Questions to Ask Your Ambulance System

The Dallas Morning News (2016, Sept) reported that half to two-thirds of city general funds are used for police, fire, and EMS. With a significant investment of tax dollars, elected officials, community leaders, and the media are not equipped with the knowledge or data to determine if their services are built to get results and where there are opportunities for improvement.

Here are twelve questions local leaders can use to learn about their communities. Each should generate ideas for more learning and improvement.

1. Who do you serve, and how? An EMS system is designed to serve many stakeholders: Critical patients, taxpayers, EMTs, and paramedics (Stout, 1986/January). Who are your key stakeholders? Is there an order of attention? How do you serve the needs of each?
2. What are your constraints? Most communities have a limited set of requirements to satisfy. What are the Federal, State, and local rules, regulations, and ordinances you must follow? Are there other requirements from grants, contracts, or accreditation that you have entered into? Knowing the minimum requirements helps you meet them and also to see where you have the ability to change. 
3. Clinical Outcomes. EMS systems clinically impact a narrow set of clinical conditions: myocardial infarction, pulmonary edema, bronchospasm, status epilepticus, diabetes, and trauma (Myers et al., 2008). NHS England developed measures (Siriwardena, 2008).  What is the clinical performance of your system in evidence-based clinical conditions? Pull your data for the last 24 months and develop a line chart for each measure. How are you doing? Do you know how you compare with the best? 
4. Response Time Compliance and Emergency Response. The limited relationship between ambulance response times and clinical outcomes is well documented (Pons, 2005; Blackwell, 2009). Only 6.9 percent of patients receive a potentially life-saving intervention by EMS, yet 86 percent are responded to with lights and sirens (Jarvis et al., 2021), creating unnecessary risk to providers and the community. What are the numbers in your community? What can you do to reduce unnecessary lights and sirens response? How can you limit ambulance response time standards that are not tied to clinical outcomes?
5. Over Utilization. Two out of three patients transported by ambulance are discharged from the emergency department (Burt et al., 2005). The Scottish Ambulance Service serviced half its callers over the phone or in the field (Scottish Ambulance Service, 2022/December). HHS estimated that 15 percent of EMS-transported Medicare patients could be cared for better by other means (DOT/HHS, 2013). What percentage of EMS calls does your system transport? What percentage could be served without transport to the emergency department?
6. Living Wages and Pay parity. The median wage for EMTs and Paramedics is $35,470 and $46,770 (US Bureau of Labor and Statistics), or $17 to $22.5 per hour. What is a livable wage for your community? Do your police, firefighters, and EMS providers have equal compensation? How does EMS compare with other local allied health professions? 
7. Workforce Safety. The injury rate for EMS workers is higher than that of most professions and several times higher than the national average (Maguire 2005, 2013, 2014). What is your community’s injury rate? What are you doing to reduce injuries?
8. Patient Harm – Patients can be harmed by medical systems. Do we miss things? Do we do things we shouldn’t? What is your service’s harm rate? Do you know?
9. Equity – We believe every person deserves equal care and outcomes, but data shows unacceptable variation when stratifying by gender, people of color, and socioeconomic factors. Is everyone in your community getting equitable care? How do you know? What are you doing about it?
10. Waste. Berwick and Hackbarth (2012) estimate at least 20 percent of healthcare expenditures are waste. Do you know where waste lives in your system?
11. Risks – what possible future scenarios should you evaluate? Reduction in reimbursement, staffing costs, universal coverage, the cost for quality, etc.
12. By What Method – To improve, leaders need a shared method. Were you able to achieve your 2022 strategic objectives? What is your method for improving your system to get enhance performance? 

This list is not exhaustive. Some leaders find these questions helpful in understanding their community and their EMS systems. What other questions might add to your learning? 

How can you use these questions? Pick one question each month to discuss as part of your team’s development. Start anywhere. Collect any available data to support the discussion and display it visually in charts or graphs. What does it tell you? What questions do you have? Where can you make changes to get a better result?

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