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Home My WebLink About20130211.tiffConsultant Report Weld County Government Department of Paramedic Services Weld County, Colorado EMS Assessment November 10, 2008 FITCH 303 Marshall Road, Box 170 Platte City, MO 64079 (816) 431-2600 www.fitchassoc.com 0Qwnitt4;Clot- 1-76 2L 3 2013-0211 Consultant Report Weld County Government Department of Paramedic Services Weld County, Colorado EMS Assessment Table of Contents EXECUTIVE SUMMARY 1 METHODOLOGY 3 INTRODUCTION 4 THE REGION 4 WELD COUNTY PARAMEDIC SERVICES 6 KEY CONTEXT AND CURRENT NATIONAL TRENDS 7 THE OPTIMAL EMS SYSTEM 8 EMS OPERATIONS REVIEW 10 911/MEDICAL COMMUNICATIONS 11 Observations & Findings 11 Recommendations 14 MEDICAL FIRST RESPONSE 14 Observations & Findings 15 Recommendations 15 MEDICAL TRANSPORTATION 16 Observations and Findings 16 Recommendations 29 MEDICAL ACCOUNTABILITY 31 Observations and Findings 31 Recommendations 32 CUSTOMER AND COMMUNITY ACCOUNTABILITY 32 Observations and Findings 32 Recommendations 33 PREVENTION AND COMMUNITY EDUCATION 33 Observations and Findings 34 Recommendations 35 ORGANIZATIONAL STRUCTURE AND LEADERSHIP 35 Observations and Findings 35 Recommendations 40 ENSURING OPTIMAL SYSTEM VALUE 40 Weld County Paramedic Services ©Fitch & Associates, LLC EMS Assessment i November 10, 2008 Observations and Findings 41 Recommendations 45 SUMMARY OF RECOMMENDATIONS 46 911/MEDICAL COMMUNICATIONS 46 MEDICAL FIRST RESPONSE 46 MEDICAL TRANSPORTATION 47 MEDICAL ACCOUNTABILITY 48 CUSTOMER AND COMMUNITY ACCOUNTABILITY 48 PREVENTION AND COMMUNITY EDUCATION 48 ORGANIZATIONAL STRUCTURE AND LEADERSHIP 48 ENSURING OPTIMAL SYSTEM VALUE 49 FIGURE 1. WELD COUNTY SERVICE AREA 5 FIGURE 2. PARAMEDIC POSTS/POPULATION DENSITY 6 FIGURE 3. ANATOMY OF AN EMS INCIDENT 19 FIGURE 4. CALLS BY DAY OF WEEK (MID 2006 TO MID 2008) 26 FIGURE 5. EXPECTED CALL VOLUMES (MID 2006 TO MID 2008) BY HOUR OF DAY 26 FIGURE 6. PERCENTAGE OF EMERGENCY CALLS COVERED AT EACH STATUS LEVEL 28 FIGURE 7. ILLUSTRATES PROPOSED RETROSPECTIVE QI PROCESS 39 TABLE 1. TIME INTERVAL BENCHMARKS 20 TABLE 2. MODEL PREVENTIVE MAINTENANCE SCHEDULE 24 TABLE 3. WCPS BILLING STEPS 44 Attachments: A. GIS Coverage Maps Levels 1-6 and Total System Coverage Percentages 8. 50 Benchmarks Weld County Paramedic Services ©Fitch 8i. Associates, LLC EMS Assessment ii November 10, 2008 Executive Summary The Weld County Government retained Fitch & Associates to review its Emergency Medical Services (EMS) System and provide recommendations for improvement. The data collection and analysis was conducted during the summer of 2008. Key Findings of the Study include: • Historic commitment to provide paramedic ambulance service is strong and provides a solid base to continue efforts to enhance the County's EMS system. • Response times are not measured in a way that facilitates comparison with other EMS systems or routine internal analysis and remedial action. • Response times can be improved by changing internal processes within both the County's Communications Center and Weld County Paramedic Services (WCPS). This includes reducing call processing times and modifying deployment strategies. These efforts can improve system performance with essentially no significant financial investment. An inter -department Service Level Agreement should be developed to formalize performance expectations. The focus of this agreement should be on creating an effective partnership/team among WCPS and WCRCC. • Advanced dispatch services, such as call routing, deployment management and demand data capture and analysis are normal and expected services industry wide. It is not unreasonable for WCPS to expect these services from WCRCC. • WCPS remains non -subsidized by local taxpayers and supported by user fees. WCPS fees have reached a level that additional price increases will result in minimal increases in cash collections. • Nationwide, ambulance services are struggling to make "ends meet" as government reimbursement for ambulance service is less than cost. To offset the costs of uncompensated care and increased future operating costs, WCPS will likely require baseline local tax support to remain viable. • WCPS is proposing to bundle charges to simplify billing. This practice is generally acceptable industry -wide and more and more payors are expecting bundled charges from service providers. • First Responder services should be more closely matched to presumptive medical need. This should result in fewer low acuity responses in urban areas. • Medical direction and quality improvement efforts should be more formally integrated on a system -wide basis with special attention being given to communications and First Responder needs. • Leadership development and leadership consistency at the supervisory level will positively impact stakeholder satisfaction and are high priorities for WCPS. • WCPS represents excellent value to the communities it serves. Its cost per capita and cost per unit hour compare favorably to other high performance systems Weld County Paramedic Services ©Fitch & Associates, LLC EMS Assessment 1 November 10, 2008 throughout North America. Its cost per transport is higher than other systems primarily due to its large geographic coverage area and low transport volume. • Further service fragmentation will drive up the costs of providing service to outlying areas of the County. Focused efforts to implement the 61 recommendations made throughout the report will further enhance the clinical, operational and financial stability of the system. Weld County Paramedic Services ©Fitch & Associates, LLC EMS Assessment 2 November 10, 2008 Methodology Weld County Government (the County), Weld County, Colorado retained Fitch & Associates (Fitch) to conduct a comprehensive review of the Weld County Paramedic Services (WCPS) system in Weld County, Colorado. This effort was undertaken as part of the County's mission to provide the best out -of -hospital emergency medical care for the citizens of Weld County. Additional informational objectives of the study were to benchmark WCPS performance in key areas against existing performance criteria, identify opportunities for organizational, operations, clinical and financial efficiencies and improvements and provide recommendations and templates for any needed improvement and ongoing self analysis and enhance program sustainability and to broadly quantify the cost of the options. During the month of June 2008, the Consultants provided an in depth self -assessment document to be completed. In August and September 2008, the Consultant team conducted a multi -day site visit to the area. During the on -site assessment, observations of communications, operations and administrative processes were undertaken. Interviews with nearly 60 stakeholders were conducted. These included: representatives of local response agencies, public health officials, hospital clinical and administrative leadership, local public safety officials (principally fire and 911 communications staff), physicians and Medical Directors. Interviews with and observations of ambulance staff, and both communications and support services employees were conducted. Leaders from all volunteer response agencies were also invited to provide input at a listening session conducted during the site assessment. Representatives from nine agencies attended. Additionally, all of the WCPS staff were invited to participate in an on-line survey and meet with the Consultants. Follow-up information, including individual ambulance call data from the County Computer Aided Dispatch (CAD) system, geographic information, and targeted reports were requested from WCPS. The Consultants compared WCPS to other services using 50 common industry benchmarks. Of the 50 benchmarks, 32 elements could be fully documented. Another 13 were partially documented and 4 remain to be completed. One benchmark was not applicable. This information is summarized in Attachment B. The Consultants wish to take this opportunity to thank all those that participated in the process or assisted in the data gathering process. Weld County Paramedic Services ©Fitch & Associates, LLC EMS Assessment 3 November 10, 2008 Introduction The Region Weld County is located in North East Colorado, approximately 60 miles north of the greater Denver, Colorado area. The County is 4,000 square miles in size with a total population of approximately 243,750. The majority of these citizens live within a fairly well defined "urban" area consisting of the cities of Greeley, Evans and Windsor. The remainder of the County is sparsely populated. The service area has a well-defined road system and is bisected north to south by Highway 85 and east to west by Highway 34. Included in the WCPS service area are 27 fire districts. Of these, the vast majority are strictly volunteer. Per the U.S. Census Bureau, the population growth for Weld County was 31% from 2000-2006.' The population density per square mile countywide is estimated at 45, which qualifies Weld County as rural. For industry comparison purposes, the more densely populated areas of the County are described as urban/suburban while the remaining areas are described as rural. The WCPS service area is outlined in Figure 1. The Paramedic Post locations are illustrated at Figure 2. ' U.S. Census Bureau —State and County quick facts. Weld County Paramedic Services ©Fitch & Associates, LLC EMS Assessment 4 November 10, 2008 Figure 1. Weld County Service Area Weld County Paramedic Services *Filch & Associates, LLC EMS Assessment 5 November lo, 2008 Figure 2. Paramedic Posts/Population Density Weld County Paramedic Services WCPS has been serving the area since September 1974. Advanced Life Support (ALS) services were added in July of 1977. The service operates as a County Enterprise Fund. The service is funded by fees collected and has operated in this manner since 1986. WCPS currently staffs ALS ambulances 24 -hours per day, seven days per week. There are four fixed stations and ten posting locations in the County. All ambulance shifts are 12 - hours with the exception of one 24 -hour car located in Ft. Lupton. Staffing consists of a mixture of EMT-Basic/EMT-Paramedic and double EMT -Paramedic teams. Weld County Paramedic Services iCrech a Associates, (SC EMS Assessment 6 November 10, 2008 Minimum staffing is four ambulances during non -peak hours up to six ambulances during peak hours. Additionally the service runs a psychiatric transport van staffed with an EMT. Current scheduled ambulance hours approximate 43,680 per year. Ambulance call volumes have increased steadily in recent years. In calendar year 2007, the service responded to a total of 12,298 requests for service and transported 8729 patients. This represents an increase of approximately 5.2% and 1.3% respectively over 2006. The extreme southwest portion of the County is covered by another full-time ambulance service. The relationship and existing mutual aid agreements are reported to be effective in providing adequate ambulance service to the area. Key Context and Current National Trends One of the key principles of an EMS system is to ensure access and appropriate response for those in need of emergency services and medical transportation. Globally, the EMS mission can be isolated to three core functions. They are: preventing and reducing the number of lives lost; minimizing the patient's pain and suffering; and, reducing the expenses associated with catastrophic injuries & illness. Historically, EMS has suffered from an identity crisis and was considered an offspring of both public safety and healthcare. Modern EMS can trace its development to the National Academy of Science White Paper of 1966. In 2006, the National Academies' Institute of Medicine White Paper titled: "EMS at the Crossroads" identified six primary issues and offers insight to communities considering EMS changes. • Insufficient Coordination • Disparities in Response Time • Uncertain Quality of Care • Lack of Disaster Readiness • Divided Professional Identity • Limited Evidence Base These same six issues are problematic in Weld County to a greater or lesser degree. Key EMS trends nationwide that are relevant in Weld County include fragmentation, changes in demand, Emergency Dispatch throughput issues, inequitable reimbursement, and personnel challenges. Fragmentation issues include - turf issues, jurisdictional boundaries and less than optimal care integration between EMS and the Emergency Department (ED) at hospitals are issues throughout the nation. Weld County Paramedic Services ©Fitch & Associates, LLC EMS Assessment 7 November 10, 2008 Changes in Demand issues include - the increasing number of uninsured and underinsured patients, hospital consolidation, increased service demand and an aging population. Nationwide those that are age 65 years or older represent 38% of all EMS Responses2; have four times the average utilization; represent the highest clinical needs; and are the fastest growing volume subset. Emergency Department (ED) throughput issues - are based upon the growth of ED visits as many more Americans use the emergency department in lieu of primary care. ED visits increased from 90.3 million to 119 million during the ten-year period 1996 to 2006. Nationwide there are 415 fewer ED's, 703 fewer hospitals and 198,000 fewer hospital beds. ED throughput is longer, and there are an increasing number of secondary ambulance transfers as specialty care has become more specialized and centralized in regional facilities. Inequitable Reimbursement Issues - nationwide, reimbursement is only available to the transporting entity. There is little recognition that the underlying costs of readiness and sophisticated care are significant. Reimbursement levels are less than cost. To facilitate billing for ambulance services, some local agencies have divided fire and EMS into separate entities. This has weakened both fire and EMS capabilities in some communities. Personnel Challenges - personnel recruitment, volunteer and staff retention, salaries and skill levels are issues nationwide. Training in pediatrics and geriatrics are weak throughout the Country. The Optimal EMS System An optimal EMS system is best designed from the patient's perspective. Patients should expect that the service would be engaged in illness and injury prevention, health education and early symptom recognition, in addition to responding to emergency and transportation requests. The EMS system should provide a rapid and appropriate response when a caller dials 911 and routinely provide medical instructions until help arrives. Medical First Responders should be able to deliver rapid defibrillation, arriving within four to six minutes with 90% reliability in urban areas. It is not possible to calculate Weld County's exact percentage due to a lack of data available from the County CAD system. Weld County Paramedic Services ©Fitch & Associates, LLC EMS Assessment 8 November 10, 2008 The arrival of a transport capable Advanced Life Support (ALS) ambulance should occur in urban areas within 8 minutes and 59 seconds (8:59) on life -threatening emergencies, within 11 minutes and 59 seconds (11:59) in suburban areas and within 19 minutes and 59 seconds (19:59) in rural areas with 90% reliability. Non -life threatening emergencies should receive a response within 12 minutes and 59 seconds (12:59) in urban areas; and within 19 minutes and 59 seconds (19:59) in rural areas with 90% reliability. Patients should be transported to a hospital that can treat their specific condition. The EMS system should be externally and independently monitored with participants held accountable for their responsibilities. Finally, the system should deliver good value for the resources invested. Weld County Paramedic Services ©Fitch & Associates, LLC EMS Assessment 9 November 10, 2008 EMS Operations Review This review focuses on how WCPS performs against certain benchmarks using the framework for the optimal EMS System. In addition, comments are provided relative to the organizational structure and leadership of the service. There is no single source for industry standards of practice. State EMS regulations reflect minimum performance requirements. Other commonly accepted "standards" are drawn from a variety of sources, including "10 EMS Standards" currently used to evaluate state EMS systems and the EMS Agenda for the Future developed by the US Department of Transportation, the National Academies of Sciences' Institute of Medicine report titled "EMS at the Crossroads," The International City/County Management Association report titled; "EMS In Critical Condition: Meeting the Challenge;" the "Community Guide to Ensure High Performance Emergency Ambulance Service" published by the American Ambulance Association and the standards developed by the National Academy of Emergency Dispatch, the Commission on the Accreditation of Ambulance Services and the National Fire Protection Association. Specific benchmarks and the service's performance in each of the following categories are described: • 911/Communications • Medical First Response • Medical Transportation • Medical Accountability • Customer and Community Accountability • Prevention and Community Education • Organizational Structure and Leadership • Ensuring Optimal System Value The results of the service's performance against the benchmarks are profiled in the following sections. Weld County Paramedic Services EMS Assessment ©Fitch & Associates, LLC 10 November 10, 2008 911/Medical Communications Communications Benchmarks • Public access through a single number preferably enhanced 911. • Single Public Safety Answering Point (PSAP) exists for the system. • Effective connection between PSAP and dispatch points, with minimal handoffs required for callers. • Certified personnel provide pre -arrival instructions and priority dispatching (EMD) and this function is medically supervised. • Data collection, which allows for key service elements to be analyzed. • Technology supports interface between 911, dispatching and administrative processes. • Radio linkages between dispatch, field units and medical facilities provide adequate coverage and facilitate communications. Observations & Findings Public Access Public access to emergency medical services is provided via an enhanced 911 (E-911) system. The Weld County Regional Communication Center (WCRCC) serves as the only Public Safety Answering Point (PSAP) in Weld County. Upon receipt in the communication center, calls are "announced" to WCPS rather than being assigned to a specific WCPS unit in accordance with a defined plan for deployment of resources. Units are not assigned based upon GIS and other data available to the control center to make closest unit assignments. The system is dependent upon individual units indicating that they are in a particular area or are closest to the call or for the EMS supervisor to intervene. Ambulance Request data is routinely sent to the ambulance unit's Mobile Data Terminals (MDT's) after a WCPS ambulance has acknowledged the request and stated that they are responding. Radios utilized are a part of the Colorado state wide 800 digital trunked radio system. All agencies in the County have full interoperability on the system with the exception that air medical providers currently do not have 800 digital capabilities. Coverage is described as adequate, with known poor areas of coverage in some locations. Cell phones are commonly used for back-up communications. The communication center operates 24 -hours per day. A minimum of 8 EMD certified dispatchers are on -duty at all times. This staffing level can increase to 12 during peak hours including supervisors. Weld County Paramedic Services ©Fitch & Associates, LLC EMS Assessment 11 November 10, 2008 Weld County Regional Communication Center (WCRCC) reports that its call processing times for Fire/EMS calls are less than 2 minutes (120 seconds) with 84.8% reliability.3 A review of data from the WCRCC CAD from mid 2006 to mid 2008 indicated that call processing times, from call receipt to initial crew notification time approximates 2 minutes 17 seconds or a total of 137 seconds measured at the 90th percentile.4 While there is no hard and fast "industry standard" for call processing time, high performance systems typically process calls from call receipt to pre -alert notification within 60 seconds at the 90th percentile. WCPS currently has no agreed performance standard with WCRCC. WCPS reimburses WCRCC approximately $245,000 per year or approximately $19.90 per request dispatched for communications services. These costs are comparable to other High Performance EMS Systems (HPEMS) receiving full service from their respective communications centers. Deployment and re -deployment services, analysis and GIS mapping and auto -routing, are an integral part of a modern EMS dispatch center but are not currently provided by WCRCC. The cost does not represent optimal value for WCPS without the provision of these services. A Service Level Agreement (SLA) between WCPS and WCRCC for provision of these advanced services should be implemented, monitored and audited regularly for compliance. Emergency medical dispatch procedures recommended by the National Academies of Emergency Dispatch (NAED) were observed to be utilized. The system utilizes computerized MPDS "ProQA" software. The key rationale for using MPDS is to correctly prioritize 911 calls by consistent use of medical protocols. Dispatch personnel are to stay on the line and provide pre -arrival first aid instructions on critical calls. These are to be routinely monitored through a Quality Improvement (QI) process and actively supervised by a physician. The Medical Director supervises the dispatch center on a limited basis. This effort needs to be expanded. The center is not accredited by the National Academies of Emergency Dispatch (NAED) which offer police, fire and EMS Accreditation programs. Computer Aided Dispatch The CAD system (Tiburon CAD and RMS) utilized at the time of the site visit does not facilitate organized reporting of EMS system component response times. WCRCC does not utilize the EMS module specifically designed by Tiburon for EMS operations. WCRCC has budgeted to upgrade the CAD system with the EMS module in 2009. 3 WCRCC Monthly Report 2008. 4 We requested specific data from WCRCC to review call -processing times. Given the difficulty of obtaining clean WCPS specific data from the WCRCC CAD system, a sampling of EMS specific trips were selected to review and estimate call processing times. This involved manually examining 400 randomized records over a two-year period. Based upon that review the call processing time at the 90th percentile was 2 minutes 17 seconds. Weld County Paramedic Services ©Fitch & Associates, LLC EMS Assessment 12 November 10, 2008 In addition to 911 requests, non -emergency ambulance calls are sometimes received at WCRCC via published 10 -digit telephone numbers. These calls appear to be handled in a business -like manner. However, the majority of non -emergency ambulance calls are handled by the operations staff at WCPS and not by the communications center. This is a system deficit and should be addressed to optimize operations to ensure that all calls are properly tracked within the system. Historically, communications centers like WCRCC performed an "order entry" or call taking function. In modern EMS systems, the communications center's role has changed dramatically to constantly manage changing levels of resources and mitigate risk of coverage changes as calls ebb and flow within the system. This management function is not performed by WCRCC. Professional working relationships exist between the WCRCC staff and WCPS, but WCPS is dependent upon the communications center to manage a core process that impacts its success. Leadership of the center has historically changed at regular intervals exacerbating the issue. Current leadership is described as responsive and working to address user needs. Beginning in January 2009, WCRCC plans to implement a "team" approach to staffing the center and will have dedicated Fire/EMS dispatchers assigned only to Fire/EMS responsibilities. Both agencies hope that this approach will facilitate enhanced communication and better relationships between WCRCC and WCPS. The functional working relationships should be clarified by memorandum of understanding or service level agreement to ensure that as personnel change the relationships and processes do not. Managing Communications Data and Deployment Dispatch data cannot be uploaded in an easily usable format that facilitates routine analysis and quality processes for deployment and optimization of resources. WCPS administration reports doing a combination of manual and billing software generated demand analysis of call volume and type, however this process is time consuming and does not provide for an adequate and timely appreciation of existing demand. Managing deployment is seen as an increased burden to WCRCC staff; however, this is normally considered standard in high performance communication centers. Without clean easy to access data, deployment decisions cannot necessarily be made with the big picture in mind. Additionally, it becomes more difficult to support/defend any deployment decisions made without adequate and timely data. Currently, WCPS does not have sufficient data to routinely perform a full demand/deployment analysis. Weld County Paramedic Services ©Fitch & Associates, LLC EMS Assessment 13 November 10, 2008 Recommendations 1. As quickly as possible, implement the EMS component of the existing CAD system. 2. WCPS and WCRCC must work together to develop systems, policies and procedures to facilitate a true system status management plan and more importantly, implement that plan with WCRCC proactively managing ambulance assignments and moves within the system in accordance with a defined plan. 3. At a minimum, all core EMS system response elements must be tracked and exportable to a data management system to enhance transparency and accountability with feedback to stakeholders at least monthly. 4. Develop a plan to make certain that the EMD center achieves NAED "Accredited Center of Excellence" status. 5. The communication center should implement random case review and adhere to the minimum review standard advocated by the NAED. 6. Ensure and document that 95% of those requiring pre -arrival instructions receive them in accordance with nationally recognized standards. 7. Strengthen prospective and retrospective medical oversight of the communications function. This should include routine case reviews by the Medical Director. 8. Develop a detailed Service Level Agreement (SLA) between WCPS and WCRCC for services purchased. 9. Send dispatch fire "team" members/supervisors to visit high performance fire/EMS communication centers to observe best practices in action. Medical First Response Medical First Response Benchmarks • First Responders are part of an integrated response system and medically supervised by a single system Medical Director. • Defined response time standards exist for First Responders. • First response agencies report fractile response times. • AED capabilities are available on first line apparatus. • Smooth transition of care is achieved. Weld County Paramedic Services ©Fitch & Associates, LLC EMS Assessment 14 November 10, 2008 Observations & Findings Medical first response services are provided by WCPS and 27 fire departments throughout the service area. The bulk of first response fire service is provided by the Union Colony Fire Rescue Authority within its district limits, with the remainder being provided by other departments throughout the County. The training levels of members and response capacity of these departments vary widely. Some respond to EMS calls in personal vehicles while others have designated response vehicles. The service provided by these agencies appears commensurate with the resources made available to them by their communities. Management reports that mutual aid agreements exist with surrounding agencies and are effective with good provider relationships being the norm. First response agencies participate in monthly meetings held at varying levels, but are not otherwise accountable to the EMS system. There is no Certificate of Need (CON) for this level of service. Medical accountability is limited. There is one unified Medical Director for all response agencies in the County. However, First Responder agencies rate their level of involvement with and feedback from medical control as low. In some areas of the County, care transitions between First Responders and ambulance personnel were reported (and observed) to be handled professionally. In others, the transitions were reported to be reflective of significant turf issues and were described as personality dependent. Friction still remains from a move last year by the Union Colony Fire Rescue Authority to initiate their own EMS transport system. This was viewed as a hostile takeover and further exacerbated strained relationships between the ranks of the two organizations. At the time of this assessment, WCPS remained the primary provider of EMS transport services within the County.' Recommendations 10. The existing Medical Director for the County should become more involved with First Responders and become a stronger integration point for the entire system including dispatch, first response and transport. 11. The total Medical Control budget should be 75% paid by WCPS as the transport agency and each first responder agency should pay a base and variable (based on volume) commitment. A defined list of services should be documented for amounts paid. If any additional services are to be added by an individual agency, they should take the form of a Memorandum of Understanding (MOU), and at the agencies own expense. All funding and MOU's should reside with the County to achieve single focus medical direction. s WCPS does not provide transport services for the extreme south-west portion of the County, and has not for a number of years. This relationship appears to be working well for the existing transport agency and WCPS. Weld County Paramedic Services ©Fitch & Associates, LLC EMS Assessment 15 November 10, 2008 12. Provide positive feedback in person or by phone to First Responder agencies on major cases. 13. First Responder response times should be reported from call receipt until "wheel" stop on a fractile basis, and appropriate QA/QI should be performed on a monthly basis. First Responder response times should be published monthly for local elected officials as part of a system scorecard. Medical Transportation Medical Transportation Benchmarks • Defined response time standards exist. • Agencies report fractile response times. • Units meet staffing and equipment requirements. • Resources are efficiently and effectively deployed. • There is a smooth integration of first response, air, ground and hospital services. • Develop and maintain coordinated disaster plans. Observations and Findings Resource Utilization & Demand An EMS system has three primary responsibilities when it comes to managing its resources; 1) cover geography, 2) cover call demand, and 3) deploy as the coverage and demand change. Geographic Coverage Weld County is a large area encompassing over 4,000 square miles. Major roadways crisscross East/West across the middle of the County and North/South across the central part of the County. Most of the major communities are accessible from these main roads and many of the ambulance stations are located in close proximity as well. This presents a deployment challenge in covering the large geographic area of the County. Large areas of the County with lower population density are not easily accessed from these main roads. This requires travel along single lane and rural road systems hindering rapid response. EMS stations are thoughtfully placed in areas with access and close to communities with higher demand. However, station placement is often based on convenience due to available land either owned or available to the County and not based on a formal demand analysis. Once a formal demand analysis is performed (based upon accurate request data) the service can formulate a basing/posting plan that meets the needs of all system stakeholders. WCPS should think "outside the box" with regards to placing resources within the County. WCPS does not necessarily need to build stations to house crews but can look Weld County Paramedic Services ©Fitch & Associates, LLC EMS Assessment 16 November 10, 2008 into partnerships with other County entities (i.e., fire service, law enforcement substations, County maintenance garages, etc.) The ability to quickly establish a "station" as well as respond to changes in demand (and move stations to cover that change) in the future is important and will allow the best use of limited capital expense. Demand Coverage Once a system has geographic coverage, call demand data should be layered on top to determine when calls occur, how many at each hour of the day, and at what locations. This helps establish where and at what time additional resources are required to meet demand. Deployment Plan The deployment model in place has recently been changed from "street corner" posting to station posting, which means ambulances are currently moved (as the system level changes) to existing stations. This change was made to reduce wear and tear on the fleet, reduce fuel costs in light of unbudgeted fuel price increases and to provide for increased crew comfort when possible. Overall this change has been successful in meeting these objectives. Response Time Performance Response times are considered a key benchmark of an EMS system's performance. In sophisticated EMS systems, response times are measured on a fractile basis with 90% reliability.' The most commonly recognized benchmark is to place an ALS transport capable ambulance on the scene of life -threatening emergencies (e.g. calls categorized under MPDS as Echo and Delta) within 8 minutes 59 seconds (8:59) in urban areas, within 11 minutes and 59 seconds (11:59) in suburban areas and within 19 minutes and 59 seconds (19:59) in very rural areas. For non -life -threatening emergencies (e.g. MPDS, Charlie and Bravo) the typical urban response time is 11 minutes and 59 seconds (11:59) and 14 minutes and 59 seconds (14:59) respectively. Typically, rural non -life -threatening calls are also benchmarked at 19 minutes and 59 seconds (19:59) due to the distance involved.' Response times measured from the patient's perspective are defined as from the elapsed time from when the initial call is received at the medical communications console of the communications center until the transport capable unit is on scene. 6 The fractile method reports the compliance percentage to a defined response time standard. Industry standard is 90% compliance. Response times that are reported using an average response time methodology report compliance at the 501" percentile. Through the use of the MPD protocol, callers receive quick, accurate, and reproducible triage and pre -arrival instructions from a trained EMD. The standardized protocol enables the EMD to quickly ascertain the nature of the caller's chief complaint, the severity of their symptoms, and identify the response recommendation that is most appropriate. Echo responses are the most critical (e.g. cardiac arrest) and range down in acuity to Alpha calls (e.g. minor extremity wound w/no active bleeding). Weld County Paramedic Services ©Fitch & Associates, LLC EMS Assessment 17 November 10, 2008 In Weld County, response times are not reported in a manner that allows benchmarking the system's performance to other EMS systems. This is a major system deficit that needs to be addressed quickly. Based upon an examination of WCPS records and WCRCC records, it is estimated that within the City of Greeley that the 90th percentile of reliability is reached between 11 and 12 minutes. The City of Greeley is the only area within the County that is currently broken out separately for urban response time reporting. All remaining areas of the County are aggregated in the twenty -minute category. Response time records are maintained within the County CAD system, but cannot be exported for simple analysis due to the fact that the existing CAD system, by design, places emphasis on law enforcement data and handles EMS data as secondary data. There is no written protocol defining how any response time reports are to be constructed or validated. WCPS analyzes information provided by dispatch into a spreadsheet to produce internal response time reports (along with data pulled from the RescueNet Billing system). Neither the EMS system nor the County 911 center routinely reports fractile response time or its associated component times in a transparent manner. The key to achieving response time performance is consistent measurement, understanding response time outliers and systematically focusing on the causative factors. Communications center staff members typically play a significant role in this analysis and routine redeployment of resources to achieve response time compliance. Response times are not only an indicator of customer satisfaction, however they have a clinical impact and every effort needs to be taken to reduce response times given the large geographic service area. Specific analysis of call component response times should be accomplished at least monthly. Response times can also be further examined by area, by unit and by individual staff member. Response time compliance should be reported on a monthly basis. Overall system response time can be improved by decreasing the existing call processing time in the communication center. By reducing the existing time from over 2 minutes to less than 60 seconds, the entire system realizes a gain of over 1 minute in response ability without the associated cost of adding additional response resources. Weld County Paramedic Services ©Fitch & Associates, LLC EMS Assessment 18 November 10, 2008 Figure 3. Anatomy of an EMS Incident I sIMP t a ;L Table 1. TIme Interval Benchmarks Time Interval Description of Time Interval Recommended Fractlle Benchmark TO -TI Length of time between when the 911 cell 6 received at the public safety answering point and when tie transferred to an EMS answering point {the same point in WCRCC) <30 seconds; 90% reliability (benchmark not applicable to WCRCC) T1 -T2 Length of ome between when the phone rings et the EMS answering point and when the cdlblaK¢r PGs oil <5 seconds: 90% reliability (Unable to document WCRCC benchmark, observed at <30 seconds) T2•T3 length of time between when the call is picked up and when the Incident type are locution are verified <25 seconds; 90% reliabliy (Unable to document WCRCC benchmark, (Unable at <25 seconds) T3 -T4 Length of time between verification of the Incident location and transfer of the ell details to the dispatcher's scam <5 seconds; 90 % reliability (aMMma/k net applicable to WCRCC at time of observation) TI-T4.t Length or time between verification of the location and conclusion of emergency medical dispatch (may occur at any time between T4 and T7) Estatfah benchmarks by call type T4 -T5 Length of time between when the mill appears in the to -be -dispatched queue and when It Is actually dispatched to a craw <25 seconds; 90% reliability (Linable to document WCRCC benchmark. observed at <25 seconds) TS -T5 Leength of time between when the crew receives the call and when the crew is en route to tie tat ;wheels turning) <45 seconds; 90% relobpbty (tV0llet•edard N <M assinde) Tb-t7 Length of brae bt . ten when die den'' 5 en route and when 4 amens at the incident scene Actual travel time (assuming a total response time of 5:59, this component would be CU seconds) T7 -TS Length of time between when the crew arrives at the scene and when it departs for the desdnatles <IS minutes; 90% reliability (depending on protocols)- - WCPS meats this bendtmerk 113-T9 Length of time between' when the crew departs from the scene and when it arrives et the destination Actual travel time T9 -T10 Length of time between when the crew arrives at the deebnblkM and when the crew becomes evadable for further work <15 minutes; 90% reliability (a0palonal bnnmmorks may be required for incidents of varying sevyrtty)-WCPS meets this benchmark TIO T11 Length of time between when the crew becomes available and when a departs from the destination Estab'ah internal benchmark when applicable 1I1 -T12 Length of time between when the crew departs from the drat/net-on end when it arrives at Its designated post Establish Internal bencslmark when a*pllcable Green -meets recommetrdad benchmark Red —unable to document benchmark. or benchmRrk I5 not mot Weld County Paramedic Services EMS Assessment 20 *Fitch & Associates, LLC November 10, 20013 Vehicles and Equipment The management of fleet operations is a critical component of any ambulance service. Ensuring vehicles are in working condition reduces the risk of missing calls, enhances the ability to meet response time goals and reduces overall fleet costs. Unscheduled fleet downtime has a tremendously negative impact on the overall operation of the service. It is very important to have a fleet maintenance provider who fully understands the nuisances of ambulance specific maintenance. The fleet is one of the largest non -personnel line items in any EMS budget. Making sound purchasing/replacement decisions and conducting frontline and preventative maintenance is critical to reducing lost unit hours and keeping ambulances in service to run calls. The fleet is managed by a County contracted fleet maintenance organization who manages the entire fleet of all vehicles for Weld County. Although WCPS reports there are individuals tasked with specifically working on ambulances, there are no emergency vehicle trained technicians assigned to WCPS vehicles. The local Ford dealer in Greeley handles repairs under warranty. Due to the complex nature of emergency vehicles, it is important to have trained technicians performing service on the ambulance fleet whenever possible. Fleet services do not maintain accurate logs of scheduled versus unscheduled out of service times nor does it report differences in predicted versus actual out of service times. An electronic log should be maintained and reported monthly to WCPS. The site visit to the fleet maintenance facility revealed that ambulances are routinely left outside, in an unfenced parking lot fully stocked without any locks or visual security devices on the interior cabinets. It is recommended that the service implement cabinet security, via breakaway plastic locks to at least provide visual cues as to the status of the supplies/equipment located within. The best solution for fleet security would be to have all ambulances located at the maintenance facility locked inside for storage. WCPS has a fleet consisting of 11 ambulances stocked and available to be placed into service if staff is available; peak staffing is 8 ambulances. The current ambulance fleet size is 137% of peak. The service should consider adding a vehicle to the fleet to increase this number to approximately 150%. The simplest way to accomplish this goal would be to keep an ambulance in reserve when it is time to retire a unit. This addition would have the dual benefits of providing a larger margin of vehicles in case of maintenance issues and in reducing overall mileage accrual in newer units. In addition, the fleet includes one psychiatric transport van and one supply/fleet pickup truck. The fleet consists of one Type I ambulance with the remainder being Type III. The entire fleet consists of Ford vehicles. The average mileage for the fleet is within normal range for the fleet age. The Consultant team met with the fleet manager and EMS personnel, conducted onsite observations and reviewed data submitted. Weld County Paramedic Services ©Fitch & Associates, LLC EMS Assessment 21 November 10, 2008 Remounting WCPS currently remounts serviceable patient care modules on new chassis as part of its fleet management program. A well -maintained patient care module or "box" depreciates in about 10 years but can last as long as 20 and a chassis depreciates over 3-5 years. With low mileage it can last longer. This means the life of a well cared for ambulance patient compartment can last as many as 4 remounts. Each module manufacturer utilizes proprietary construction and wiring methods so having a single manufacturer simplifies remounting. Also, when a manufacturer remounts its own product, it will inspect it and offer a new warranty on the box. Total savings, when considering remounting versus buying new, range from $10-$15,000. It is important to note that a remount removes the unit from service for an extended period depending on the unit and the vendor providing the service. This practice works best with a fleet with generally lower than average mileage and high levels of ambulance specific technical competence from the fleet maintenance providers. WCPS is currently studying a change to an outright replacement of ambulances as part of its fleet management program. Benefits of this change include having more of the fleet in a manufacturer warranty status and anticipated decrease in unscheduled maintenance and subsequent downtime. This plan would be even more advantageous to WCPS if the service had access to emergency vehicle certified technicians for related maintenance issues. The County fleet maintenance service would then be utilized for preventative maintenance along with general mechanical work (such as routine service, tires, brakes, etc.) to decrease fleet and individual unit downtime. Replacement Schedule There are several schools of thought as to what makes sense for deciding when an ambulance should be replaced. A benchmark study of 16 high performance systems reported in 2005 by the Coalition of Advanced Emergency Medical Systems found the median mileage for replacement to be 200,000 or 5 years. Several systems extend to 250,000 to 300,000 miles.8 These services tend to put more wear on their ambulances, but in general an industry ballpark for ambulance replacement is 250,000 miles or 5 years of service. WCPS averages 35,000 miles per year per ambulance. It needs to be emphasized that mileage numbers are only a rough guideline and maintenance practices must be considered in any fleet management plan. Without ambulance specific maintenance technicians, a fleet tends to have a higher than average failure rate, higher unscheduled maintenance downtime and lower than expected service life. 6 Overton, 3. & Andersen, D. (2005). High performance and EMS: Market study 2005. Richmond, VA: Coalition of Advanced Emergency Systems. Weld County Paramedic Services ©Fitch & Associates, LLC EMS Assessment 22 November 10, 2008 WCPS is considering changing its replacement model from one of remounting to outright replacement. Benefits of this change include having more of the fleet in a manufacturer warranty status and expected less unscheduled maintenance downtime. This plan would be even more advantageous to WCPS if the service had access to ambulance specific technicians for related maintenance issues. The County fleet maintenance service could still be utilized for general mechanical work (such as routine service, tires, brakes, etc.). Fleet Performance Measures For quality assurance purposes, measuring the systems compliance with its PM program is essential. Additional measures may include time to complete vehicle service at the 90th percentile. A common measure of fleet performance that has a direct impact on operational effectiveness is the number of vehicle failures per 100,000 miles. WCPS reports a critical vehicle failure rate of .78 per 100,000 miles traveled, which is below the mean (2.30/100,000) and median (2.00/100,000) of other high performance systems. The system also reports a fleet collision rate of .78 per 100,000 miles. This rate is also lower than the mean (1.35/100,000) and median (1.30/100,000) rates reported by CAEMS benchmark study participants. Training of Staff & Daily Unit Checks The field providers have the most intimate experience with the vehicles they use every day. Staff must be trained to identify basic problems with a vehicle's operation and know the proper procedures for reporting immediate and to -be -scheduled maintenance needs. Adherence to this practice can greatly reduce unscheduled maintenance and critical failures. It is common to assume that new employees either come with this knowledge when hired or will receive instruction on-the-job from their field trainers. This is not always true. For best results, the fleet manager should participate in orientation, and in-service each new employee on exactly what they should be looking for each day. To ensure the entire department is currently aware of their responsibilities, every field person (provider and supervisor) should participate in a refresher of the process in an in-service with fleet staff. This training will enable a successful daily check procedure as part of the start of shift unit check off. Each new crew should perform a vehicle check and document it was completed. If there are any problems or questions, they should be documented and the fleet personnel should be consulted to determine if there is a need for immediate intervention or if it is something that can be handled at the next scheduled preventative maintenance. WCPS uses a paper based inspection process where forms are forwarded to the shift supervisor. Issues are supposed to be reported when noted. This process should be formalized and expanded to better capture vehicle issues before they become out of service problems. Weld County Paramedic Services ©Fitch & Associates, LLC EMS Assessment 23 November 10, 2008 Behavioral Feedback Driving System WCPS is not currently using any quality control, monitoring and feedback mechanism for driving performance. While the department does not appear to have a high accident rate, this technology is worth considering in the future. When effectively implemented, this type of system has been shown to dramatically reduce accident rates, lower maintenance costs by as much as 10-20%, and extend the life of parts (i.e., brake pads).9 Investing in a driving system such as "Road Safety" or "DriveCam" is a smart investment that will likely pay for itself in cost savings. Preventive Maintenance An efficient and cost effective fleet requires continued Preventive Maintenance (PM), in addition to daily crew checks that is able to maintain the unit for uninterrupted service and hopefully address repair issues before they occur and impact service. Currently fleet maintenance follows a fairly aggressive maintenance regimen. Table 2. Model Preventive Maintenance Schedule1° Service Level Mileage Interval Service Points Daily n/a Check lights, signals, warning systems, fluid levels, tire pressure, AC & heating systems, wipers, brake pedal travel, & monitor engine conditions A 3,000 Change oil & filters, check suspension, belts, alternator, tire & break wear, & load test battery B 6,000 All A items, plus check suspension & differential, fuel filter, brake rotors & pads C 9,000 All A & B items, plus replace belts, fuel filters, air filters, transmission fluid D 50,000 All A, B, & C items, plus replace A/C compressor & dryers, hoses, oil bypass lines, repack bearings, replace shock absorbers E 100,000 All A, B, C, & D items, plus replace water pump & radiator The vehicles are well equipped medically. Purchase orders are utilized and administrative oversight of this function is within accepted norms. Logistics support is provided by a fleet/supplies coordinator dedicated to this process. He is enthusiastic about this role and provided a detailed list of future oriented goals at the interview. An enhanced supply and vehicle checkout system, including keeping internal cabinets locked with tagged ties to facilitate rapid check out and enhance accountability, especially when vehicles are located at the maintenance facility, is recommended. 9 Levick NR, Swanson 3. An optimal solution for enhancing ambulance safety: Implementing a driver performance feedback and monitoring device in ground emergency medical service vehicles. Annul Proc Assoc Adv Automat Med 49: 35-50, 2005. 1° Bill Vidacovich, VP of Fleet Operations, Acadian Ambulance, Louisiana. Weld County Paramedic Services ©Fitch & Associates, LLC EMS Assessment 24 November 10, 2008 Staffing and Deployment WCPS operates at different levels of service based upon availability of staff. This varies by time of day and day of week. Previous recommendations address the need for WCPS to proactively advise the communications center of their anticipated response capacity to avoid delayed responses. Staffing is described as a challenge by the management team. Personnel turnover has increased in recent years and well -qualified candidates are becoming harder to recruit. The biggest competitor for candidates seems to be the career fire services. Employees are typically scheduled for an average 42 -hour workweek. Facilities and stations for WCPS are reasonably well kept. Scheduling is done via an automated system called "Tele Staff". The staff and supervisors report that this technology functions well. It is reported to ease the challenges of maintaining and managing the schedule. Deployment at WCPS is based on a schedule developed using demand data, but is described as being in need of an update. Deployment favors the "central" area of Weld County and coverage from outlying areas of the County is pulled as resource levels are utilized. When comparing the number of available units against the patterns of call volume per hour of the day, it appears that there is sufficient capacity during the overnight hours but not enough capacity on a regular basis to meet the average peak demand hours which occur daily in the afternoon/evening. The coverage level maps in Attachment A illustrate a "hole" in typical coverage in the Johnstown/Milliken area that should be addressed. In addition to this coverage "hole" WCPS is in need of at least 8 additional hours of coverage daily during periods of peak demand. One area of contention for the staff is required monthly on -call 24 -hour shifts to fill schedule holes or peak demand when all other options have been exhausted. Currently, when a shift is open due to sick call, part-time staff, followed by full-time staff are contacted to see if anyone is willing to cover. If no positive response is received, the on -call staff member is required to come in and cover the shift. Interviews with multiple staff members indicate that this solution is not favored; however staff did not present an alternative solution. Given the "leanness" that WCPS operates at, it may not be possible to craft a solution that resolves the on -call issue. WCPS Field Supervisors currently staff an ambulance basically 24 hours per day. During some daytime hours, this car is also staffed by either the transport van EMT or another qualified field provider from the office/supervisory staff. During overnight hours, this vehicle is only staffed by one paramedic caregiver. This vehicle will respond to all MPDS "Echo" dispatches as well as filling in when closest to calls or when demand has taxed the system beyond capacity. In these cases, the Field Supervisor will utilize a First Responder to drive Weld County Paramedic Services ©Fitch & Associates, LLC EMS Assessment 25 November 10, 2008 the unit to the hospital. This is reported to occur on approximately 2%-3% of all transports. This is not an optimal solution, and the addition of another resource during peak load periods will help minimize this from occurring. The graphic representations in Figures 4 and 5 below represent typical baseline information available from an EMS CAD and that are used by the system to work with staffing and deployment". Figure 4 describes historical call volumes by day of week and Figure 5 outlines the anticipated call volume by hour of day. Figure 4. Calls by Day of Week (Mid 2006 to Mid 2008) *Tula Call Volume 10000 9000 6000 1000 6000 5000 4000 3000 2000 1000 0 Non.lmagrn•y 'wreaks Figure 5. Expected Call Volumes (Mid 2006 to Mid 2008) by Hour of Day 4000 3500 1000 2500 2000 ,+ _ 1500 1000 500 i 1 2 3 4 5 G 7 8 9 1011121314.15 16 11 18 19 20 21 22 23 24 - -Total Call Volume -� Non.Fmergency - a-Emergency u The date in these figures was pulled from the WCPS tieing software, not Me'NCACC CAD Syatem. Weld County Paramedic Services ©Fitch 8 Associates, LLC EMS Assessment 26 November 10, 2008 The maps in Attachment A demonstrate WCPS's coverage for emergency calls based upon specific coverage levels. These maps indicate the percentage of emergency calls that are covered at the corresponding WCPS ambulance coverage status.12 The results of a routine geospatial and temporal call review are significant in planning how resources can be deployed, re -deployed and where additional ambulance resources may be required to provide adequate coverage in the service area.'3 To illustrate the coverage capabilities of the system at different levels of ambulance availability (system demand), the Consultants worked with the Weld County GIS Department to profile historical call volumes against exiting station locations. Using 10 miles per hour over the posted speed limit, drive bubbles were established to illustrate the striking response footprint of ambulances at various defined response intervals. In Attachment A, the orange bubble shows the current response capability to meet the 8:59/90 response goal. When the 2 -minute call processing time is considered, it results in a comparable travel time of 6 minutes and 59 seconds (6:59). The Teal bubble shows the response capacity with the improved call processing times. 12 Note: the totals may exceed 1000/0 due to overlapping coverage at higher ambulance status levels. The Final figure demonstrates the percentage of all emergency calls covered at individual levels. 13 Full-size maps are included as part of Attachment "A". Weld County Paramedic Services ©Fitch & Associates, LLC EMS Assessment 27 November 10, 2008 Figure 6. Percentage of Emergency Calls Covered at Each Status Level lsergeert9 Mar • la19r9e*q 2Nd CSt/ 14201 Total 15564 Total 29605 Total Lent I 469 66.6% 60.4% 74.0% 5.19 71.6% 66.1% 76.1% 1961 94.4% 974% 99.2% Lima 2 969 79.0% 09.3% 64.4% 1999 94.4% 96.7% 97.6% tad S 549 52.1% 91.1% 648% 1999 90.9% 99.0% 98.0% Lewd 4 569 62.1% 913% 84.9% 1569 94.9% 99.0% 98.0% Leoe1 S 569 52.1% 913% 80.9% 1919 96.9% 99.0% 96.0% L99d • 59 82.1% 913% 46.9% 199 96.9% 99.0% 98.0% In the current system, there is overlapping coverage at higher levels of ambulance availability. figure 6 illustrates the consolidated percentage of emergency calls WCPS could expect to cover at each status level without adjusting current station locations to reduce coverage overlap. As the system develops more sophisticated deployment plans and system status management processes, it will be able to adjust posting locations to reduce coverage overlap and increase the total response capacity of the system at each response level. This has a corresponding positive effect on response times. Veld County Paramedic Services Witch a Associates, LLC EMS Assessment 28 November 10, 2008 Provision of Mental Health Transports WCPS currently staffs a mental health transport van during peak hours daily. However, the service has seen an increase in mental health transport requests during hours when the transport van is not staffed. The transportation of these patients after hours by ambulance crews has a negative impact on the provision of emergency medical services in the County. The vast majority of these patients originate at NCMC and require transportation from the facility to mental health centers located not only in Greeley but as far south as Pueblo, CO (over 3 hours one-way). WCPS cannot continue to provide staff to cover these transports after hours without a negative financial and operational impact on the overall service. The service should insist that NCMC creates a staffing proposal to cover these non -emergency, routine transports. This includes providing staffing to cover their needs for these transports. Integration of First Response, Air, Ground and Hospital Services The area has historically received air (helicopter) support from the local, affiliated trauma center. Recently, the service area has seen an expansion of air medical providers, and interviews with these providers and WCPS management indicate that the relationship between the service and air medical providers is generally good. One item noted during staff interviews was the fact that the next closest trauma center (over 30 minutes further) has different trauma activation criteria than the facility located in Greeley. This is something that the service and its Medical Director should work to refine. Integration with ED nursing personnel is described as professional and team oriented. Mutual Aid & Disaster Plans Mutual aid agreements are reported to be in place and have not been described as problematic. Disaster response plans exist and are exercised at least annually. Information Technology The service has recently implemented a new electronic charting system, RescueNet Tablet PCR. This is a full -featured ePCR system that integrates completely with the RescueNet Billing system already in use by the service. Currently there is no integration between WCRCC's CAD system and either the billing or charting solutions. Additionally, the AVL components of the CAD were not operational at this writing. Recommendations Response Time Performance 14. Reduce call -processing times within WCRCC to realize immediate gains in response coverage within the system. 15. Response time exception reports identifying why a deviation occurs should be generated to assist management in identifying causative factors should be implemented. Weld County Paramedic Services ©Fitch & Associates, LLC EMS Assessment 29 November 10, 2008 16. Routinely analyze and report tractile response times. Work with all County response agencies to report these times as well and facilitate plans to improve response times for all agencies. 17. Develop call density bands that reflect urban, suburban and rural areas of the County and report response times on a tractile basis at 90% reliability to defined standards established for each density band. Deployment 18. Accurate geographic and temporal demand data should be acquired through an appropriate CAD program. Operational decisions and deployment adjustments should be response data driven. 19.A detailed deployment plan should be developed to move resources in a timely and organized fashion as calls and resources within the system ebb and flow. This should include consideration of a "mid -west" post as well as a Johnstown/Milliken post. WCRCC should ultimately be in control of all system resources, dispatches and post moves. 20. Add 8-12 hours peak demand unit daily. 21. Proactively anticipate coverage issues and modify/flex response plans to deploy available resources to improve response capability. 22. Rapidly complete the hardware and software necessary to provide mapping and Automatic Vehicle Locator (AVL) services to the EMS system. Fleet 23. Hold the next ambulance due for retirement as an additional system spare, giving the system additional reserve capacity. This would also effectively reduce the number of miles put on newer vehicles. 24. Fleet services should send at least one technician for ambulance specific mechanical (factory) training. 25. Fleet services should fully document and routinely benchmark all out of service hours, both scheduled and unscheduled as well as performance to scheduled out of service times versus actual out of service times for scheduled events. 26. Secure interior cabinets with breakaway locks once vehicles are stocked. These should be replaced at shift change or when vehicles are sent to fleet maintenance. 27. Implement a comprehensive daily vehicle check procedure with timely follow up and action when appropriate. Crews should be held accountable for completion of this daily documentation. Weld County Paramedic Services ©Fitch & Associates, LLC EMS Assessment 30 November 10, 2008 Medical Accountability Medical Accountability Benchmarks • Single point of physician medical direction for entire system. • Written agreement (job description) for medical direction exists. • Specialized Medical Director training/certification. • Physician is involved in establishing local care standards that reflect current national standards of practice. • Proactive, interactive and retroactive medical direction is facilitated by the activities of the Medical Director. • PCR data transparency facilitates MD review. • Clinical education effectiveness efficiency. Observations and Findings James Tyler, MD is employed in the emergency department at North Colorado Medical Center (NCMC) and serves as the Medical Director for WCPS, WCRCC as well as the remainder of responding agencies in Weld County. Dr. Tyler is regularly involved in training activities and retrospective reviews and is regularly available to meet with the administrative leadership and/or field providers. A written job description/contract was provided for the Medical Director. Dr. Tyler is well respected by the staff and his peers. In fact, the Medical Director and protocols were consistently ranked among the highest positive factors in the employee survey and during one-on-one interviews. Dr. Tyler would benefit from WCPS sponsorship of his participation in the National Association of EMS Physicians.'4 Clinical protocols are used and appear consistent with acceptable clinical practices. The service historically perceived itself as being a clinical leader but some concern has been expressed that increased turnover and the use of less experienced personnel could make sustaining excellence an increasingly challenging proposition over time. Medical accountability for dispatch needs to be more clearly established. 14 This is the largest North American physician's professional association specifically involved in EMS and EMS research. Weld County Paramedic Services ©Fitch & Associates, LLC EMS Assessment 31 November 10, 2008 Recommendations 28. Provide clinical feedback in a progressive manner involving the Medical Director to bring about increased accountability among all caregivers. 29. Significantly expand physician oversight of medical dispatch. 30. Encourage the Medical Director's involvement in training sponsored by NAEMSP. 31.The Medical Director should attend County board meetings at least once per quarter to report current status on clinical matters. Customer and Community Accountability Customer/Community Accountability Benchmarks • Legislative authorities to provide service and written service agreements are in place. • Units and crews have a professional appearance. • Formal mechanisms exist to address patient and community concerns. • Independent measurement and reporting of system performance are utilized. • Internal customer issues are routinely addressed. Observations and Findings Service Agreements & Coordination This EMS system has historically served its respective constituents well. It grew from a neighbor helping neighbor approach. It has been pressured by significant growth and other factors. From an objective perspective, the community accountability relationship can best be characterized as one offering "best efforts" of the provider. No specific response performance or formal accountability is required. The system operates as a County Enterprise. Both Management and Members of the Board of County Commissioners describes the relationship with the local county government through the Board as strong. User fees are set as part of the annual budget process with the Board of County Commissioners. The local focal point for EMS oversight is provided by the County. The County's commitment to EMS and its efforts to strengthen the system needs to become a high priority. Expanding written service agreements in a positive manner need to be thoughtfully revised to better "knit together" the loose weave of the quilt of service providers and provide tighter accountability, clinically, operationally and financially. Developing a performance -based agreement that provides additional operational flexibility, increased transparency, accountability and possibly a County subsidy (e.g. fuel and/or other baseline system funding) is recommended. This may require a paradigm shift at both strategic and operational levels within participating organizations and within the region as a Weld County Paramedic Services ©Fitch & Associates, LLC EMS Assessment 32 November 10, 2008 whole. No funding should be provided to any individual agency by any local unit of government unless the agency is participating and performing in accordance with the EMS system agreement. Professionalism Units and personnel generally present a professional appearance in the community. Procedures have been developed pursuant at the system level to ensure that customer and community inquiries are addressed. WCPS operates as a clearinghouse when a patient care concern or complaint is received. In addition to being responsive to external and community based customers, ambulance services must also be accountable to its internal customers (agencies and employees). While the County convenes meetings to share information on a regular basis with members, it should expand efforts to communicate with all participants of the system on a regular basis. Formal mechanisms to track suggestions, concerns and actions need to be established. Recommendations 32. Develop service agreements between the County and response agencies consistent with local legislative authority to require defined performances (e.g. response times, minimum availability/911 notification requirements to be dispatched, etc.). 33. Develop a performance -based agreement that provides additional operational flexibility, increased transparency and accountability. 34. Develop a detailed strategy and implementation plan to ensure that the County's EMS program has the operational flexibility and necessary resources to achieve its mission. 35. Publish monthly reports of First Responder and the ambulance service's fractile response times to all system participants and units of local government. 36. Expand EMS quality improvement processes and evaluate annually. Prevention and Community Education Prevention and Community Education Benchmarks • System personnel provide positive role models. • Programs are targeted to "at risk" populations. • Formal and effective programs with defined goals exist. • Targeted objectives are measured and met. Weld County Paramedic Services EMS Assessment ©Fitch & Associates, LLC 33 November 10, 2008 Observations and Findings The field providers serving customers view themselves as professionals and attempt to provide the best service they can within their capabilities. There is no indication that WCPS staff are viewed in any way other than professional and representing a positive role model. The EMS system does not report the number of hours of public education, prevention or public awareness programs accomplished by participants in the system. Community education and awareness activities are conducted by individual agencies, but these are not coordinated in a systemic fashion. The overarching observation is that WCPS has not successfully communicated its value and contribution to the health and safety of its customers. It has been consistently undervalued. Board members are relied upon to communicate the service's contribution and needs to their respective districts. WCPS needs to develop multi -focal mechanisms to communicate its story and build grass roots constituencies throughout its service area. There are significant opportunities for system participants to become more tightly linked with the broader community through education programs directly and through allied organizations such as the County Public Health Service, Hospitals and/or Hospital Foundations, Red Cross and American Heart Association. Ambulance services typically offer a wide variety of public education activities as a mechanism to maintain community connectivity. These programs range from on -demand car seat inspections to free home injury prevention inspections for families with toddlers or seniors. Junior Paramedic programs, Mass CPR training events and Scouting Explorer Posts are meaningful ways the service can engage their respective community. These can be designed and implemented with little investment and are limited only by the creativity of the individual services' leadership. Paramedics are in short supply. Attracting, retaining and developing staff is increasingly becoming a priority for emergency medical system operations. While retention is tightly related to the manner in which the individual agencies operate, recruitment efforts can be supported by the larger County system and should be a legitimate role added to the mission of WCPS. In addition to general community education programs and efforts to recruit volunteers, the Weld County Department of Health & Human Environment should integrate EMS in its educational programming to reach at risk populations. If the County wished to expand the public education to include "at risk" populations that may directly impact clinical outcomes, it should consider reviewing the call types commonly requested and do an analysis of specific at risk groups within the service area. Some sources have identified elderly (falls), diabetics, asthmatics and heart failure patients as key "at risk" groups. Redirecting outreach Weld County Paramedic Services ©Fitch & Associates, LLC EMS Assessment 34 November 10, 2008 efforts to those patients, as an attempt to prospectively reduce their probability of requiring EMS service at a measurably significant rate, would be very beneficial. Recommendations 37. Develop a program and identify resources to improve community awareness of the EMS system. 38. Identify key "at risk" groups in the community that would benefit from educational intervention. 39. Identify and support priority projects for community health improvement, utilizing the ambulance service as a primary focus. 40. Develop and promote a higher Internet profile for EMS, posting key service facts and response time information. 41. Prepare and distribute an annual report to elected officials and community stakeholders describing the accomplishments of the EMS System. Organizational Structure and Leadership Organizational Structure and Leadership Benchmarks • A local lead agency is identified and coordinates system activities. • Organizational governance, structure and relationships are well defined. • Human resources are developed and otherwise valued. • Business planning and measurement processes are defined and utilized. • Operational and clinical data guides the decision process. • A structured performance/quality improvement (QI) system exists, addressing administrative as well as clinical issues. Observations and Findings The organization reports to the Board of County Commissioners (BOCC). There have historically been collateral reporting relationships through the County Director of Finance and the Director of Administrative Services. The Board, while not involved in daily operations of the service, is ultimately responsible for the entity's operational and financial performance. Management team structures vary from organization to organization and are typically based on system model, coverage area, and call volume. Traditionally, an organization of the size of WCPS will have a management team that includes a director, operations manager, business manager, and a clinical quality & education manager supported by a single supervisor on each shift. The titles and specific responsibilities vary. Weld County Paramedic Services ©Fitch & Associates, LLC EMS Assessment 35 November 10, 2008 The WCPS team is lean and includes a Director, Operations Manager, Office Manager, four field supervisors and fleet/supply coordinator. Shift supervisors have additional collateral responsibilities assigned. The Supervisors are deployed on ambulances with other office personnel to support coverage when system status is low. During non -peak hours, supervisors respond alone in an ambulance and rely upon personnel from first response agencies to assist in staffing the supervisory vehicle as an ambulance. Each day, there is a field supervisor on duty. While their main focus is to support and manage the field providers, much of what they do is troubleshooting for staff, delivering needed items, collecting paperwork and managing "sick calls". Each supervisor has collateral task assignments for which they are responsible. There are a variety of styles among the supervisors and staff view them as having different strengths. Staff interviews indicate that there are distinct "ways of doing things" depending upon who the shift supervisor is. A professional development program for all members of the management team needs to be formulated with specific goals. Generally, human resources are valued and this group functions reasonably well in a laid back environment. Supervisory personnel would benefit from opportunities to participate in industry specific supervisory training such as the Ambulance Service Manger Certificate program conducted for public and private services under the auspices of the American Ambulance Association. There is movement to develop clear plans and objective performance measures for this organization. Business planning and measurement processes need to be further developed and utilized. The Consultants were informed that the County is undertaking a "Human Capital Management" program and intends to include the Service in this undertaking. This program will help the Service in creating more objective and reliable employee reviews, which is very desirable. It is envisioned that the findings of this report coupled with management's plan to accomplish its recommendations will be the basis for a go forward plan. Employee Survey Results As part of the scope of the review, the consulting team conducted focus group type sessions for employees and conducted a confidential employee survey. There were 107 surveys sent and 68 completed responses received resulting in a response rate of 64%. The survey utilized a five point Likert scale and involved over 90 questions. The vast majority of responses were within the expected ranges. More important however were the open-ended questions that asked the staff what they appreciated most and least about working with WCPS. Weld County Paramedic Services ©Fitch & Associates, LLC EMS Assessment 36 November 10, 2008 Common positive comments included: strong leadership, equipment and technology, the organization's clinical focus and teamwork among crews. The most commonly noted areas for improvement included: Lack of consistency and accountability among supervisors, morale and concerns about job stability. The employee survey results have been provided under separate cover to County officials. Quality Improvement Processes Quality management practices in the EMS industry are far behind other industries and focus heavily on reviewing individual calls for protocol compliance. Little attention is placed on actually measuring performance over time and improving processes and reducing variation. EMS organizations find that sustaining high quality service is a difficult task. EMS leaders are encouraged to integrate continuous quality improvement practices into their EMS operations and administrative practices to the extent that those practices become an essential and seamless part of normal EMS routines. WCPS has just recently added a Quality Assurance/Quality Improvement (QA/QI) position. An interview with the responsible staff member indicated that the position is still getting its "legs" and there is no formal system wide QI plan currently. The current QI approach is largely limited to retrospective chart review and providing feedback to ambulance personnel. Data is not collected on a system -wide basis to populate a scorecard. Instead, much of the data collected is based on specific data requested by the Medical Director. There are several steps the system can take to develop a comprehensive quality system, and this approach should be used for both clinical and operational practices. The following are recommended components of a quality program: 1. Key Performance Indicators based on call requests --Upon review of the Medical Priority Dispatch System (MPDS) data, it's common to find call types fall into four categories: respiratory, cardiac, traumatic injuries and everything else. By building performance measures for the first three big categories and then doing targeted studies on the miscellaneous call types in category four, the system can have an ongoing pulse of the service's clinical performance. 2. Targeted Case Studies —Each month, targeted reviews on certain call types (e.g., Refusals, CHF, 12 -leads, etc.) provide a deeper look at clinical performance. This is also an effective way to target key call types or the miscellaneous category of call types. The results of these reviews can be directly tied into in-service training, making it a pertinent and data driven educational exchange. This can also allow follow up later with another Targeted review to see if things have changed and allows a more robust approach to meeting the content areas required for recertification. Weld County Paramedic Services ©Fitch & Associates, LLC EMS Assessment 37 November 10, 2008 3. Episodic Review —Event driven reviews round out the final piece of a sound quality program. This is traditional quality assurance and includes sentinel events, complaints, and specifics like cricothyrotomies, pharmacological assisted intubations, etc. These activities should be a small amount of overall time commitment. To change the quality efforts to become more system focused and away from just clinical errors, weekly quality meetings would benefit from implementing an agenda structure similar to the following: 1. Review Key Performance Indicator (KPI) Data —Each meeting should begin with a review of the system's performance scorecard. Are all processes in statistical control, are there any statistical variances worthy of exploration, are improvements noted following improvement efforts? 2. Updates on Targeted Review —As targeted reviews are conducted each month, updates on the progress, new data and findings should be included in the weekly meeting. What are the results? Any system or process changes indicated? How should the data be effectively deployed through education? 3. New Directions —Based on the results of KPI data, targeted reviews, or other indicators, the committee should check -in to see if there are areas requiring further exploration or a change in course. This may include discussion of whether the performance measurement system in place is adequately capturing the critical data necessary. 4. QA Update —The last order of business includes a summation of any complaints or individual call reviews conducted. This should be a small portion of the total meeting time and is done assuming that improving processes and systems and not putting too much attention on individual errors best improve system performance. Implementation of a quality approach similar to the one just described will provide WCPS and the Medical Director with a much more in-depth perspective on the clinical quality of the system. This approach can also be expanded department -wide for addressing operational aspects of service delivery. With the implementation of electronic care reporting, the department should realize major productivity gains requiring many fewer work hours for data processing and report generation. Data access will increase exponentially. It is important that the individual in the role understand quality improvement and statistical process control. Training at a local community college or in one of the EMS specific six - sigma efforts is recommended. Weld County Paramedic Services ©Fitch & Associates, LLC EMS Assessment 38 November 10, 2008 Figure 7. Illustrates Proposed Retrospective QI Process fil if _, u44 .1h Asti] -I'' I ii I i 1\11 II ii- /- HI ti HOHiltHill-A-P-ci .ti i_ e I 9 if I J Jce O -Io _n fl 2.0 a < y Recommendations 42. Strengthen WCPS lead agency role and continue to develop mutual respect from other community organizations as that role is fulfilled. 43. Undertake a Board education initiative to include travel to several best practice sites to build awareness and a strategic planning process that the Board actively participates in developing. 44. Develop a detailed work plan with specific timelines for service enhancements. The plan needs to have clear goals matched to each of the key areas outlined in the report and that provide both direction and accountability over the next 3-5 year period. 45. Consider sending key managers to the AAA Ambulance Service Manager's (ASM) Certificate Program. 46. Develop a performance management plan to be reviewed on an annual basis. 47. Identify key performance indicators to track organizational performance. 48. Provide QA specific training for individuals involved in the services QA process. 49. Use a performance improvement methodology to improve key processes. 50. Present a summary of the Consultant report to WCPS staff. 51. Provide supervisory training (line and administrative) for all personnel holding supervisory positions within the EMS system; assure that each supervisor has the knowledge, skills and aptitudes to be an effective supervisor. 52. Expand physician supervised and EMS administered QI process involving communications, first response, medical transportation and administrative components of the system. Ensuring Optimal System Value Ensuring Optimal System Value Benchmarks • Clinical and customer satisfaction outcomes are enhanced by the EMS system. • Unit Hour Utilization is measured and hours are deployed in a manner to achieve efficiency and effectiveness. • Cost per unit hour and transport document good value. • Financial systems accurately reflect system revenues and both direct and indirect costs. • Revenues are collected professionally and in compliance with federal regulations. • Local tax subsidies are minimized. Weld County Paramedic Services EMS Assessment ©Fitch & Associates, LLC 40 November 10, 2008 Observations and Findinas Satisfaction is best measured by analyzing and measuring both outcomes and key indicators. Quality processes that support the determination of the efficacy of treatment modalities are becoming increasingly common in EMS. It is difficult to accomplish outcome measurement given the high number of other variables in the "chain of survival" that impact the patient's ultimate outcome. However, in the interim, process measures and outcomes for target conditions are frequently utilized. In Weld County, tracer conditions such as cardiac arrest and trauma are routinely reviewed but have not been sufficiently quantified to empirically document the system's benefits. Other supportive indicators including pain relief and customer satisfaction are not routinely measured within the EMS system. External customer experiences are not monitored in a manner that can be used to quantify system value. Efforts to improve clinical outcome measurement are underway. WCPS is implementing an ePCR platform that will greatly improve the quality of the data captured, enhance the monitoring of performance and improve the reimbursement process. Converting to an ePCR will also reduce storage issues and result in major gains in staff time as processes are eliminated such as transporting, sorting and storing records and reviewing hard copies for quality control. Expenses and Revenues In 2007, the service had operating expenses (excluding bad debt) of $5,250,942 and net revenues (including patient fees, other fees, grants and miscellaneous income) of $5,324,454 resulting in a net income prior to transfers of $73,512.15 This leaves basically no room for growth/expansion of the system to meet increasing demand. Without further revenue sources, the system will soon be unable to meet existing demand, let alone future growth. WCPS patient charges are on the high end of what would be expected for the region and simply raising rates is not an acceptable solution, especially given the County's patient mix. The service's expenses are within the expected range for this type system. WCPS costs are $22 per capita and $120 per unit hour while its cost per transport is $623. The Coalition of Advanced Emergency Medical Service Systems (CAEMS) annually reports 13 benchmark communities. The most recent published data is for 2006 and reflects a mean cost of $38 per capita; $120 per unit hour and $396 per transport. The reporting systems tend to be more densely populated areas with higher call volumes. Some of these systems receive tax subsidies while others do not. 15 Weld County Basic Financial Ledger Statements as of December 31, 2007 (Weld County Website). Weld County Paramedic Services ©Fitch & Associates, LLC EMS Assessment 41 November 10, 2008 Unit hour utilization is reported by the service to be .18 based upon 43,680 unit hours per year. Benchmarks of UhU for similar agencies typically range from .11 to .25. In other words, WCPS crew productivity levels are within the expected range of similar service environments. It is unlikely that the organization can remain fiscally viable given the increased unit hour coverage recommended without focused efforts to improve its accounts receivables and other additional funding being made available. WCPS and the County should take action sooner rather than later to consider a baseline subsidy per capita to ensure WCPS' viability. Revenues, Patient Fees and Collection Processes Review of the billing operations did not involve an audit of individual claims, but rather an assessment of the current processes and outcomes. Data was primarily collected through interviews with the billing manager and billing staff as well as review of data supplied during the information data request phase. Reported net cash collection in 2007 was approximately 32.8% of billed charges. The department reported a $15,077,867 in total charges for service and net collections of $4,944,352. The services payer mix is: Self Pay —including indigent (30%), Private Insurance (20%), Medicare (38%) and Medicaid (12%). The days in accounts receivable is an important measure of billing and collection performance and is calculated for WCPS at 75.5 days16. This is consistent but at the higher end of optimal industry performance benchmarks. WCPS manages most of its billing function in-house. Private Pay accounts are transferred to an outside agency after 20 days if no response or payment results for the initial invoice. These private pay accounts are kept on the books, and if the outside agency collects on these accounts, the payments are posted to the patient accounts. Other open accounts are referred to the outside collection agency after 120 days if payments have not been received. When an account is turned over to the collection agency after 120 days, it is written off and removed from the accounts receivable. When a payment is received by the collection agency, WCPS reverses the write-off entry to post the payment. Most services do not reverse the write-off entry; rather any payments received on accounts that have been closed are posted to a general ledger revenue account for receipts from previously written off accounts. Changing this process will reduce unnecessary activities, provide more accurate reports and be more efficient. 16 Calculated from Aging Summary as of 7/23/2008 for all accounts from 2/1/2003 with total accounts receivable equaling 3,324,975. The average daily charges were calculated from the first six months of 2008 charges ($44,048 per day). The days in accounts receivable equal 75.5 ($3,324,975 = $44,048). Weld County Paramedic Services ©Fitch & Associates, LLC EMS Assessment 42 November 10, 2008 WCPS has proposed a change in its billing practice to the BOCC. This proposed change would have WCPS bundling charges instead of charging for individual procedures and supplies. This practice is common in the industry and in fact, many payors prefer this structure versus individual itemized charges. The Consultants concur that this approach could provide some billing office efficiencies and simplify the process of accounting for bad debt and write-offs. A total of 4.5 full-time employees (FTEs) are dedicated to the billing and collection processes. WCPS also provides billing and collection to two outside agencies (North Park Ambulance Service and Limon Ambulance Service). The call volume of WCPS justifies 3.0 FTEs for billing and collection activities especially after the completion of the implementation of the ZOLL Tablet PCR, which will reduce redundant data entry activities. The 3.0 FTEs would also have the capacity to manage the private pay accounts. Billing for two additional services may justify an additional 0.5 FTE to manage the workload. The average patient bill in 2007 was $1.727." The overall collection rate of WCPS is 32.8%18 with a net collection rate (after reduction of contractual allowances) of 58.1%.19 The importance of these measures is that the WCPS pricing has reached a level that additional price increases will result in minimal increases in cash collections. The fee schedule payers (Medicare and Medicaid) will pay the same regardless of increases in charges and there is minimal ability to collect more from private pay sources. These groups represent 80% of the patients. Using the same individual to prepare patient accounts records and receiving cash/posting in the receivables is not an optimal business practice for ambulance services. While there is no indication that any misappropriation of funds has occurred, it was recommended at the time of the site visit that this procedure be changed immediately. Follow up activity on accounts is on time available basis by staff rather than in accordance with a predetermined schedule with defined performance measures. 17 $15,077,867 in total charges _ 8,729 transports 18 $15,077,867 in total charges - $4,944,352 in cash collections 19 $15,077,867 in total charges - $6,567,052 in contractual allowances = $4,944,352 in cash collections Weld County Paramedic Services ©Fitch & Associates, LLC EMS Assessment 43 November 10, 2008 Table 3. WCPS Billing Steps 1. Dispatcher records call via Tiburon CAD at WCRCC 2. Crew documents patient care via ZOLL Tablet PCR 3. Crew completes one -page encounter sheet and turns in with face sheet (if available) 4. Paperwork is gathered by field supervisors 5. Billing staff organize paperwork in CR order 6. Billing staff print Tiburon paperwork 7. Billing staff check for missing trip sheet paperwork 8. Electronic PCR's are downloaded into billing system 9. Daily electronically check for Medicaid and Colorado Access 10. Daily pre -billing (call, email, etc., for insurance information) 11. Review PCR's in billing and data entry of information (including charges, insurance information, etc.) 12. Daily verification of trips after they have reviewed (done by a different biller than the original entry staff) 13. Daily bill electronically the bills that have been verified (not all are billed electronically) 14. Daily send electronic batches of bills to Dantom 15. Daily post cash receipts and include any electronic funds from Medicaid and Medicaid ERA 16. Daily deposit cash receipt to the bank and Treasurer (County) 17. Weekly review Medicare and Medicaid workflows 18. Daily or as needed review insurance workflow 19. Twice weekly electronic files are sent to self pay 20. Monthly electronic files are sent to collection and accounts are written off 21. Weekly collection phone calls are made on accounts 22. Weekly phone calls on accounts with balances after insurance paid or Medicare paid 23. Weekly or monthly refunds are made on accounts with overpayments 24. Monthly closing reports run 25. Monthly journal entries are entered into Banner (County's accounting system) Subsidies There are no direct tax subsidies at the County level for individual WCPS. Subsidies will be required to ensure service availability in the future, especially given the fact that the service is barely covering expenses at its current level. While the primary funding method should remain user fee based, the Board of County Commissioners is strongly encouraged to set a baseline per capita funding level for the service. Weld County Paramedic Services EMS Assessment ©Fitch & Associates, LLC 44 November 10, 2008 Recommendations 53. Streamline data entry process and work to fully integrate trip data from CAD through the billing system. 54. Routinely benchmark A/R processing times and collections results to industry standards. 55. Ensure A/R procedures adhere to industry best practices. 56. Track percentage of paperwork that is "complete" from field providers. Follow up with non -compliant crewmembers to ensure 100% compliance. 57. Manage private pay accounts in-house and implement processes to identify those accounts that should be transferred to the collection agency prior to 120 days. 58. Reduce the number of FTEs by 1.0 to 1.5 for working ambulance accounts. 59. Measure and monitor the days in accounts receivable ratio and strive to reduce the number to 65 to 70 days. 60. Post payments received from outside collection agencies for accounts that have previously been written off directly to a general ledger account rather than reversing the write-off entries. 61. Develop a baseline per capita funding mechanism to ensure that the service continues to be primarily user fee based but has additional funding not dependent upon third party payers. Weld County Paramedic Services ©Fitch & Associates, LLC EMS Assessment 45 November 10, 2008 Summary of Recommendations 911/Medical Communications 1. As quickly as possible, implement the EMS component of the existing CAD system. 2. WCPS and WCRCC must work together to develop systems, policies and procedures to facilitate a true system status management plan and more importantly, implement that plan with WCRCC being the facilitator of all ambulance assignments and moves within the system. 3. At a minimum, all core EMS system response elements must be tracked and exportable to a data management system to enhance transparency and accountability with feedback to stakeholders at least monthly. 4. Develop a plan to make certain that the EMD center achieves NAED "Accredited Center of Excellence" status. 5. The communication center should implement random case review and adhere to the minimum review standard advocated by the NAED. 6. Ensure and document that 95% of those requiring pre -arrival instructions receive them in accordance with nationally recognized standards. 7. Strengthen prospective and retrospective medical oversight of the communications function. This should include routine case reviews by the Medical Director. 8. Develop a detailed Service Level Agreement (SLA) between WCPS and WCRCC for services purchased. 9. Send dispatch fire "team" members/supervisors to visit high performance fire/EMS communication centers to observe best practices in action. Medical First Response 10.The existing Medical Director for the County should become more involved with First Responders and become a stronger integration point for the entire system including dispatch, first response and transport. 11. The total Medical Control budget should be 75% paid by WCPS as the transport agency and each first responder agency should pay a base and variable (based on volume) commitment. A defined list of services should be documented for amounts paid. If any additional services are to be added by an individual agency, they should take the form of a Memorandum of Understanding (MOU), and at the agencies own expense. All funding and MOU's should reside with the County to achieve single focus medical direction. 12. Provide positive feedback in person or by phone to First Responder agencies on major cases. 13. First Responder response times should be reported from call receipt until "wheel" stop on a fractile basis, and appropriate QA/QI should be performed on a monthly basis. First Responder response times should be published monthly for local elected officials as part of a system scorecard. Weld County Paramedic Services ©Fitch & Associates, LLC EMS Assessment 46 November 10, 2008 Medical Transportation Response Time Performance 14. Reduce call processing times within WCRCC to realize immediate gains in response coverage within the system. 15. Response time exception reports identifying why a deviation occurs should be generated to assist management in identifying causative factors should be implemented. 16. Routinely analyze and report fractile response times. Work with all County response agencies to report these times as well and facilitate plans to improve response times for all agencies. 17. Develop call density bands that reflect urban, suburban and rural areas of the County and report response times on a fractile basis at 90% reliability to defined standards established for each density band. Deployment 18. Accurate geographic and temporal demand data should be acquired through an appropriate CAD program. Operational decisions and deployment adjustments should be response data driven. 19.A detailed deployment plan should be developed to move resources in a timely and organized fashion as calls and resources within the system ebb and flow. This should include consideration of a "mid -west" post as well as a Johnstown/Milliken post. WCRCC should ultimately be in control of all system resources, dispatches and post moves. 20. Add 8-12 hours peak demand unit daily. 21. Proactively anticipate coverage issues and modify/flex response plans to deploy available resources to improve response capability. 22. Rapidly complete the hardware and software necessary to provide mapping and Automatic Vehicle Locator (AVL) services to the EMS system. Fleet 23. Hold the next ambulance due for retirement as an additional system spare, giving the system additional reserve capacity. This would also effectively reduce the number of miles put on newer vehicles. 24. Fleet services should send at least one technician for ambulance specific mechanical (factory) training. 25. Fleet services should fully document and routinely benchmark all out of service hours, both scheduled and unscheduled as well as performance to scheduled out of service times versus actual out of service times for scheduled events. 26. Secure interior cabinets with breakaway locks once vehicles are stocked. These should be replaced at shift change or when vehicles are sent to fleet maintenance. Weld County Paramedic Services ©Fitch & Associates, LLC EMS Assessment 47 November 10, 2008 27. Implement a comprehensive daily vehicle check procedure, with timely follow up and action when appropriate. Crews should be held accountable for completion of this daily documentation. Medical Accountability 28. Provide clinical feedback in a progressive manner involving the Medical Director to bring about increased accountability among caregivers. 29. Significantly expand physician oversight of medical dispatch. 30. Encourage the Medical Director's involvement in training sponsored by NAEMSP. 31. The Medical Director should attend County board meetings at least once per quarter to report current status on clinical matters. Customer and Community Accountability 32. Develop service agreements between the County and response agencies consistent with local legislative authority to require defined performances (e.g. response times, minimum availability/911 notification requirements to be dispatched, etc.). 33. Develop a performance based agreement that provides additional operational flexibility, increased transparency and accountability. 34. Develop a detailed strategy and implementation plan to ensure that the County's EMS program has the operational flexibility and necessary resources to achieve its mission. 35. Publish monthly reports of First Responder and the ambulance service's fractile response times to all system participants and units of local government. 36. Expand EMS quality improvement processes and evaluate annually. Prevention and Community Education 37. Develop a program and identify resources to improve community awareness of the EMS system. 38. Identify key "at risk" groups in the community that would benefit from educational intervention. 39. Identify and support priority projects for community health improvement, utilizing the ambulance service as a primary focus. 40. Develop and promote a higher internet profile for EMS, posting key service facts and response time information. 41. Prepare and distribute an annual report to elected officials and community stakeholders describing the accomplishments of the EMS System. Organizational Structure and Leadership 42. Strengthen WCPS lead agency role and continue to develop mutual respect from other community organizations as that role is fulfilled. Weld County Paramedic Services ©Fitch & Associates, LLC EMS Assessment 48 November 10, 2008 43. Undertake a Board education initiative to include travel to several best practice sites to build awareness and a strategic planning process that the Board actively participates in developing. 44. Develop a detailed work plan with specific timelines for service enhancements. The plan needs to have clear goals matched to each of the key areas outlined in the report and that provide both direction and accountability over the next 3-5 year period. 45. Consider sending key managers to the AAA Ambulance Service Manager's (ASM) Certificate Program. 46. Develop a performance management plan to be reviewed on an annual basis. 47. Identify key performance indicators to track organizational performance. 48. Provide QA specific training for individuals involved in the services QA process. 49. Use a performance improvement methodology to improve key processes. 50. Present a summary of the Consultant report to WCPS staff. 51. Provide supervisory training (line and administrative) for all personnel holding supervisory positions within the EMS system; assure that each supervisor has the knowledge, skills and aptitudes to be an effective supervisor. 52. Expand physician supervised and EMS administered QI process involving communications, first response, medical transportation and administrative components of the system. Ensuring Optimal System Value 53. Streamline data entry process and work to fully integrate trip data from CAD through the billing system. 54. Routinely benchmark A/R processing times and collections results to industry standards. 55. Ensure A/R procedures adhere to industry best practices. 56. Track percentage of paperwork that is "complete" from field providers. Follow up with non -compliant crewmembers to ensure 100% compliance. 57. Manage private pay accounts in-house and implement processes to identify those accounts that should be transferred to the collection agency prior to 1.20 days. 58. Reduce the number of FTEs by 1.0 to 1.5 for working ambulance accounts. 59. Measure and monitor the days in accounts receivable ratio and strive to reduce the number to 65 to 70 days. 60. Post payments received from outside collection agencies for accounts that have previously been written off directly to a general ledger account rather than reversing the write-off entries. 61. Develop a baseline per capita funding mechanism to ensure that the service continues to be primarily user fee based but has additional funding not dependent upon third party payers. Weld County Paramedic Services ©Fitch & Associates, LLC EMS Assessment 49 November 10, 2008 Attachment A GIS Coverage Maps Levels 1-6 and Total System Coverage Percentages FITCH 4 (21 el b2. fooir <0 or 4 d Y a a a t Y 5 iU0100/00- H J _ i &s... M a C s O a gagr a • A I. e e • r a a P a N. w a s M' A : lme4uv s ° °de- a, i r n O H e n O 0 V d_ !33; • 3:8; • I e 'f k -t F If ilea IP —l.f.....P, !ialliit fill ,R.. 3+at 'II. ilia fit Visr ' I 4 f kisriLit-rilliiiiii O.• 4• .. Patel T� I I_� I • oa :as IOHO 1000- 11 �`� Cri I� eit -11 I -DTI H o ITT al 3- -Cl 1 g; 0$ MT d P 4" w I a ii 8 S4 " a as .ff a IT! i" 4 f Ai e+ : i 2 n d 2 a e i3 j g E• e a y 55 ffi A A I; 2.111i:1! Sg i 3 3 000010000 ES' , I _I-}- air 1 I, 4 1(4Th r' �i t L I�rL �Ii H' J I 11 I 4i iw 4 ig it wx it 4; II i e :a s H !ail i Di a # I Iii 1 a - s§ 6� yy'�11AA r. u wsaliq�g,ge!p i00000100000 - ti cu J 3j1 A i >l "et A� � a 58 $c dt i za it 3;,: ti eg f4 eg i r- 1 55 it rd S g;$ I ®r 1 $t Iij Iii inn iii I Iii • J '_r U a,.t og9�gT 10000il0000u- -� — l 4 Et tE a) J 31 gi 55 fi ii cc dd 1 a 9 9 a5 Si H {{ 3i JiH iii iil Iil i Iii I t 4 !the Sri illiii}al.f 04% W ji it r Ld ii U H 1I . H i i 41 H H II ii if fi H I i$ !ii Di jib 1 I IIi elk Attachment A GIS Coverage Maps Eminent, Non - [morso.ay Total Calls 14206 Total 14384 Total 29865 Total Level 669 66.8% 80.6% 74.0% Na, 71.6% 84.1% 78.1% 1949 94.6% 97.8% 96.2% LeN11 8439 79.0% 89.3% 84.4% 19439 96.4% 98.7% 97.6% Level 3 ■69 82.1% 91.1% 86.8% 1949 96.9% 99.0% 98.0% Level 4 1149 82.1% 91.3% 86.9% 1949 96.9% 99.O% 98.0% Level S 8.59 82.1% 91.3% 86.9% 10139 96.9% 99.0% 98.0% Level 6 149 82.1% 91.3% 86.9% 1949 96.9% 99.0% 98.0% Page #7 Attachment B 50 Benchmarks FITCH Attachment B 50 Benchmark Summary System Components Benchmarks Overview Communications Benchmarks — Comments Public access through a single number, preferably enhanced 911 D Coordinated PSAPs exist for the system. D WCRCC is the PSAP for Weld County Certified personnel provide pre -arrival instructions and priority dispatching (EMD) and this function is fully medically supervised PD WCRCC lacks full involvement from system Medical Director Data collection which allows for key service elements to be analyzed ND Current CAD system does not allow for comprehensive and timely analysis Technology supports interface between 911, dispatching & administrative processes ND There is no interface between CAD and WCPS charting/billing system Radio linkages between dispatch, field units & medical facilities provide adequate coverage and facilitate communications D Medical First Response Benchmarks — Comments First responders are part of a coordinated response system and medically supervised by a single system medical director. D Defined response time standards exist for first responders. PD Not all responders have established response time standards First response agencies report/meet fractile response times. PD Not all agencies report/meet goals AED capabilities on all first line apparatus. PD Not all agencies have AED capability Smooth transition of care is achieved. D Medical Transportation Benchmarks - Comments Defined response time standards exist. D Agency reports/meets fractile response times. PD WCPS only partially tracks response times Units meet staffing and equipment requirements D Resources are efficiently and effectively deployed D To meet future growth WCPS will need to undertake a formal demand/deployment analysis process There is a smooth integration of first response, air, ground and hospital services D Develop/maintain coordinated disaster plans D Key D=Documented, ND=Not Documented PD= Partially Documented Weld County Paramedic Services EMS Assessment ©Fitch & Associates, LLC 1 November 10, 2008 Attachment B 50 Benchmark Summary Medical Accountability Benchmarks — Comments Single point of physician medical direction for entire system. D Written agreement (job description) for medical direction exists. D Specialized medical director training/certification. ND Physician is effective in establishing local care standards that reflect current national standards of practice. D Proactive, interactive and retroactive medical direction is facilitated by the activities of the medical director D PCR/QI data transparency for MD review D Clinical Education/Development Effectiveness D Clinical Education Efficiency D Customer/Community Accountability Benchmarks — Comments Legislative authority to provide service and written service agreements are in place. PD WCPS could use stronger service agreements with the County and affiliated agencies Units and crews have a professional appearance. D Formal mechanisms exist to address patient and community concerns. D Independent measurement and reporting of system performance are utilized. ND Internal customer issues are routinely addressed PD Consultants were not able to validate the disparity of perceptions between frontline and supervisory/management personnel Prevention and Community Education Benchmarks — Comments System personnel provide positive role models. D Programs are targeted to "at risk" populations. PD Existing programs are limited in scope Formal and effective programs with defined goals exist. D Targeted objectives are measured and met. D Weld County Paramedic Services ©Fitch & Associates, LLC EMS Assessment 2 November 10, 2008 Attachment B 50 Benchmark Summary Ensuring Optimal System Value Benchmarks — Comments Clinical outcomes are enhanced by the system. D Amb Response Utilization and transport Utilization (UHU) is measured and hours are deployed in a manner to achieve efficiency and effectiveness. D Ambulance cost per unit hour & transport document good value. D Service agreements represent good value PD WCPS needs an effective SLA with WCRCC Non -emergency ambulance effective & efficient PD Transfer's frequently draw resources out of the system and there needs to be a better process or threshold to assure emergency coverage Non -Ambulance but medically necessary (MAV) services are effective and efficient D System facilitates appropriate medical access D Financial systems accurately reflect system revenues and both direct and indirect costs. PD Pulling all direct system costs is sometimes difficult due to the service being "bundled" into the County accounting system Revenues are collected professionally and in compliance with regulations. D Tax subsidies when required are minimized. NA Organizational Structure and Leadership Benchmarks— Comments A lead agency is identified and coordinates system activities. D WCPS standing as "lead agency" is not always honored by other response agencies Organizational structure and relationships are well defined. D Human resources are developed and otherwise valued. D Business planning and measurement processes are defined and utilized. PD KPI's are at a minimum across all department functions Operational and clinical data informs/guides the decision process. D A structured and effective performance based quality improvement (QI) system exists. PD This program is just gaining traction within the service Weld County Paramedic Services ©Fitch & Associates, LLC EMS Assessment 3 November 10, 2008 Hello