to Ratchet Up (and Squeeze Out Those Final Percentage Points of Performance) Jonathan D. Washko, BS-EMSA Director of Deployment – REMSA President –

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Presentation on theme: "How to Ratchet Up (and Squeeze Out Those Final Percentage Points of Performance) Jonathan D. Washko, BS-EMSA Director of Deployment – REMSA President –"— Presentation transcript:

1 How to Ratchet Up (and Squeeze Out Those Final Percentage Points of Performance) Jonathan D. Washko, BS-EMSA Director of Deployment – REMSA President – Washko & Associates, LLC Partner – Stout Solutions & FirstWatch

2 The journey of tightening up response time performance can be daunting. Learn the tips, tricks, traps and mental models that allow your team to break the final barrier

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…

4 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

5 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

6 Homeostasis & The EMS Success Triad The Constant Balancing of 3 Key Elements Patient Care Employee Well-Being Financial Success (however you define it) Patient Care Employee Wellbeing Economic Stability Success Triad

7 Homeostasis & The EMS Success Triad Patient Care Response Times Clinical Performance Customer Service Patient Care Success Triad

8 Homeostasis & The EMS Success Triad Employee Well-Being Retention Health / Safety / Welfare Satisfaction Schedules Work Environments Compensation Recruitment Family Patient Care Employee Wellbeing Success Triad

9 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 Patient Care Employee Wellbeing Economic Stability Success Triad

10 Production Model EMS Theory QUESTION: Is EMS a Service Industry or Production Industry?

11 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

12 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

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

14 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

15 The Quality Unit Hour Concept The Quality Unit Hour Human Resources Public Education Control Center Training & Edu Operations Finance Supply / Logistics Data Analytics QI / CQI / PI Fleet Maint. Safety & Risk IT / Technology PR/Marketing

16 The Quality Unit Hour Manufacturing / Production Cycle Based on Supply & Demand Production Model EMS Theory

17 Ratcheting Up 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?

18 The HPEMS Theoretical Performance Model

19 Its actually a graphic representation of my last trip with my wife, twin two year old boys and my 5 year old little girl

20 The HPEMS Theoretical Performance Model

21 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

22 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

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

24 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

25 Understanding The HPEMS Theoretical Performance Model - Variables Patient Care

26 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 Notice that Patient Care degridation crosses over Response Time Performance – Why?

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

28 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

29 Understanding The HPEMS Theoretical Performance Model - Variables Employee Well-being

30 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 Note that employee satisfaction is the first to go as systems attain higher performance….why?

31 The Homeostatic Balancing of 3 Key Elements Patient Care Employee Well-Being Financial Success (however you define it - Productivity) Patient Care Employee Wellbeing Economic Stability Success Triad These Elements Should Look Familiar

32 Understanding The HPEMS Theoretical Performance Model - Zones

33 Union Formation Zone

34 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)

35 Understanding The HPEMS Theoretical Performance Model - Zones Contractual Danger Zone

36 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)

37 Understanding The HPEMS Theoretical Performance Model - Zones Performance Comfort Threshold

38 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)

39 Understanding The HPEMS Theoretical Performance Model - Zones Performance Improvement Zone

40 Understanding The HPEMS Theoretical Performance Model - Zones Performance Improvement Zone Represents an area where experienced operators improve systemic system performance Can increase performance upwards of 3 or 4 percent 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

41 Understanding The HPEMS Theoretical Performance Model - Zones Triad Homeostasis

42 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)

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

44 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

45 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.

46 Understanding The HPEMS Theoretical Performance Model - Zones Deployment Aggression Zone

47 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

48 Understanding The HPEMS Theoretical Performance Model - Discussion

49 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!

50 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 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

51 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!

52 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 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

53 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

54 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!

55 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 ;-)

56 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 (see last day) 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

57 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!

58 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 improve…isnt 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

59 Performance Improvement Pitfalls & Tips 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

60 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 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 (its why its the same color) Remember hasty Greed Kills EMS Systems Slow and steady wins the race

61 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 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!

62 Summary / Review / Questions

63 Jonathan D. Washko Contact Information REMSA Phone: x140 Website: Washko & Associates, LLC. Phone: / Website:

64


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