Implementing change without breeding discontent

By Mike Taigman and Heath Wright

Often, the most difficult improvements to make in EMS systems involve things we do every day. Too often, EMS leaders notice a problem, like getting patient signatures on the patient care report, long chute times or failing to notify the hospital that they are coming in with a patient suffering from sepsis. They write a memo, issue an edict or tell a subordinate, “It’s your job to fix this!” The result tends to be whole lot of pissed off people and zero improvement in performance.

It is possible to make meaningful improvement that also results in happier employees. The recipe for success includes:

• Have a clear aim.
• Build measures collaboratively.
• Engage the folks that actually do the work up front and keep them involved throughout.
• Maintain complete transparency.
• Be willing to abandon, adjust or change your ideas as you go.

The team from EMSA in Tulsa, Oklahoma City, and surrounding cities lead by Operations Director Heath Wright, co-author of this article; and Medical Director Jeffery Goodloe, M.D., took on an improvement project that did all of the above. The improvement project required every EMT and paramedic in their system, hundreds of frontline professionals, to actively participate.

Refining EMS on-scene and hospital transfer processes

The problem came to light on a particularly busy day, when at one moment, the Tulsa operation had nine paramedic units holding the wall at hospitals waiting for beds, four 911 calls holding with no units to respond, and two mutual aid requests that they could not handle. Crews were blaming management for not having enough rigs on the street, dispatch was blaming crews for not clearing the hospitals fast enough, and management was frustrated with everything.

Turnover was high, recruiting was a challenge and folks had lost sight of their mission. The Tulsa leadership team knew improvement was needed and they chartered a project with this aim; “Our mission is to make a positive difference for the team members and patients by refining on-scene and hospital transfer processes.”

Their goals included:

• Increase the amount of true down-time shared by all EMSA crews, as less time on scene or at the hospital means more time to relax.
• Get Oklahoma City Fire Department, Tulsa Fire Department and other first responders back in service faster.
• Reassure patients that their situation is taken seriously, and that responders act with urgency when appropriate.
• Create a model that could be reproduced in Oklahoma City.

Surveying the EMS providers and firefighters involved

They didn’t start by issuing a memo, changing a policy or blaming anyone. What they did do is ask the folks closest to the work about their perspectives on the problem. They didn’t just ask a few folks; they surveyed every EMT and paramedic that works for EMSA. They surveyed all of the fire departments they work with. They asked about teamwork among crews and between agencies. They asked how empowered people felt to make change. They asked about scene time and its impact on patient care.

They learned most people did not feel like they could make changes for their team or with other agencies, even though they felt like they could make things better for their patients. One wake up call for the leadership team was that people felt like they worked pretty well as a team until management got involved.

Next, EMSA leaders built a measurement system aligned with their aim and created a data dashboard that allowed EMSA team members to see system level, division level and individual performance. Their primary outcome metric was overall task time, defined as the time from when a call was dispatched to when the unit went in service at the hospital.

Their quantitative process measures included average chute time, average drive time, average scene time, average transport time and average hospital drop time. Their qualitative measures included employee engagement, employee perception of ability to make positive changes and employee level of trust with the management team.

Strategies that created a culture of change

While focused on improving their performance, they dedicated themselves to transforming their culture. They wanted people to feel empowered to make meaningful change and like they were really part of a team working toward the same goals. Here are just a few of their strategies to get this done:

• Quit blaming and switched to focusing on solutions. They quit blaming crews, dispatch, hospitals, supply and everyone else.
• Implemented the seven-point Baldrige Award Model as the framework for organizational leadership.
• Taught the basics of how to interpret data displayed on Shewhart Statistical Process Control Charts to everyone. They wanted front line EMTs, medics and dispatchers to come to the same conclusions their manager did when looking at a chart full of performance data.
• Started a leadership team reading club including Lean Thinking by Womak and Jones; Hardwiring Excellence by Quint Studer; The Toyota Way by Jeffery Liker; and Extreme Ownership: How Navy Seals Lead and Win by Willink and Babin. They read the books as a group and then discussed how to apply the lessons in their system.
• Set up front line leaders with login credentials to their system’s FirstWatch data analytics and triggers so that front-line leaders could monitor performance in real time. One supervisor became such a super-user of the system that they had him work with FirstWatch to customize the system to work the way he wanted it to work.
• Provided education from the medical director on the clinical case for shorter scene times for a variety of conditions.
• Invited their fire department partners into the process. They asked about their colleagues’ perspectives and shared all their data with them.
• Practiced total data transparency – sharing the good, the bad and the ugly with their team and colleagues.
• Empowered their supervisors to take crews out of service and buy them lunch even when it was busy to thank them for making progress.
• Empowered supervisors to instantly put crews that were working against the goal on administrative leave.
• Started providing hospitals with data on their turnaround times and wall times.

With all the focus on data, EMSA made sure that everyone remembered that each data point represents a real person.

A friend of ours has a granddaughter named Gabriella and told this story to the crews. “She went into cardiac arrest when she was 5 days old. Her dad who had no CPR training was talked through compressions by our call taker in the 911 dispatch center. Crews were on scene in less than four minutes and defibrillated her. She went home from the hospital three days later and has no deficits. We are not doing all of this stuff to beat you up or make your jobs harder, we are doing it for people like Gabriella.”

Increased performance leads to wage increase for EMS

How’d they do?

These drops in task time translated to an additional 54-unit hours added back to the system. That’s more than four additional ambulances on the streets for free! They are 110 percent staffed and are turning away applicants. Lost unit hours went from 9 percent of scheduled hours to 1 percent. They have a real-time workload management report designed by FirstWatch that allows them to balance the workload in the system real time.

They are 1.5 million ahead of budget and turned a significant portion of that into a wage increase for employees, moving them from the bottom 25 percent of the EMS wage market to the top 90 percent. Employee trust went from 3/10 to 8/10. EMSA is now 100 percent staffed, producing the best response time performance in the history of EMSA, and is seeing a record number of applicants for management positions.

These folks have shown that it’s possible to make improvements that pay off financially while helping patients get better service and making things much better for your team. Next, they will be applying the team engagement they have developed and the improvement practices they have hardwired, and focusing them on improving clinical outcomes.

About the author

Heath Wright is the director of operations of EMSA’s Eastern Division. In his role, he is responsible for ensuring performance standards are met in a high-volume, dynamic system. Heath considers empowering frontline leaders, supporting quality initiatives and helping driving cultural change to be among his most exciting and worthwhile challenges.

Heath received his paramedic license in 1993. Prior to joining the EMSA team in mid-2016, Heath held various leadership roles in large, governmental and hospital-based EMS systems in Texas and New Mexico. He has also worked in rural, fire-based EMS.

Heath has deep experience in project management, data analysis and system status management. He is a quality examiner with the Texas Award for Performance Excellence and is a certified ASQ Black Belt in Lean and Six Sigma principles.