Newfoundland)and)Labrador)Ambulance)Program)Review) Department)of)Health)and)Community)Services) Government)of)Newfoundland)and)Labrador)

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1 ConsultantFinalReport 21August2013 NewfoundlandandLabradorAmbulanceProgramReview DepartmentofHealthandCommunityServices GovernmentofNewfoundlandandLabrador FITCH&ASSOCIATES,LLC 2901WilliamsburgTerrace#G PlatteCity Missouri JaneHelleur&AssociatesInc. P.O.Box21041 St.John s NewfoundlandandLabrador A1A5B2 NewfoundlandandLabrador Page1 Fitch&Associates,LLC AmbulanceProgramReview JaneHelleur&AssociatesInc. DepartmentofHealthandCommunityServices 21August2013 CONSULTANTFINALREPORT

2 ConsultantFinalReport TheFirmsagreethatconfidentialinformationabouttheClientoritsrelatedentitieswill notbereleased,exceptasrequiredbyacourtofcompetentjurisdiction,withoutthe priorapprovaloftheclient,unlessthatinformationisotherwisereleasedaspublic information.theclientagreesthatitshallnotreleasenorallowitsemployeesoragents toreleaseanyofthefirms proprietarymaterialsprovided,orutilizedduringthe process,withoutwrittenpermission. NewfoundlandandLabrador Pagei Fitch&Associates,LLC AmbulanceProgramReview JaneHelleur&AssociatesInc. DepartmentofHealthandCommunityServices 21August2013

3 ConsultantFinalReport EXECUTIVESUMMARY InDecember2012,Fitch&Associates,inpartnershipwithJaneHelleur&Associates (collectively,the Consultants beganacomprehensivereviewofthe NewfoundlandandLabradorProvincialAmbulanceProgramonbehalfofthe provincialgovernment sdepartmentofhealthandcommunityservices.the objectivesofthereviewincludedanalysisandrecommendationsforprogram improvements. Thereviewwasshapedbythefollowingtenant: MostEmergencyManagementService(EMSsystemsfunction accordingtodefinitionsthathavebeensetbythesystemsthemselves, orbythesystems serviceproviders.however,bydefiningand evaluatingemergencyambulanceservicefromthepatient spointof view,thefocusisonthepatientfirst:beforeanyotherinterests.in thisway,onecancomparevariousproviderservicemodelsandresults objectively,accordingtohowtheybestservethepatient,ratherthan howtheybestservetheprovider. MedicaltransportationserviceinNewfoundlandandLabradoriscomplex.Itfaces numerouschallenges,someofwhichareuniquetothegeographyoftheprovince includingalargelandmass,harshweatherandawidelydispersedservicepopulation. Theseelementsputemergencymedicalservicesandambulancetransportationin NewfoundlandSLabradortothetesteveryday. Yet,EMSisnotabouttheenvironment.Itisaboutpeople.Itisaboutthecriticallyill orinjuredpatientsandthosewhocareforthem.emsisaboutensuringatransport systemthatsafelymovespatientstohealthcarefacilitiesandservesasaneffective andefficientlinktotertiaryandspecialtyclinicalservices.itissupportedbyems personnelwhoarecommittedtohighstandardsofcare. LikemanyambulanceservicesinNorthAmerica,NewfoundlandandLabrador s AmbulanceProgrambeganasagrassroots,humanitarianefforttoaddresstheneeds oftheillorinjuredwhorequiredcareandtransporttomedicalfacilitiesinruralareas oftheprovince.thecommunityambulancesserviceswerestartedbyvolunteers withlimitedmedicaltraining.overthepastdecade,theprovincialgovernmenthas NewfoundlandandLabrador Pageii Fitch&Associates,LLC AmbulanceProgramReview JaneHelleur&AssociatesInc. DepartmentofHealthandCommunityServices 21August2013

4 ConsultantFinalReport investedheavilytoincreasethesizeandprofessionalismoftheprogram.for example,theroadambulanceprogrambudgethasincreasedinsizeby350%from $14millionin2001S02toalmost$50millionin2011S12. In2011S12,theNewfoundlandSLabradorAmbulanceProgramcompletednearly66,000 transportsthroughitsroadambulanceprograms,whichutilize: 61hospital,privateandcommunitybasedambulanceservices,operating171 ambulances; 3governmentownedandoneleasedairambulanceconfiguredaircraft stationedontheislandandinlabrador; 6utilityhelicoptersthatcanprovidedaytimemedevacresponse;and 800ambulanceprofessionals. Duringthereviewprocess,theConsultantsheardopinionsthat: EMSisnotbeingoperatedasefficientlyandeffectivelyasitcouldbe; Demographicshiftsarehavingasignificantimpactondemandforservice; and Provincialcostsforambulanceservicesareescalating. Despitetheincreasedinvestment,theNewfoundlandandLabradorAmbulance ProgramhasnotreacheditsfullpotentialasahighSperformanceemergency ambulanceservicethatconsistentlyandpredictablydeliversclinicalexcellence, responsestimereliability,economicefficiencyandpatient/customersatisfaction.high performanceemergencyambulanceservicesexhibitthefollowingfivehallmarks: Hallmark1 Holdingtheemergencyambulanceserviceaccountable. Hallmark2 Establishinganindependentoversightentity. Hallmark3 Accountingforallcosts. Hallmark4 Requiringsystemfeaturesthatensureeconomicefficiency. Hallmark5 EnsuringlongStermhighperformanceservice. NewfoundlandandLabrador Pageiii Fitch&Associates,LLC AmbulanceProgramReview JaneHelleur&AssociatesInc. DepartmentofHealthandCommunityServices 21August2013

5 ConsultantFinalReport Currently,theprovince sfundingmodelresultsinthepaymentofhighlevelsof ambulanceavailabilitywhentherearelowperiodsofambulanceservicedemand.in otherwords,theprovinceispayingforambulanceswhentheyarenotneeded.the privateandcommunityoperatorsarealsofunded,inpart,byamodelthatrecognizes volumeandpaysformileage.thisfundingmodelprovidesanincentiveforthe Program scoststoincrease. TheConsultantsalsofoundthattheNewfoundlandandLabradorAmbulance Programisnotanorganizedsystemasthereisnocentralcoordinationorlegislatively enabledauthority.further,thecurrentpoorqualityofavailabletransportdata hobblessystemimprovementorredesign. Thesurveys,interviewsanddiscussionsheldrevealedaserviceindustrydoingits best,despiteahostofchallenges. Operatorsexpressedconcernoverwidespreadworkforceshortages,unsuccessful recruitmenteffortsandlowemployeeretention.somereportedsituationswhere otherambulanceoperators,otherprovincesandevenotherindustrieshireaway staffthroughhigherpay.unscheduledandnonsemergencylateday,eveningor weekendtransfersarehinderingtheoperators abilitytoservelocalcommunities. Latenightcallsalsoplacestaffinharm sway,especiallyiftheyexperiencefatigue anddecliningweatherconditionsastheytravelacrosstheprovince. Theemergencymedicalresponders,primarycareparamedicsandadvancedcare paramedicsspokeproudlyandpassionatelyabouttheirwork.despitetheirlovefor theirprofessions,theyvoicedconcernswiththeindustry.intheprivateambulance sectorspecifically,theyidentifiedpaydisparity,longhoursandpoorqualityoflife issues.professionalsvoicedconcernswithfearofreprisal,orworse,lossof employmentforspeakingupaboutproblemsorissues. TheNewfoundlandandLabradorAmbulanceProgramisnotsufferingfromalackof determinationorcommitment.acrosstheprovinceareindividuals,groupsand communitieswithakeenfocusonsystemimprovement,innovationandsolutionsto theseissues,manyofwhichweincludeinourfindingsandrecommendations.infact, thegenesisofourrecommendationscamefromstakeholdersthemselves. Thefollowingrepresentthestrategicrecommendationstoenablethechanges requiredtooperateanefficient,effective,sustainableandqualityambulancesystem NewfoundlandandLabrador Pageiv Fitch&Associates,LLC AmbulanceProgramReview JaneHelleur&AssociatesInc. DepartmentofHealthandCommunityServices 21August2013

6 ConsultantFinalReport foraprovincepatientcentricmodel.alloftheserecommendationsshouldbe implementedwithinafivesyeartimehorizon,beginningnow. ImmediateRecommendations:(tobecompletedwithinthefirst18L24months" 1. Transitiontheambulance levelofeffort contractstoperformancesbased contracts.thiswillprovideforhigherlevelsofaccountabilitybyestablishing performancemetricsthataretobereportedbyallambulanceoperators.the assignmentofauditorstoassessandreportonconsistentcomplianceisan importantcomponentofthisrecommendation. 2. Clarifyambulanceoperatorroles,responsibilitiesandrightsinrelationto serviceareaexclusivity.thisisfundamentaltotheimplementationofa CentralizedMedicalDispatchCentre(CMDC. 3. CommenceimplementationofAmbulanceDispatchandManagementSystem (ADAMSwithintheRegionalHealthAuthorities. 4. EnactEmergencyMedicalServices(EMSlegislationtogoverntheambulance servicesintheprovince.thelegislationwouldprovidethedepartmentof HealthandCommunityServiceswiththeauthorityto: a. Licenseandregulateambulanceoperators; b. Establishmedicaloversightforambulanceprofessionals; c. Establishstandardsforambulancesandequipment;and d. Registerambulancevehicles. 5. BuildandoperationalizeaCentralizedMedicalDispatchCentre(CMDC. a. BegintodevelopaCMDCwithatargettobeoperationalwithin18months. Thisincludesensuringthetechnologyandtoolsexisttoelectronically captureprovinceswideservicedeliveryoutputsandperformancedatafor measuring,monitoringandqualityimprovement;and b. Intandemwiththerecentlyapproved911centre,theCDMCshouldworkin tandemwithfireandemergencyservicestoprovidefortheseamless receiptandcoordinationofemergencyrequests,effectivemedicaland operationalcontrol,realtimeperformancemonitoringandharddatafor NewfoundlandandLabrador Pagev Fitch&Associates,LLC AmbulanceProgramReview JaneHelleur&AssociatesInc. DepartmentofHealthandCommunityServices 21August2013

7 ConsultantFinalReport theprovince semssystemdesignandcontinuousoperational improvements. 6. EstablishEMSNewfoundlandandLabradorwithdirectaccountabilitytothe DeputyMinisterofDepartmentofHealthandCommunityServices.EMS NewfoundlandandLabradorshould: a. Assumeaccountabilityandresponsibilityforallaspectsofroadandair ambulanceservicesdeliveredbyoperatorsandagentsexceptforthe registrationandlicensureofemsprofessionals; b. Assureaccountabilityforthesystem sperformanceresultsincludinginthe areasofclinicalexcellence,responsestimereliability,economicefficiency andpatientsatisfaction; c. DefineprovincialqualitybenchmarksforthedeliveryoftheEMS NewfoundlandSLabradorsystem;and d. ReplacetheexistingPMOofficeandincorporateanOfficeofMedical Director(OMDwithinthenewgovernancestructure. MediumTermRecommendations(tobecompletedwithin36L42months 7. ReviewoptionsforselfSregulationofEMSpersonnelthroughthe NewfoundlandSLabradorCouncilofHealthProfessionalsandtheexisting HealthProfessionsAct. 8. DesignandbeginimplementationofatieredEMSresponseincludingarobust MedicalFirstResponderprogram.Inthedesignofsuchacapability,the uniqueattributesanddemographicsoftheprovince scommunitiesmustbea drivingfactorindeterminingthelevelofemspersonnelrequiredata communityandlocalareabasis. 9. Establishandimplementaplantoaddresshumanresourceissuesraisedby stakeholderstoincluderecruitment,retention,pay,benefits,qualityofwork life,trainingprogramaccessandaccreditation. LongerTermRecommendation(tobecompletedwithin48 60months 10. FinalizethedesignoftheNewfoundlandandLabradorEMSsystemandbegin implementation.thekeydataandperformanceresultsfromthe NewfoundlandandLabrador Pagevi Fitch&Associates,LLC AmbulanceProgramReview JaneHelleur&AssociatesInc. DepartmentofHealthandCommunityServices 21August2013

8 ConsultantFinalReport recommendationslistedabovewillhavebeencompiledforapplication validatingthefinalemssystemdesign. Noneoftherecommendationsshouldbeimplementedwithoutanunrelenting commitmenttothefundamentalreasonforthesignificantinvestmentoftime,talent andresources:thepatient.itisthepatientwhowillexperiencethemostgain. However,asignificantlyimprovedEMSwillbenefittheentireprovinceasitmoves towardahighperformanceemsservice. " NewfoundlandandLabrador Pagevii Fitch&Associates,LLC AmbulanceProgramReview JaneHelleur&AssociatesInc. DepartmentofHealthandCommunityServices 21August2013

9 ConsultantFinalReport ACRONYMS ACP AdvancedCareParamedics ADAMS AmbulanceDispatch&ManagementSystem ALS AdvancedLifeSupport AVL AutomatedVehicleLocation CAD ComputerSAidedDispatch CCAC CommunityCareAccessCentre CCP CriticalCareParamedic CCT CriticalCareTransport CMDC CentralizedMedicalDispatchCentre CME ContinuingMedicalEducation CAN CollegeoftheNorthAtlantic CPR CardioSPulmonaryResuscitation ECP ExtendedCareParamedic EHIS EmergencyHealthInformationSystem EHS EmergencyHealthService EMD EmergencyMedicalDispatch EMR EmergencyMedicalResponders epcr ElectronicPatientCareRecord GAS GovernmentAirServiceDivision GIS GeographicalInformationSystem GPS GlobalPositioningSystem HEMS HelicopterEmergencyMedicalServices IDR InformationDataRequest IFR InstrumentFlightRules MFS MedicalFlightService MPDS MedicalPriorityDispatchSystem OHS OccupationalHealth&Safety PCP PrimaryCareParamedics PCR PatientCareRecord(Report PMO ProvincialMedicalOversight PMT ParamedicineandMedicalTransport PSAP PublicSafetyAnswerPoint RHA RegionalHealthAuthority VOIP VoiceOverInternetProtocol NewfoundlandandLabrador Pageviii Fitch&Associates,LLC AmbulanceProgramReview JaneHelleur&AssociatesInc. DepartmentofHealthandCommunityServices 21August2013

10 ConsultantFinalReport TableofContents 1. INTRODUCTION BackgroundofProvincialAmbulanceProgram OrganizationsandTheirRole RoadAmbulanceServiceEvolution FixedWingAmbulanceServiceEvolution RotaryWingAmbulanceServiceEvolution AmbulanceFundingModels ProjectMethodology DescriptionofStakeholderConsultation DataCollectionMethodsandLimitations DataLimitations FINDINGS:STAKEHOLDERCONSULTATIONS PublicSurveyResults PrivateOperatorRoundtables CommunityOperatorRoundtables HospitalcBasedOperatorRoundtables AmbulanceProfessionalSurveyandTownHallResults TownHallMeetingAttendanceBarriers FINDINGS:CURRENTOPERATINGENVIRONMENT AmbulanceVolumeandCallTypes DemandandServiceDelivery ManagementofRoutineandReturnTransfers InterfacilityTransports:HubandSpoke ProgramFundingMethodsandAccountability ServiceAreaExclusivity EMSCoordinationandDispatch QualityStandards:IssuesandChallenges DataCaptureforQualityImprovement VehicleStandards AmbulanceProfessionals EMSProfessionals,TrainingandWorkforceSupply ProfessionalRegistration EMSSalaries MedicalAirServices ProvincialMedicalOversight EMSGovernanceandLegislation TOWARDSAHIGHPERFORMANCEEMSSYSTEM HallmarksofaHighPerformanceEMSSystem StaffingaHighPerformanceEMSSystem TieredSystemResponse MedicalFirstResponders AnAllSALSSystem AlternativeModelsforPreSHospitalCommunityCare EnablingTechnologyandProcessesforaHighPerformanceEMS AutomaticVehicleLocation(AVLandGlobalPositioningSystems(GPS ComputerSAidedDispatch(CADtoMobileDataTerminals CallProcessesandStandards ElectronicPatientCareRecords(ePCR EMSGovernanceandLeadership...60 NewfoundlandandLabrador Pageix Fitch&Associates,LLC AmbulanceProgramReview JaneHelleur&AssociatesInc. DepartmentofHealthandCommunityServices 21August2013

11 ConsultantFinalReport Governance StructureandComponentsofEMSNewfoundlandSLabrador FinancesandFunding RECOMMENDATIONSANDIMPLEMENTATIONTARGETS SUMMARY...68 ListofTables Table1:AmbulanceOperatorsperRHAandNumberofAmbulancesperRHA...7 Table2:AmbulanceProfessionalsperCategory,April Table3:TypesofFunding,WhoReceivesFundingandtheIntendedPurpose...10 Table4:AmbulanceOperatorIDRResponseRate...14 Table5:GroundAmbulanceVolumeforFY2011/ Table6:NewfoundlandLabradorAmbulanceProgramCostsforFY2011L Table7:Patient(UserFees,Fiscal2011/12(Millions...32 Table8:OperatorTrips,KilometersFunds(Fiscal2011/ Table9:MileageRatesPaidperAttendantTypeasofJanuary1, Table10:EMSLegislationinCanadianProvinces...48 Table11:AnnualCommunityAmbulanceTransports,FY2011/ ListofFigures Figure1:RHA,Populationand#ofPatientTransportsbyRHA...5 Figure2:GroundAmbulanceCallsbyTypeforFY2011/ Figure3:AmbulanceVolumebyMonth(2011L Figure4:AmbulanceDailyAverage(2011L Figure5:AmbulanceAverageWeekday(2011L Figure6:AmbulanceAverageHourlyforFY2011L Figure7:TenYearTrend:RoadAmbulanceProgramCosts2002L Figure8:TypicalCADDesign...38 Figure9:StructureandComponentsofEMSNewfoundlandLLabrador...62 ListofAnnexes AnnexA:ProjectTimeline AnnexB:PublicSurveyTemplate AnnexC:AmbulanceProfessionalSurveyTemplate. 76 AnnexD:PublicSurveyNarrative AnnexE:PublicSurveyTabularResults AnnexF:AmbulanceProfessionalSurveyNarrative...93 AnnexG:AmbulanceProfessionalTabularResults AnnexH:ManitobaExample HubandSpoke AnnexI:CallProcessing&DispatchStandards AnnexJ:AmbulanceAge&MileageComparison 143 AnnexK:AmbulanceProfessionalSalaries AnnexL:Community/MedicalFirstResponderModel WORKSCITED.150 NewfoundlandandLabrador Pagex Fitch&Associates,LLC AmbulanceProgramReview JaneHelleur&AssociatesInc. DepartmentofHealthandCommunityServices 21August2013

12 ConsultantFinalReport 1. INTRODUCTION MedicaltransportationserviceinNewfoundlandandLabradorisacomplexand highlyvisiblehealthcareprogram.thechallengeistoprovideappropriate,safeand timelytransportandeffectiveclinicalinterventionsinresponsetomedical emergenciesforcriticallyillorinjuredpatients.theprogrammustalsoensurea medicaltransportsystemeffectivelyservesasalinktotertiaryandspecialtyclinical services. ProvidingambulanceservicesinNewfoundlandandLabradorisnotwithoutitsshare ofchallenges.theprovincehasapopulationofjustover514,000peopleanda landmassofapproximately400,000squarekilometres.approximately92percentof theprovince'spopulationresidesontheislandportionoftheprovince(includingits associatedsmallerislandsandmorethanhalfofthetotalpopulationlivesonthe AvalonPeninsula.Hometoavarietyofclimatesandweather,fromahumidmarine climateontheislandtosubarcticandsubpolarclimatesinlabrador,transportation evenunderthebestofconditionsisnotalwayseasy.atitsworst,heavyfog,blizzard andhighwindconditionscanshutdowntransportationbetweencommunities. LikemanyambulanceservicesinNorthAmerica,theNewfoundlandandLabrador AmbulanceProgrambeganasagrassroots,humanitarianefforttoaddresstheneeds oftheillorinjuredwhorequiredcareandtransporttoahospitalorclinic.today, ambulanceservicecontinuestobuildonthelegacyofcommunitygoodwilland receivesstrongcommunityandgovernmentsupport.aswell,ambulanceservices benefitfromitspersonnelwhodeliveraconsistent,strongefforttosupportpatient care. InDecember2012,Fitch&Associates,inpartnershipwithJaneHelleur&Associates (collectively, TheConsultants,commencedacomprehensivereviewofthe NewfoundlandandLabradorAmbulanceProgramonbehalfoftheDepartmentof HealthandCommunityServices.TheprojecttimelineisincludedinAnnexA.Thus,the reviewincludedathoroughanalysisofthecurrentoperatingenvironmentand detailedanalysestosupportrecommendationsaimedatachievingahigh performanceemergencymedicalservices(emssystem. NewfoundlandandLabrador Page1of151 Fitch&Associates,LLC AmbulanceProgramReview JaneHelleur&AssociatesInc. DepartmentofHealthandCommunityServices 21August2013

13 ConsultantFinalReport WhiletheConsultants scopeofworkconsideredhowthemedicalairplanes helicoptersintegratewiththegroundambulanceprogram,thelocation,selection, fundingand/oroperationofemergencyairtransportationwerealloutsidetheproject scope. TheinformationreflectedinthisreportwascollectedfromDecember1,2012to March8,2013.Whereveravailable,threeSyearprogramdatawascollected. Benchmarksforstandardsandperformancecriteriaweredeterminedthrough industryguidesandstandards,nationalandprovincialpracticesandinternational industryguidelines. 1.1 BackgroundofNewfoundlandandLabradorAmbulanceProgram Asimportantcontextforthisreport,itisfirstnecessarytoprovidebackground informationaboutthenewfoundlandandlabradorambulanceprogram. TheprimarymandateoftheProgramistorespondtopatientsinemergency situations.however,ambulancesandaircraftarealsoutilizedfortheconveyanceof patientsrequiringspecializedmedicalattentionortestsatanothermedicalfacility. Therearethreeprograms,including: 1. TheRoadAmbulanceProgramwhichcontractswith27privateambulance operators,22communityambulanceoperatorsand12hospitalbasedservices witheachdeliveringserviceintheirrespectiveregions.throughtheroad AmbulanceProgram,approximately66,000patientsaretransferredannually. 2. TheFixedWingAmbulanceProgram,theaircraftareoperatedbythe GovernmentAirServiceDivision(GASofTransportationandWorks,with3 governmentsownedkingairsandamonthstosmonthleasedcitationjet.the medicalcomponentisoperatedbyeasternhealth sparamedicineandmedical Transportdepartment.ThroughtheFixedWingAmbulanceProgram, approximately1,200patientsaretransferredannuallythroughoutthe provinceandtooutsofsprovincefacilities. 3. Rotarywing(helicopteremergencymedicalevacuationsareprovided throughouttheprovincethroughtheuseofsixutilityconfiguredbell206and 407helicoptersleasedbyGASfromUniversalHelicoptersLimited.These helicoptersarealsousedbyseveralgovernmentdepartmentsforsearchand NewfoundlandandLabrador Page2of151 Fitch&Associates,LLC AmbulanceProgramReview JaneHelleur&AssociatesInc. DepartmentofHealthandCommunityServices 21August2013

14 ConsultantFinalReport rescue,firefighting,wildlifetracking,etc.in2011/12therewereapproximately 80RWmedicalflights:40weremedevacsandanother40flightswere scheduledtotransportphysiciansandpatientstoandfromremote communities.ifthebellhelicoptersarenotavailable,gaswillcalluponthe DepartmentofNationalDefenseSearchandRescue(SARorcharterCougar HelicoptersLimited OrganizationsandTheirRole ThissectionintroducestheorganizationsinvolvedintheNewfoundlandand LabradorAmbulanceProgram. Department"of"Health"and"Community"Services" TheDepartmentofHealthandCommunityServicesprovidesleadershipinhealthand communityservicesprogramsandpolicydevelopmentfortheprovince.this involvesworkinginpartnershipwithanumberofkeystakeholdersincludingregional HealthAuthorities(RHAs,communityorganizations,professionalassociations,postS secondaryeducationalinstitutions,unions,consumersandothergovernment departments. TheDepartmentofHealthandCommunityServicesprovidesfunding,leadspolicy andprogramdevelopment,monitorsandprovidessupporttotherhasforthe deliveryofambulanceprogramsintheirregion. " Regional"Health"Authorities" FourRHAsdeliverhealthprogramsandservicestothecitizensoftheirregion.These are: 1. EasternHealth 2. CentralHealth 3. WesternHealth 4. LabradorSGrenfellHealth Figure1identifiesthegeographicareasservicedbyeachRHAandidentifiesthe approximatenumberofambulancetransfersineachregion. NewfoundlandandLabrador Page3of151 Fitch&Associates,LLC AmbulanceProgramReview JaneHelleur&AssociatesInc. DepartmentofHealthandCommunityServices 21August2013

15 ConsultantFinalReport EachRHAhasaParamedicineandMedicalTransportstaffthatmanagestheir hospitalsbasedambulanceservicesandoverseestheoperationsoftheprivateand communitysbasedambulanceoperatorsintheirregion. TheDepartmentofHealthandCommunityServiceshasdelegatedfourProgram responsibilitiestoeasternhealth sparamedicineandmedicaltransport(pmt DivisiontoprovidethefollowingservicestoalltheRHAs: 1. RegionalServices Monitorscomplianceandperformancetoprovincial ambulancepolicesandadherencetoprovincialstandards.themedical CommunicationsCenter(MCCprovidesmedicalcommunicationsand dispatchcoordinationforprovincialairambulance,onslinemedicalcontrol, androadambulanceservicessuchasnortheastavalon911medicaldispatch, provinceswideroadambulancedispatchforrcmp,royalnewfoundland ConstabularyandtheHealthLine,aswellaslongSdistancetransport coordinationfromtertiarycarecentresinst.john s. 2. FinancialServices Processesallambulanceoperatormileage/attendant claimsforeachtransfercompletedintheprovince.privateandcommunity operatorssendtheirclaimstofinancialserviceswheretheclaimsare adjudicatedagainstthedepartmentofhealthandcommunityservices rules andregulationsandthenapprovedforpayment.batchesofapprovedclaims aresenttotherhasforpayment. 3. ProvincialMedicalOversight(PMOProgram SeethePMOSectionbelow fordetails.pmoalsoadministerstheprovincewidepurchaseofnew technology. 4. MedicalFlightTeam Ateamof12flighttrainedRegisteredNursesand AdvancedCareParamedicsflyontheprovincialfixedwingandrotarywing aircraft.recruitmentandtrainingisunderwayforasecondmedicalflight TeamtobestationedinHappyValleySGooseBaytoserviceLabradorand northernnewfoundland. NewfoundlandandLabrador Page4of151 Fitch&Associates,LLC AmbulanceProgramReview JaneHelleur&AssociatesInc. DepartmentofHealthandCommunityServices 21August2013

16 ConsultantFinalReport Figure"1:"RHA,"Population"and"Number"of"Patient"Transports"by"RHA" Source:DepartmentofFinanceNewfoundlandandLabradorStatisticsAgencyandParamedicineandMedical TransportAnnualReport2009S10 " Provincial"Medical"Oversight" Allparamedicinepersonnelpracticingintheprovincecarryoutstandardizedmedical diagnosisandtreatmentprotocolsthatarerequiredduringtransport,underthe licenseoftheprovincialmedicaldirectorforparamedicineandmedicaltransport. TheProvincialMedicalOversight(PMOProgramwasestablishedtosupportthe registrationandmedicaldelegationtoattendantsthroughfourfunctions: 1. ActsastheProvincialRegistrarofAmbulanceAttendantsthroughthe followingactivities: a. Reviewandapproveofeligibilitytopracticerequirements; NewfoundlandandLabrador Page5of151 Fitch&Associates,LLC AmbulanceProgramReview JaneHelleur&AssociatesInc. DepartmentofHealthandCommunityServices 21August2013

17 ConsultantFinalReport b. Administertheentrytopracticeexam; c. Administertheannualprotocolexams; d. Overseeandtracktheattendants ContinuingMedicalEducation courses;and e. Trackattendants clinicskillscompletionrequirements. 2. WorkswiththeMedicalDirectortoestablishandupdatetheBasicLife Support,AdvancedLifeSupportandCriticalCareTransportprotocols. 3. Provides24/7onSlinemedicalcontroltoattendantswhorequiretheadviceof aphysicianduringatransfer. 4. Qualityassurancemonitoringandcontinuousqualityimprovementofthecare providedbyattendantsthroughauditandinvestigationofpatientconcerns. Road"Ambulance"Operators" The61provincialroadambulanceserviceslicensedbythePublicUtilitiesBoardare classifiedinoneofthreecategories: 1. PrivateAmbulance 27privatebusinessesprovideroadambulanceservicesin designatedgeographicareas.dependingonthesizeoftheservicean operatormayhavebetweentwoandtenambulancesintheirfleet.therehas beenageneraltrendtowardsconsolidation,withlargeroperatorsbuyingthe licensesandassetsofsmalleroperators. 2. CommunityAmbulance 22volunteerornotSforSprofitorganizationsprovide ambulanceservicesindesignatedgeographicareas.mostcommunity ambulanceoperatorshaveoneambulanceintheirfleet. 3. HospitalAmbulance In12regionalcentres,RHAshavetheirownambulance servicesthatarestaffedbyhospitalemployees. " AmbulanceoperatorsperRHAandambulancenumbersperRHAarelistedinTable1. " " " " NewfoundlandandLabrador Page6of151 Fitch&Associates,LLC AmbulanceProgramReview JaneHelleur&AssociatesInc. DepartmentofHealthandCommunityServices 21August2013

18 ConsultantFinalReport " Table"1:"Ambulance"Operators"per"RHA"and"Number"of"Ambulances"per"RHA"(2012" RegionalHealth Authority Private Operators Community Operators 2012 Hospital Operators Total Numberof Ambulances Eastern Central Western LabradorSGrenfell Total Source:EasternHealth PMTDivision Currently,the61operatorsworkindependentlyfromeachotherwithintheirdefined serviceareasandeachhastheirowndispatchprocess. Therearetwoassociationsrepresentingtheprivateambulanceoperatorsandone associationrepresentingthecommunityoperators.noformalassociation representingthehospitalsbasedambulanceservicesexists.thecurrentambulance ServiceAgreementforprivateandcommunityoperatorsexpiredonMarch31,2012. Theagreementisautomaticallyrenewedforsuccessiveperiodsof180days. Emergency"Medical"Service"Professionals" Therearethreecategoriesofroadambulanceattendantsintheprovince.Their minimumtrainingrequirementsareasfollows: EmergencyMedicalResponder(EMRS2weeksclassroomtraining; PrimaryCareParamedic(PCPS8monthsclassroomtrainingwithaclinical skillscomponent;and AdvanceCareParamedic(ACPSPCPqualificationplus16monthsofadditional classroomtrainingwithanadvancedclinicalskillcomponent. Table2belowoutlinesthebreakdownofEMSstaffintheprovince. NewfoundlandandLabrador Page7of151 Fitch&Associates,LLC AmbulanceProgramReview JaneHelleur&AssociatesInc. DepartmentofHealthandCommunityServices 21August2013

19 ConsultantFinalReport Table"2:"Ambulance"Professionals"per"Category,"April"2012" Category NumberofAmbulanceProfessionals AdvancedCareParamedic(ACP 30 PrimaryCareParamedic(PCP 444 EmergencyMedicalResponders(EMR 336 Total 810 Source:ProvincialMedicalOversight Government"Air"Services" GovernmentAirServices(GASoperatesairassetsonbehalfoftheGovernmentof NewfoundlandandLabradorandservesfourambulancefunctions: 1. Operates(pilots,maintenance,etc.threeGovernmentownedKingAirs.Two arestationedinst.john sandoneinhappyvalleysgoosebayinlabrador. Theaircraftareusedtotransferpatientstoandfromtheprovince shealth carefacilitiesandoutsofsprovincefacilities. 2. ManagestheuseofaCitationjet(onmonthStoSmonthretainertothe DepartmentofHealthandCommunityServicesusedforrapidemergency responseofthemedicalflightteamandthejanewaychildrenhospital s NeonatalTeamfromSt.John stolabradorandforthetransportationof patientstoandfromoutsofsprovincemedicalfacilities. 3. ManagesthecharterofsixnonSdedicatedutilityBell206&407helicopters stationedaroundtheisland.whenusedformedevacsorbushrescues,the helicoptersareconvertedtocarryastretcherandmedicalattendants. 4. Overseestheselectionandmovementoffixedandrotarywingassetswhen requiredforairtransfersandmedevacsthroughacentralizeddispatch operation RoadAmbulanceServiceEvolution PriortoApril1,2005,anEmergencyHealthServicesDivisionwithintheDepartment ofhealthandcommunityserviceswasresponsiblefortheambulanceprogram.this divisionwasresponsibleforalloperationalissues,medicalcontrol,registrationof ambulancepersonnelandvehicles,policydevelopmentaswellasnegotiations NewfoundlandandLabrador Page8of151 Fitch&Associates,LLC AmbulanceProgramReview JaneHelleur&AssociatesInc. DepartmentofHealthandCommunityServices 21August2013

20 ConsultantFinalReport relatedtotheserviceagreementsbetweenthedepartmentandtheindividual ambulanceoperators. OnApril1,2005,responsibilityforoperationalissuesrelatedtotheroadandair ambulanceprogramwasdevolvedtotherhas.theprovincialgovernmenthas maintainedresponsibilityforcontractnegotiationswithprivateandcommunity operatorsaswellasthedevelopmentandmaintenanceofprovincialpolicies, proceduresandoperationalstandards FixedWingAmbulanceServiceEvolution Theprovincialgovernmenthasoperatedafixedwingairambulanceservicesincethe early1960s.inthelastthreeyears,theprovincialgovernmentinvestedinnew aircraftwiththepurchaseoftwonewstateoftheartkingair350sinanair ambulanceconfiguration.theprovincehasanetworkofairportsandairstrips adjacenttomedicalfacilitieswhichallowsforasystemofairtransporttomove patientstotheappropriatelevelofmedicalcare RotaryWingAmbulanceServiceEvolution Sincethelate1960stheprovincialgovernmenthascharterednonSdedicatedutility helicoptersthatprovidemedevacservices.theunderlyingmedevacprincipleisthe stabilizationofthepatientbeforeflightandthemonitoringofthepatientduringthe flighttothenearestmedicalfacility.thesehelicoptersoperateundervisualflight rules(vfrandarenotavailableforuseatnightandinperiodsofinclementweather. Inemergencysituationsrequiringinstrumentflightoperationsand/orinvolvingnight operations,thedepartmentofnationaldefense(dndsearchandrescue(sar helicopters(stationedinganderandinhappyvalleysgoosebaymayprovide assistance AmbulanceFundingModels " Road"Ambulance"Program" HospitalSbasedambulanceservicesreceiveannualglobalfundingthroughtheRHA s operatingbudgets.privateandcommunityoperatorsreceivefundingasoutlinedin Table3. " " NewfoundlandandLabrador Page9of151 Fitch&Associates,LLC AmbulanceProgramReview JaneHelleur&AssociatesInc. DepartmentofHealthandCommunityServices 21August2013

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