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

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

2 TheFirmsagreethatconfidentialinformationabouttheClientoritsrelatedentitieswill notbereleased,exceptasrequiredbyacourtofcompetentjurisdiction,withoutthe priorapprovaloftheclient,unlessthatinformationisotherwisereleasedaspublic information.theclientagreesthatitshallnotreleasenorallowitsemployeesoragents toreleaseanyofthefirms proprietarymaterialsprovided,orutilizedduringthe process,withoutwrittenpermission.

3 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

4 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.

5 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

6 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

7 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

8 recommendationslistedabovewillhavebeencompiledforapplication validatingthefinalemssystemdesign. Noneoftherecommendationsshouldbeimplementedwithoutanunrelenting commitmenttothefundamentalreasonforthesignificantinvestmentoftime,talent andresources:thepatient.itisthepatientwhowillexperiencethemostgain. However,asignificantlyimprovedEMSwillbenefittheentireprovinceasitmoves towardahighperformanceemsservice. "

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

Newfoundland)and)Labrador)Ambulance)Program)Review) Department)of)Health)and)Community)Services) Government)of)Newfoundland)and)Labrador) ConsultantFinalReport 21August2013 NewfoundlandandLabradorAmbulanceProgramReview DepartmentofHealthandCommunityServices GovernmentofNewfoundlandandLabrador FITCH&ASSOCIATES,LLC 2901WilliamsburgTerrace#G

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