CONSULTANT REPORT EMS ASSESSMENT. Schertz EMS Schertz, Texas. March 11, Prepared by:

Transcription

1 March 11, 2013 EMS ASSESSMENT Schertz EMS Schertz, Texas Prepared by: FITCH & ASSOCIATES, LLC 2901 Williamsburg Terrace #G Platte City Missouri CONSULTANT REPORT

2 Schertz Emergency Medical Services Schertz, Texas EMS Assessment Table of Contents EXECUTIVE SUMMARY 1 METHODOLOGY 3 SYSTEM BACKGROUND AND DEMOGRAPHICS 4 THE REGION 4 SCHERTZ EMERGENCY MEDICAL SERVICES (SEMS) 5 OPERATIONS 5 THE OPTIMAL EMS SYSTEM 6 EMS DESIGNS, BEST PRACTICES AND BEST PRACTICE SYSTEMS 7 PROCESS AREA SUMMARIES 8 COMMUNITY ACCESS AND EMERGENCY COMMUNICATIONS 8 Description of Best Practices 8 OBSERVATIONS AND FINDINGS 9 Public Access to EMS 9 Radio Communications 11 RECOMMENDATIONS 11 MEDICAL FIRST RESPONSE 12 Description of Best Practices 12 OBSERVATIONS AND FINDINGS 13 Medical First Responders 13 RECOMMENDATIONS 14 AMBULANCE OPERATIONS AND CLINICAL PERFORMANCE 14 Description of Best Practices 14 OBSERVATIONS AND FINDINGS 15 Medical Transportation 15 Clinical Service Levels 15 Education and Training 15 Quality Management 16 RECOMMENDATIONS 18 MEDICAL DIRECTION AND ACCOUNTABILITY 18 Patient Refusals 20 RECOMMENDATIONS 20 FLEET AND LOGISTICS 20 Training 21 Preventive Maintenance 22 Driver Training 23 Quality Control Driving System 24 Schertz, Texas EMS Page i Fitch & Associates, LLC

3 Fleet Performance Measures 24 RECOMMENDATIONS 24 PREPAREDNESS 25 RECOMMENDATIONS 25 Crew Configuration and Staffing 25 TECHNOLOGY UTILIZATION 26 Description of Best Practices 26 OBSERVATIONS AND FINDINGS 26 Electronic Patient Care Reporting 27 RECOMMENDATIONS 27 RESOURCE UTILIZATION AND DEMAND 28 Description of Best Practices 28 OBSERVATIONS AND FINDINGS 28 Geographic Coverage 28 Demand Coverage 29 Response Time Performance 33 RECOMMENDATIONS 34 SYSTEM FINANCES AND FUNDING 34 Description of Best Practices 34 OBSERVATIONS AND FINDINGS 34 Billing and Reimbursement 35 RECOMMENDATIONS 37 SYSTEMS COST AND FINANCE 38 OBSERVATIONS AND FINDINGS 38 UNIT HOUR UTILIZATION 39 RECOMMENDATIONS 39 CUSTOMER AND COMMUNITY ACCOUNTABILITY 40 OBSERVATIONS AND FINDINGS 40 Accountable Care 40 Internal Customer Satisfaction 41 RECOMMENDATIONS 41 PREVENTION AND COMMUNITY EDUCATION 41 OBSERVATIONS AND FINDINGS 42 STAND-BY SERVICES 42 COMMUNITY EDUCATION 42 RECOMMENDATIONS 42 GOVERNANCE, GROWTH, ORGANIZATIONAL STRUCTURE AND LEADERSHIP 42 Description of Best Practices 43 OBSERVATIONS AND FINDINGS 43 Governance and Regulatory Compliance 43 Growth Opportunities and Competitive Issues 44 Organizational Structure and Human Resources 44 Schertz, Texas EMS Page ii Fitch & Associates, LLC

4 OBSERVATIONS AND FINDINGS 45 Executive Leadership 46 Operational Leadership 46 Leader Development 47 RECOMMENDATIONS 48 COMMUNITY PARAMEDICINE ALIGNING FOR THE FUTURE 49 PRINCIPLES OF EMS SYSTEM DESIGN 52 SEMS Status Quo is Unsustainable 53 Status Quo Improved (additional costs offset by improved productivity) 53 SUMMARY OF RECOMMENDATIONS /MEDICAL COMMUNICATIONS 54 MEDICAL FIRST RESPONSE 54 AMBULANCE OPERATION AND CLINICAL PERFORMANCE 54 MEDICAL ACCOUNTABILITY 55 FLEET OPERATIONS 55 PREPAREDNESS 55 TECHNOLOGY UTILIZATION 56 RESOURCE UTILIZATION AND DEMAND 56 SYSTEM FINANCES AND FUNDING 56 SYSTEM COSTS AND FINANCES 56 CUSTOMER AND COMMUNITY ACCOUNTIBILITY 57 PREVENTION AND COMMUNITY EDUCATION 57 GOVERNANCE, GROWTH, ORGANIZATIONAL STRUCTURE AND LEADERSHIP 57 FIGURE 1. AMBULANCE SERVICE AREA ORIENTATION 5 FIGURE 2. TYPICAL EMS CALL PROCESSING FLOW 10 FIGURE 3. SAMPLE CONTROL CHART 17 FIGURE 4. DRIVE TIME MAP 29 FIGURE 5. CHART OF DEMAND REQUESTS 30 FIGURE 6. CURRENT ORGANIZATION CHART 45 TABLE 1. AMBULANCE FLEET UTILIZED BY SEMS AT INITIATION OF CONSULTING PROJECT 22 TABLE 2. MODEL PREVENTIVE MAINTENANCE SCHEDULE 23 TABLE 3. RESPONSE TIME CHART 33 TABLE 4. AVERAGED BASE CHARGES 36 TABLE 5. OVERALL COMBINED EXPENSES 38 ATTACHMENTS A. Ambulance Benchmark Summary B. Leadership Benchmark Summary C. Sample Service Clinical Indicators D. NAED Accreditation 20 Question Guide E. Demand/Drive Time Maps Schertz, Texas EMS Page iii Fitch & Associates, LLC

5 EXECUTIVE SUMMARY Schertz Emergency Medical Services (SEMS) operates as a department of the City of Schertz, Texas, providing Advanced Life Support (ALS) emergency responses to eight communities in the Greater Randolph Region. SEMS has posted significant financial losses, causing City leaders to become concerned about the department s financial stability. Fitch and Associates (Fitch or Consultant) was engaged by the City to conduct an independent review of SEMS operations and to evaluate service options for providing highquality EMS support to this rapidly growing area of Texas. SEMS is committed to providing emergency paramedic service, as well as enhancing its EMS system. In its assessment, Fitch reviewed SEMS communications equipment and call center processes; EMS responder, fleet and billing operations; staffing and overall management practices. Although SEMS billing processes were found to be within industry standards, and reflective of good practices for receiving reimbursement, several other operational areas were identified as needing improvement: call center and dispatch processes, staff scheduling and communications, fee structure, and fleet management. Specifically, the Fitch study found : Initial call information from two of the three SEMS public safety-answering points (PSAPS) is not recorded in real time, thus impeding accurate response tracking. Compliance-to-contract standards of <8:59, at 90% reliability for all calls needs improvement, as it is estimated to be achieved approximately 61.1% of the time, system wide. Call taking and dispatching processes are fragmented. Of the three PSAPs, only one utilizes Emergency Medical Dispatcher (EMD) personnel. Excessive vehicle breakdowns and critical failures are contributing to high ambulance fleet costs. Staff scheduling is not synchronized to demand times and is resulting in inefficiencies, as well as high costs. SEMS performs patient-billing services internally. This process appears to be working very well and collection amounts seem to be within industry standards. Management-staff communication can be enhanced to improve morale and positively impact relationships Recommendations include: Tracking SEMS public safety answering points (PSAPS) with greater specificity to provide accurate feedback for improving response times and staff scheduling. Schertz, Texas EMS Page 1 Fitch & Associates, LLC

6 Matching staffing patterns with demand trends to yield higher operational effectiveness and lower costs. Improving and increasing management-staff communications, while developing stronger leadership to create an environment where employees feel valued and motivated to achieve mission goals. Continuing the Enterprise Fund option in governance, which seems to be working well for SEMS and is a better fit than other options. Developing a more transparent and accountable EMS delivery model and partnership. Customizing pricing with structures that reflect the true cost of service. The existing program has strengths that can be utilized to support the strategic objectives of the City. The recommendations made throughout this report are intended to further enhance the clinical, operational and financial stability of SEMS in support of those objectives. Schertz, Texas EMS Page 2 Fitch & Associates, LLC

7 METHODOLOGY The City of Schertz retained Fitch & Associates (Fitch or Consultant) to conduct a comprehensive review of SEMS operating system. Fitch objectively benchmarked current system performance capabilities, as well as compared and contrasted current practices against industry recognized best practices. Fitch & Associates used a seven-phase approach to accomplish the scope of work. The first phase launched the project. Phases 2-3 consisted of comprehensive data collection. Phases 4-6 involved data analysis and benchmarking. The final, seventh phase is complete with the presentation of this report. A description of each of the seven phases follows: 1. Project Initiation. The Fitch consultant team initially met with executive staff by phone and subsequently in person to identify project goals and initiate the project activities. 2. Materials and Data Collection. The SEMS management team was forwarded a detailed Information Data Request (IDR) that included key questions to be answered and requests for specific documentation and reports related to every area of the organization. 3. Onsite Interviews and Direct Observations. Fitch site visited the system and conducted interviews with leaders of key functions (process leads), as well as external stakeholders and employees. The Consultant team also conducted field observations and observed radio traffic from the PSAPs and the SEMS Center. 4. Data Compilation and Client Input. All data from onsite interviews and the IDR were compiled and organized for analysis. Emerging questions were directed to SEMS staff, as appropriate. 5. Benchmarking and Compliance Assurance. The department was compared with the Fitch 50 EMS System Benchmarks (see Attachment A). In addition, the organization s local enabling legislation and practices were reviewed. 6. Define Future State. The report provides brief descriptions of improvement opportunities for SEMS consideration. 7. Reporting Results. The information and analysis summary of the first six phases is compiled in a report to the client. The seven phases resulted in a comprehensive analysis that draws from both qualitative and quantitative data, addressing the specific needs outlined in the initial scope of work. Schertz, Texas EMS Page 3 Fitch & Associates, LLC

8 SYSTEM BACKGROUND AND DEMOGRAPHICS THE REGION The SEMS service area (Figure 1) contracts with eight communities in three counties (Bexar, Comal and Guadalupe) just northeast of San Antonio, Texas. Schertz is the largest city in the area, which includes Randolph Air Force base. The total service area population approximates 107,500. Described as a bedroom suburban community, its property use can be described as suburban and rural as part of the Randolph Metrocom surrounding an Air Force base. The primary service area is 220 square miles. The rural portion has new residential developments under construction. There are twenty acute care hospitals near and in San Antonio: Closest (and in SEMS district) is Northeast Methodist Hospital in Live Oak. Northeast Baptist, SAMMC, North Central Baptist, and Methodist Stone Oak Hospital are next. Guadalupe Regional Medical Center in Seguin is the only hospital in Guadalupe County. Christus Santa Rosa-New Braunfels is in New Braunfels. In addition, Christus Santa Rosa - Creekside and Baptist Emergency Hospital - Schertz are two Free-Standing Emergency Centers under construction in or near Schertz. Schertz City Council and City Manager John Kessel are anticipating a 60% growth in the City of Schertz by the year Live Oak and Universal City are maxed out for growth, while those municipalities on the outskirts are also projecting population growth. Schertz, Texas EMS Page 4 Fitch & Associates, LLC

9 Figure 1. Ambulance Service Area Orientation SCHERTZ EMERGENCY MEDICAL SERVICES (SEMS) SEMS is a department of the City of Schertz, Texas. It responds only to 911 requests for ambulance service. In addition to the City of Schertz, SEMS responds to 911 calls under contract with eight communities in three counties. SEMS receives direct local (per capita) tax subsidies from all of its operations for the paramedic ambulance service it provides. User fees are collected for patient transports. Any carry-forward losses are the responsibility of the City of Schertz to resolve. SEMS ambulance fleet is licensed by the State of Texas as a paramedic-level transport service. Ambulances are primarily staffed by two Texas-licensed paramedics. The eleven-member administrative support staff includes an EMS Director, Assistant Director, Clinical Manager, Public Training and Outreach Coordinator, Executive Assistant, three Field Supervisors, and three individuals doing the billing. OPERATIONS SEMS has four 24-hour ambulances located throughout the service area. The data collected was not detailed enough to determine the call volume by jurisdiction or EMS station. Without this differential, it is difficult to assign work values or costs to individual locations. Back-up unit staffing is accomplished by reassigning units from one district to another or from neighboring EMS communities. Schertz, Texas EMS Page 5 Fitch & Associates, LLC

10 Current scheduled ambulance hours are 35,040 per year. Ambulance call volumes have shown an incremental increase each year for the last two calendar years (CY 2010 to CY 2011, 2.5%). In CY 2010, SEMS responded to 7,230 service requests that resulted in 4,570 ambulance patients transported. In CY 2011, there were 7,374 requests, with 4,640 of those resulting in transports. Of these, 72% of the transports were categorized as Advanced Life Support (ALS). Overall, the service achieves a Unit Hour Utilization (UHU) level of According to demand charting (Figure 5), one station may be much busier than another at any given time. The cost per transport averages at $ SEMS does not routinely perform non-emergency responses or transports. SEMS provides occasional non-emergency transports for Northeast Methodist in Live Oak. Discussions with the new Baptist Emergency Hospital in Schertz are ongoing. Several private operators that are licensed to do business in the region provide these services. THE OPTIMAL EMS SYSTEM An optimal EMS system is best designed from the patient's perspective. Patients should expect that the service will 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. The arrival of a transport-capable ALS ambulance should occur within eight minutes and 59 seconds (8:59) for life-threatening emergencies in urban areas, 11:59 in suburban areas and 19:59 in rural areas with 90% reliability. Non-life threatening emergencies should receive a response within 12:59 in urban areas. 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. The performance of SEMS and the regional EMS system is compared to these optimal system standards in the following section. Schertz, Texas EMS Page 6 Fitch & Associates, LLC

11 EMS DESIGNS, BEST PRACTICES AND BEST PRACTICE SYSTEMS Milestone documents in the early development of Emergency Medical Services Systems (EMSS) included the National Academy of Sciences-National Research Council White Paper Accidental Death and Disability: The Neglected Disease of Modern Society, the federal Highway Safety Act of 1966, and the federal Emergency Medical Services (EMS) Systems Act of They guided the first 30 years of Emergency Medical Services System growth on the local, regional and state levels. These early systems evolved from neighbor helping neighbor volunteer groups to highly complex response systems of physician extenders that function as part of the larger healthcare delivery system. In many areas of the country, EMS systems are struggling to meet clinical, operational and financial performance objectives. Ambulance services are primarily funded under a complex and flawed federal reimbursement methodology that does not cover the full cost of operations or the cost of readiness. Studies, including those prepared for the International City and County Management Association (ICMA) and the National Academies of Science Institute of Medicine, (IOM) document the underlying issues. No single identifiable source for industry standards of practice exists. 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 EMS Agenda for the Future, developed by the US Department of Transportation EMS at the Crossroads, developed by the National Academies of Sciences Institute of Medicine 2006 EMS In Critical Condition: Meeting the Challenge, produced by The International City/County Management Association 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 Commission on the Accreditation of Ambulance Services National Fire Protection Association In like manner, there is no single universally best EMS system design model or single best practice system that can be identified. Schertz, Texas EMS Page 7 Fitch & Associates, LLC

12 PROCESS AREA SUMMARIES Every EMS organization is comprised of multiple process areas to address specific functions of the operation. The Consultant team met with the specific process owners and process leads within SEMS, as well as with community, hospital and local stakeholders. A summary of the best practices and findings for each process is described below. Recommendations for enhancing activities are included where appropriate. Specific benchmarks and SEMS performance in each of the following categories are described: 911/Communications Customer and Community Accountability Medical First Response Prevention and Community Education Medical Transportation Organizational Structure and Leadership Medical Accountability Ensuring Optimal System Value The summary of these 50 benchmarks can be found in Attachment A Benchmark Summary. SEMS clearly documents its achievement of 21 of these 50 objective measures. Several other measures are partially achieved. Approximately nine others remain to be accomplished. COMMUNITY ACCESS AND EMERGENCY COMMUNICATIONS DESCRIPTION OF BEST PRACTICES Best practice EMS systems are organized to facilitate wire-line, cellular, voice over internet protocol (VoIP), automatic crash notification, patient alerting system devices and other public 911 access to the Emergency Medical Services System. Voice, video, telemetry, and other data communications conduits are employed, as necessary, to best enhance real-time information management for patient care. A medically directed system of protocol-based Emergency Medical Dispatch (EMD) and communications is in place. The call reception and EMS call processes are designed logically and should not delay activation of medical resources. Technology supports the caller being directed to the appropriate Public Safety Answer Point (PSAP) for the geographic location of the call. All 911 callers should receive National Academies of Emergency Dispatch (NAED) [or similar process] call prioritization and pre-arrival instructions. Automated quality improvement (QI) processes are used facilitating results being reported to clinical and operations executives in a concise manner. Data collection facilitates the analysis of key service elements and these data are routinely benchmarked and reported. Technology supports interface between 911, medical dispatch functions and administrative processes. Radio/cellular linkages between dispatch, field units and medical Schertz, Texas EMS Page 8 Fitch & Associates, LLC

13 facilities provide adequate coverage and facilitate both voice and data communications. There is interoperability between allied public safety agencies. Communications Benchmarks Public access through a single number preferably enhanced 911. Single 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 key service elements to be analyzed. Technology supports interface between 911, dispatching and administrative processes. GPS/AVL in each vehicle enables dispatch to alert the closest unit. Radio linkages between dispatch, field units and medical facilities provide adequate coverage and facilitate communications. Observations and Findings PUBLIC ACCESS TO EMS Public access to emergency medical services throughout the service areas are provided via an enhanced 911 (E-911) system. Requests for service are initially received by one of three 911 centers or PSAPs, which are located in public safety centers. The City of Schertz is primary for EMS and also receives dispatches from Live Oak Police and Universal City Police. Emergency medical dispatch procedures recommended by the National Academies of Emergency Dispatch (NAED) were reported to be utilized by the City of Schertz PSAP. Its center is licensed to use the version 12.2 of the Medical Priority Dispatch System (MPDS) cards. Schertz PSAP has the computerized ProQA version or the automated AQUA software, but has not been able to utilize the program due to technical issues with the Bexar Metro 911 regional Computer-Aided Dispatch (CAD) program that went operational July Incoming calls are not classified according to Medical Priority Dispatch System (MPDS) priority codes; however, pre-arrival instructions are given on a regular basis. Life-threatening and non-life-threatening emergency calls are not correctly differentiated, causing all calls to be dispatched as emergent. The PSAPs in Live Oak and Universal City do not subscribe to EMD; their manner of call taking was to get the location of the emergency, general nature of the call, and dispatch the call. 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 QI process and actively supervised by a physician. Schertz, Texas EMS Page 9 Fitch & Associates, LLC

14 Neither the PSAPs, nor the SEMS dispatch center, are actively supervised by the medical director. None of the communication facilities are accredited by NAED. Of the applicable twenty focal review areas required for NAED Accreditation (Attachment D), only four could be documented at SEMS. Figure 2. Typical EMS Call Processing Flow 911 Phone Rings Call transferred to a medical call-taker Call location pre-alerted to the dispatcher First Responders and ambulance crew are notified Ambulance Enroute Ambulance arrives on scene Crew departs scene Crew arrives at medical facility Crew available for call T0 T1 T4 T5 T6 T7 T8 T9 T10 Event Identification Dispatch Chute Travel Treatment Transport EMS System Response Time Ambulance Time-on-Task The current call processing times could not be determined with accuracy. Because Schertz PSAP enters call data as it is dispatched from Live Oak and Universal City, these calls have no T0 to T5 (Figure 2) intervals. SEMS calculates response times from time of crew notification (T5) to end of travel (T7). At a minimum, SEMS should begin calculations with the time the call to Telecommunicator (T1) is received to time of dispatch (T4) and then the time the crew is notified (T5). Analysis of the data will determine SEMS current ability to meet the 90th percentile of reliability (using the fractile statistical method). The Regional TriTech CAD provides limited reporting capabilities to SEMS. Only the Schertz PSAP has access to a Regional TriTech CAD. When emergency calls come into 911, call information is forwarded to a mobile data terminal (MDT) in the ambulance for responding crews to see. Schertz, Texas EMS Page 10 Fitch & Associates, LLC

15 Each SEMS vehicle is equipped with a fleet tracking Global Positioning System/Automatic Vehicle Locator (GPS/AVL) system that is interfaced to the Schertz CAD. The AVL updates approximately every 10 seconds enabling the CAD to geographically select the closest available SEMS unit to dispatch. The Consultant team observed on multiple occasions the PSAP assigning a SEMS unit to an alarm, followed by a crew or SEMS supervisor contacting the PSAP to have it reassigned. This is the result of the PSAP dispatchers not re-assigning an alarm when a unit comes available after a dispatch is made. A SEMS supervisor must notify the PSAP to re-assign the alarm. Dispatchers should take the initiative to make sure the closest ambulance responds to an alarm, especially when an ambulance comes available and is closer after an alarm has been assigned. RADIO COMMUNICATIONS SEMS operates on an 800/700 MHz IP system tied to the regional radio network. Radio channels are recorded in each of the three PSAPs. All ambulances have the 800 MHz radios capable of communicating with most of the first responder agencies. There is a VHF narrow band-compliant radio to communicate with first responders still on the VHF net. The VHF radios also allow communications on the statewide interoperability channels during state deployment. Each ambulance also has a cellular phone and mobile data terminals (MDTs) for receipt of CAD information. Each of the three local counties currently operates its own radio system and allows SEMS access to each of the VHF repeater radio systems. Medical control communications are primarily broadcast on the 800 MHz radio utilizing a subset assigned for ambulance-to-hospital communications. Christus Santa Rosa Hospital New Braunfels serves as the Medical Control point when physician orders are necessary. SEMS protocols are available at the base station, but have received no specific EMS base Station Control training. Particularly in cardiac emergencies, when an EMS medic needs an order, and the physician/nurse responding to communications is not familiar with SEMS protocols, they may ask the EMS medic to vary from protocol or administer medication not within the context of their protocols. A second communications call advising of pending arrival is made to the receiving facility, if it is different from Medical Control. Telemetry is sent via an in-unit modem attached to a cellular card direct to the hospital emergency department (ED). Once received in the ED, the base station physician or nurse can interpret and forward digitally to the Cardiologist on call for his direct view of the EKG from the field. SEMS medics have a high rate of positive STsegment elevation myocardial infarction (STEMI) activations and have earned the trust of the facilities to identify STEMI patients accurately. Recommendations 1. Live Oak and Universal City should transfer all calls for an ambulance directly to Schertz PSAP for EMD and dispatch. Schertz, Texas EMS Page 11 Fitch & Associates, LLC

16 2. Schertz PSAP personnel should follow the processes prescribed in MPDS, EMD, and dispatch based on type of call and emergency versus non-emergency. 3. Train selected 911 center staff to provide regular, medically supervised quality review of EMD activities consistent with NAED standards. 4. The PSAP dispatcher must be prepared to re-assign an alarm if an ambulance comes available and is closer, after initial dispatch of the call. 5. Implement the AQUA QI processes to ensure that 95% of those requiring pre-arrival instructions receive them in accordance with nationally recognized standards. 6. Strengthen prospective and retrospective medical oversight of the communications function. This should include routine case reviews by the medical director. 7. Develop necessary training, enforce procedures, and engage in quality assurance activities to insure that data produced by and contained in the SEMS CAD is accurate to an acceptable community standard. MEDICAL FIRST RESPONSE DESCRIPTION OF BEST PRACTICES Medical first responders in best practice systems are organized appropriately for the communities in which they serve. They function as part of an integrated response system that is guided by state and local legislative authority, and reflects accepted medical practice. First responders (paid or volunteer) are certified at a minimum EMT-Defibrillator or Medical First Responder (MFR) level. They are medically supervised by the system medical director, including participation in performance improvement audits/activities. Defined response time standards exist for formal first responders and those response times are reported with those of the system. Early defibrillation capabilities are available for EMS first responders and in areas of high-density response areas such as airports, hotel complexes. When community or first response personnel are involved in patient care, a smooth transition of care is achieved. Medical First Response (MFR) Benchmarks MFRs are part of an integrated response system and medically supervised by a single system medical director. Defined response time standards exist for MFR. MFR agencies in accordance to National Fire Protection Association (NFPA) 1710 report fractile response times. AED capabilities on first line apparatus. Smooth transition of care is achieved. Schertz, Texas EMS Page 12 Fitch & Associates, LLC

17 Observations and Findings MEDICAL FIRST RESPONDERS Medical first responders play a critical role in life-threatening emergencies and support the communities EMS efforts as part of the public safety mission. In the vast majority of North American cities, this role is funded by local tax dollars as part of the public safety budget. Medical director involvement with first responder agencies, and the engagement of first responders in a system-wide QI process, is a must. All MFRs fall under the auspices of the SEMS medical director. MFR scope of practice follows the SEMS system medical protocols, which are intended to make patient care transparent and seamless. Although fire chiefs in the system report having access to the Medical Director, they report not taking advantage of the opportunity as often as they should. MFR services are provided by fire departments throughout the SEMS service area. BLS is provided by Marion and Lake Dunlap VFDs. EMT-Intermediate level response is provided by Cibilio, Braken VFD and Selma. Live Oak, Schertz and Universal City provide paramedic/firefighters most of the time. MFR paramedics and EMT-Intermediates can become credentialed to provide ALS services. All MFR vehicles are equipped with automated electronic defibrillators (AED). The determination to send a MFR varies. For example, MFRs are dispatched on every emergency medical call in every service area except the City of Schertz. In Schertz, the fire department only responds to life threatening calls, unless the SEMS unit is not in quarters, then it will respond to any emergency. Fire chiefs reported that their response times generally were less than five minutes for most responses. They were not able to specifically report the use of averaging or fractile calculations nor provide exact calculations, however. Typically, First Responder agencies response times are not measured using the fractile method in this service area. The fractile methodology is required by standards established by the National Fire Protection Association (NFPA) and the Commission on Accreditation of Ambulance Services (CAAS). An average response time does not provide the system with a reliable and consistent response measurement with which to gage the responder. According to the Consultant s interviews, transitions between first responders and ambulance personnel are generally handled professionally. One MFR agency reported that his staff feels like when the EMS team arrives, it is fire guys move over. That particular MFR agency expects a more respectful in-field interaction. Because SEMS rotates their staff between stations every month, the crews are not as familiar with the geography of their assigned location as they should be. SEMS would benefit from a Pit-Crew patient care model. The Pit Crew model designates that each crewmember has a defined role, which they perform in practiced harmony. It limits Schertz, Texas EMS Page 13 Fitch & Associates, LLC

18 confusion, improves scene times, and improves patient care. For example, MFR-A is responsible for an immediate Basic Life Support (BLS) assessment and treatment. MFR-B is responsible for gathering history and prescriptions. MFR-C is responsible for retrieving additional equipment or assisting in setting up equipment, as required. Recommendations 8. MFR leadership should take advantage of greater interaction with the Medical Director and actively participate in medical QI processes. 9. First Responder response times should be reported from call receipt until wheel stop on a fractile basis, based on NFPA standards. 10. SEMS crews should participate more often in initial and CEU level training with fire staffs to promote camaraderie and teamwork. 11. This system would benefit from pit-crew style patient care. AMBULANCE OPERATIONS AND CLINICAL PERFORMANCE DESCRIPTION OF BEST PRACTICES In a best practice EMS system, a mechanism exists to identify and assure adequate deployment of ground, air and other transportation resources meeting specific standards of quality, to assure timely response, scaled to the nature of event. There is capability to monitor safety and response time issues. Defined response time targets come into play, according to severity of call, and individual response components are measured by using both mean and 90th percentile measures. Defined clinical service levels use current medical research to guide the medical interventions of the system. Changes to improve clinical practice can be introduced rapidly. Ambulances are staffed and equipped to meet the identified service requirements. Procurement, maintenance and logistics processes function to optimize unit availability. Resources are efficiently and effectively deployed to achieve response time performance for projected demand with due regard for taxpayers and endusers. When multiple agencies are involved, a smooth integration and transition of care is achieved. The system is capable of scaling up day-to-day operations to meet the needs of larger, all-hazards events, based on threat and capabilities assessments of the likeliest events to occur in the state. It is essential that mass casualty responses involve logical expansion and extension of daily practices and not the establishment of new practices reserved for large-scale events. Schertz, Texas EMS Page 14 Fitch & Associates, LLC

19 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 MEDICAL TRANSPORTATION This section addresses key components of ambulance service operations and performance including clinical service levels; education and training; quality management; medical direction and accountability; fleet and logistics; preparedness; field supervision and crew configuration. Information regarding response times is presented in the section titled, Resource Utilization. CLINICAL SERVICE LEVELS The State of Texas allows ALS programs such as SEMS to operate based upon The Texas Administrative Code, Title 25, Health Services, Part 1 of the Department of Health Services, Chapter 157 Emergency Medical Services. SEMS has been issued a license by the State of Texas for the operation of City of Schertz EMS License (# ) and is valid until October 31, EDUCATION AND TRAINING SEMS operates an EMS Training Academy. The Academy provides three initial EMT courses each year. Pass rates on state exams are quite high. SEMS education department offers initial EMT classes and provides for all of the EMT/paramedic recertification needs for each MFR agency at no charge to the department. Although the MFR agencies typically hire EMTs, they also have access to place members into these classes. Along with several adjunct instructors, most of the required CEUs for the National Registry of EMTs (NREMT) and recertification core programs are taught by EMS in house. A paramedic program was added in the current budget. SEMS tracks recertification dates and the Clinical Manager prompts employees when they are due to recertify. Employees whose certifications have lapsed are not eligible for duty. The Clinical Manager maintains a file with everyone s certifications and tracks expiration dates. A master database is kept with expiration dates that are reviewed monthly for upcoming expirations. During the Consultant s interviews, the field staff suggested that more relevant training topics should be offered. For example, two ambulances are equipped with extrication equipment and a Class A Foam System (CAFS) to provide immediate rescue when encountering rural and interstate vehicle crashes with entrapment and fire when fire apparatus is delayed. Training only takes place during new hire Schertz, Texas EMS Page 15 Fitch & Associates, LLC

20 orientation. Some field staff members reported receiving no skill maintenance training on extrication/cafs since they were hired. Automated External Defibrillator (AED) placement is a primary component of SEMS community education programs. AEDs are acquired by grants or fund raising and placed in key locations in the community. Every law enforcement vehicle has an AED, as well as gyms, community buildings and schools. SEMS monitors these devices to ensure they are accessible and in good working order. Additionally, SEMS conducts monthly and on-demand first aid and community CPR training. The Clinical Manager reported that in 2009, there were nine cases of field cardiac arrest resuscitations and each save had a citizen performing CPR. Seasonally, SEMS participates with the health organizations to assist in providing flu and pneumonia immunizations. Regular screenings at local senior centers for blood pressure and other health related issues are conducted monthly. Although the key community intervention program is the placement of AEDs, none of the programs are set up with targets or other measures of success. New hire orientation is overseen by the Clinical Manager and each field supervisor has a specific piece. Orientation lasts approximately 40 hours and includes ride time with a Field Training Officer (FTO). The Consultant team observed FTOs working with a new hire in demonstrating pieces of equipment and their hands-on practice of each item. QUALITY MANAGEMENT SEMS has a Clinical Manager. This Manager is the liaison between the Medical Director and the caregivers. All Electronic Patient Care Reports (epcrs) are reviewed by a shift supervisor before the end of shift for completeness and demographic accuracy. After the epcr is routed to billing for coding, the Clinical Manager then has the FTOs perform a 100% review of every epcr for protocol compliance. Cases of cardiac arrest, advanced airway use, STEMI/Stroke Alerts, helicopter requests and the use of scheduled pharmaceuticals receive additional review by the training department. If indicated, the Clinical Manager may select different events for review by the medical director. The medical director does not perform any random epcr reviews independently. The following are examples and recommended components of a quality program. The Sample Control Chart (Figure 3) is a useful statistical process tool for QI. Schertz, Texas EMS Page 16 Fitch & Associates, LLC

21 Figure 3. Sample Control Chart SCA ED 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% UCL % 10.0% CL 0.21 LCL % 7-Jan 7-Feb 7-Mar 7-Apr 7-May 7-Jun 7-Jul 7-Aug 7-Sep 7-Oct 7-Nov 7-Dec Date/Time/Period Key Performance Indicators These are 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 miscellaneous. By building performance measures for the first three categories and then doing targeted studies on the miscellaneous call types in category four, the system has continuous feedback of the EMS system s clinical performance. 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. 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 cricothyrotomy, pharmacological assisted intubations, etc. These activities should be a small amount of overall time commitment. It is important that the person in the quality manager role understands quality improvement and statistical process control. Training at a local community college or in one of the EMS specific Six-Sigma efforts is recommended. Schertz, Texas EMS Page 17 Fitch & Associates, LLC

22 Making a transition to system-focused quality management and away from simply recording clinical errors can be accomplished, in part, with weekly quality meetings that follow an agenda structure similar to the following. Review Key Performance Indicator (KPI) data Each meeting should begin with a review of the EMS system s performance scorecard. Are all processes in statistical control? Are there any statistical variances worthy of exploration? What are the results of improvement efforts? Updates on targeted reviews 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? Are any system or process changes indicated? How can the data be deployed most effectively through education? New Directions Based on the results of KPI data, targeted reviews, or other indicators, the committee should check 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 capturing critical data adequately. QI 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 in the spirit of improving processes and systems and an emphasis on achieving best performance targets. Finger pointing at individual errors should be minimized. Implementation of a quality approach similar to the one described will provide SEMS 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. Recommendations 12. Key staff members assigned to the quality management function should be trained in quality improvement and statistical process control. 13. A scorecard should be developed and used on a monthly or quarterly basis so that data can be easily utilized to improve the patient outcomes. 14. Effectiveness of a quality improvement program is required to maintain modern practice standards. EMS participation in larger scale research projects within one of the hospitals should be a focus for the department with associated resources identified. MEDICAL DIRECTION AND ACCOUNTABILITY Dr. R. Donovan Butter, D.O. is the designated Medical Director for SEMS. Until recently, he was active as an emergency room physician and has experience with pre-hospital EMS systems. Now that Dr. Butter no longer has an emergency department affiliation, SEMS may want to recruit a new medical director Schertz, Texas EMS Page 18 Fitch & Associates, LLC

23 actively engaged in the practice of emergency medicine and who has an affiliation with the medical control center. SEMS uses a service contract for the medical director position. The language is vague and does not stipulate a minimum number of hours per month for EMS, however. A minimum of 25 hours is necessary for a medical director to be active and accomplish the minimum tasks required. The Description of Services and the Performance Measures listed therein should be updated and spelled out in additional detail. A 10% review of epcr s reviews should be performed and the evaluation based on a flow chart of specific criteria, with charted results promptly reported to the Director. The role of medical director in this system is described as moderate. He is less than moderately involved in the actual review of medical control tapes and PCRs. The QI focus for the department is handled primarily by the SEMS Clinical Manager who reviews individual cases internally. Based on those reviews, personnel are provided feedback with and without the medical director s direct involvement. He reviews the Medical Priority Dispatch protocols, but he is not actively engaged with the communication centers or the first responders. (Although both the communication center and the MFRs report they have access to the medical director, they do not participate.) Call reviews should become an integral part of field provider meetings involving the medical director. Additional efforts should be made to conduct positive call reviews of all those involved (e.g. medical communicators, first responders, field personnel, and hospital care providers). Schertz EMS should consider establishing an assistant medical director position that would be filled by an EMS fellow. EMS fellows are physicians seeking an Emergency Medicine board subspecialty in prehospital emergency care by participating in a one- or two-year program. Approved in 2010, the first graduates will be taking their board exams in October Accreditation Council for Graduate Medical Education approved EMS fellowship program for physicians requires a minimum of twelve months of clinical experience as the primary or consulting physician. In that role, the fellow is responsible for providing direct patient evaluation and management in the prehospital setting, as well as supervision of care provided by all allied health providers in the prehospital setting. The National Association of EMS Physicians (NAESMP) lists 58 EMS fellowship programs. Five are in Texas Dallas: University of Texas Southwestern Houston: University of Texas Medical School at Houston San Antonio: University of Texas Health Science Center San Antonio Temple: Scott and White / Texas A & M Health Science Center College of Medicine San Antonio Military Medical Center EMS Fellowship (approved Feb 2013) Schertz, Texas EMS Page 19 Fitch & Associates, LLC

24 PATIENT REFUSALS An area of high liability that should be monitored through Key Performance Indicator (KPI) reports and QI is patient refusals. This is where a patient has activated the 911 system requesting an ambulance to be transported to the hospital. Benchmark standards in other similar sized systems experience patient refusal rates from 12% to 18%. Non-transport rates for the last three-year period were 26.6%. This includes outright refusal (16.7%), plus refusals after treatment was rendered, that is, calls cancelled prior to arrival or no patient found calls are not included in this calculation (9.9%). To authenticate the validity of patient refusals, several actions can be initiated. Each case in which the patient refused care or transport should be reviewed (100% audit). This should include a review of the PCR to determine if protocol was followed and if a valid assessment took place. It should be determined if the patient placed a second call for an ambulance within 12 hours of the refusal or if they obtained private transportation to the hospital. As a courtesy follow up, a phone call to the patient should be made within 24 hours to determine if any change has taken place in the patient s condition. Recommendations 15. Develop a long-term succession plan in order to recruit a medical director that is actively engaged in emergency medicine, preferably located at the medical control center. 16. Consider utilizing an EMS Fellow as assistant medical director. 17. Medical Director Contract should be expanded and hours increased. 18. Regularly measure both clinical and operational skills and use appropriate remediation processes to ensure all staff maintains required competencies. 19. Conduct a 100% audit of patient refusals to review and validate the decision to not transport. FLEET AND LOGISTICS The fleet is one of the most important resources of an EMS system and a significant non-personnel expense. Making sound purchasing decisions and conducting frontline and preventative maintenance is critical to reducing lost unit hours and keeping ambulances in service and available for assignments. The fleet consists of twelve various types of vehicles. It includes four in-service ambulances, six support units, and two reserve ambulances. In-service medical units and back up units are a mixture of Type 3 transport capable ambulances. Odometer readings on the units range from 115,000 miles to over 302,411 miles. The average mileage per truck is 167,692. The age of the fleet ranges from 1999 to 2007 model years. Ambulance vehicle conversions (build out of the patient care areas) are mostly from the manufacturer Med-Tech, mounted primarily on Ford and International chassis. Visual inspection revealed the fleet to be in fairly good condition, with the exception of the oldest ambulance, which looked worn and aged (manufactured by National). Schertz, Texas EMS Page 20 Fitch & Associates, LLC

25 There is no quantifiable capital fleet replacement program in place. Vehicles are replaced when the City of Schertz Council has funds available to do so. Presently, there are two ambulances being built and will be delivered early in These will replace the two oldest and most costly vehicles. Best Practice EMS systems have fleets that represent % more than the peak number of units staffed on a daily basis. The system in-service peak is four units. The SEMS fleet approximates 150% of peak staffing. However, consideration of staffing for peak demand will drop SEMS under the recommended number of ambulances. An increase in fleet size may need to be considered. Fleet management/mechanic/driver training, preventative maintenance, fleet standardization, quality control driving systems and fleet performance monitoring are areas needing improvement. TRAINING The fleet manager position has been in place for just over one year. The current fleet manager is certified as an Emergency Vehicle Technician (EVT). There are several other mechanics in EVT training at this time. One mechanic has one AES certification and two other mechanics with six ASE certifications. They would like to be factory trained by the ambulance manufacturer for maintenance on the patient care module. The city shop is a six bay, four lift drive-in facility. The city fleet is responsible for 222 vehicles. Emergency services have priority in the shop for maintenance over other city service vehicles. Table 1 is a listing of vehicles utilized by SEMS at the time the consulting project was initiated. The ambulance fleet is beginning to show head gasket failures and brake work is constant. Additionally, EMS drivers tend to pop curbs and break side mirrors. Even cab mounts have had to be replaced. The six ambulances consume over 33% of the maintenance budget and time over the rest of the fleet. Preventative Maintenance (PM) schedules were lacking. Until recently, the City hired a Fleet Manager. The EMS preventative maintenance schedule is as follows. o 5,000 miles (diesel) - replace filters o 6,000 miles (gas) - replace oil and filters o 10,000 miles (diesel) - replace oil and filter o Synthetic oil products are utilized in the ambulances o An hourly maintenance schedule is being prepared for vehicles that idle a lot such as ambulances It is doubtful that the City mechanics understand the PM schedules to follow for the maintenance of the patient care box and its related components. Optimal fleet ratios can only be achieved with world-class EMS fleet maintenance. The SEMS fleet is not standardized and contains units manufactured by multiple vendors. The fleet is not well maintained compared to similar operations. Fleet maintenance recordkeeping has been hit and miss in the past. Stacks of maintenance files need to be input into the relatively new fleet maintenance computer software. Current work is entered as it is performed and the records are slowly getting caught up. Based on the new Schertz, Texas EMS Page 21 Fitch & Associates, LLC

26 system, the fleet manager will be able to track cost per mile on each vehicle and make recommendations on replacing fleet units as their incremental costs begin to rise. Table 1. Ambulance Fleet Utilized by SEMS at Initiation of Consulting Project Schertz EMS Truck Manifest Truck # Year Make Type Mileage (Oct 2012) International Type 3 302, International Type 3 147, International Type 3 115, International Type 3 136, Ford Type 3 251, Ford Type 3 255,350 OPS Chevrolet ,073 OPS Chevrolet Tahoe 37,431 Clinical 2003 Ford Expedition 126,655 Staff Chevrolet 2, ,023 Supervisor 2009 Chevrolet 3,500 99,186 Gator - Land Pride 4, Hrs PREVENTIVE MAINTENANCE Emergency vehicles are typically driven long and hard. Best practice preventive maintenance programs keep vehicles on the road and out of the shop. Maintenance is also critical for matching time frames for capital replacement schedules. Cost per mile is an important tool for monitoring effectiveness of maintenance. It should include all costs associated with the operation of a vehicle and include fuel costs measured congruently over the life span of the vehicle. Management reported an average cost per mile to be $0.83. This result is slightly higher than other operations the Consultants have observed, but this calculation was determined with a short period of data and not over the life span of the vehicle and may not be comparable. The cost per mile should be reduced by following the tables and recommendations below. Efficient and cost effective fleets use sophisticated Preventive Maintenance (PM) processes in addition to daily crew checks. This allows for uninterrupted service and will address repair issues before they occur and impact service. A minimum 26-point inspection is recommended to be conducted every 3,000 miles and at other intervals as illustrated at Table 2. Schertz, Texas EMS Page 22 Fitch & Associates, LLC

27 Table 2. Model Preventive Maintenance Schedule Service Mileage Service Points Level Interval Daily n/a Check lights, signals, warning systems, fluid levels, tire pressure, AC & heating systems, wipers, brake pedal travel, & monitor engine condition. 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. Best practice programs tend to check vehicles every 3,000 miles and have a graduated inspection and replacement schedule as the vehicle increases in miles. By taking a comprehensive approach, the fleet department has the ability to catch potential maintenance problems before they cause vehicle failures. When an outsourced vendor is utilized, the PM should follow a prescribed checklist that is signed and dated by the vendor. Vendors must be monitored to assure completion of that check sheet is followed. This is necessary in the event of litigation as a result of a mishap. These check sheets should be filed by vehicle and maintained throughout the lifespan of each vehicle to evaluate its cost effectiveness. This is also a common mechanism to mitigate risk should litigation occur. Cost per mile should include all labor, parts and fuel consumed by each vehicle. Mileages must be recorded monthly and a running average should be established for comparison each month. Vehicles with consistently higher averages should be replaced. DRIVER TRAINING SEMS does not provide driver training for the staff. Every staff member who drives an emergency vehicle must participate in an Emergency Vehicle Operator Course (EVOC) to manage the inherent risks of operating EMS units. This training should be conducted during new hire orientation. Scheduled refresher courses to ensure maintenance of driver proficiency should occur annually, or as needed for remediation. Emergency vehicle driver proficiency and awareness is critically important for two reasons: EMS accidents are the leading cause of death for EMS providers and poor driving results in increase wear and tear, body damage, and accidents. Annual refresher training is beneficial for maintaining skills and keeping crews conscious of their performance and the maintenance of the vehicles. Although the incidence of accidents appears to be low for SEMS, the types of unscheduled repairs required of ambulances indicate that the vehicles are being driven hard necessitating excessive repair and maintenance costs. Schertz, Texas EMS Page 23 Fitch & Associates, LLC

28 QUALITY CONTROL DRIVING SYSTEM SEMS does not use a monitoring system such as a Drive Cam or other black box technology that provides behavioral feedback and accountability for emergency response vehicle operators. When implemented effectively, these types of systems have reduced accident rates dramatically, lowered maintenance costs by as much as 10-20%, and can extend the life of parts (i.e., brake pads). There are several products available that can provide this information. FLEET PERFORMANCE MEASURES SEMS does not measure critical failure rates. 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 critical failures per 100,000 miles. The median for Coalition of Advanced EMS Systems (CAEMS) most recent national study is 2.00 vehicle failures per 100,000 miles. Another important measure is the number of vehicle collisions per 100,000 miles. The CAEMS Benchmark participants report a median of SEMS does not maintain accurate information regarding accidents so an analysis could not be made. SEMS would benefit from hosting a NAEMT EMS Safety Course and sponsor several of their staff as instructors, incorporating this program into their new hire orientation. Recommendations 20. Maintain the proper ratio of correct vehicles in reserve for back up and special duty functions. 21. Develop a fleet replacement program in the budget and plan for regular replacements. 22. Calculate age, miles and cost per mile in determining when a vehicle is scheduled for replacement. 23. Acquire an electronic maintenance reporting process that allows for rapid review and recording of fleet issues. 24. Evaluate the cost benefit relationship of high performance logistics processes. 25. Ensure fleet maintenance processes are continuous. 26. Implementation of black box technology would enhance the service s ability to monitor and provide feedback on driving habits; reduce vehicle wear and tear and maintenance costs. 27. Immediately implement an Emergency Driver education program for SEMS drivers. SEMS should invest in both a quality control system and associated training to improve safety and reduce vehicle collisions. 28. Anytime a vehicle sustains damage or is involved in an accident, a report should be filed and a determination of preventability should be made. 29. Review driving policies to bring into line with EMS safety training and implement and enforce use of spotter when vehicle is in reverse. Have a no tolerance policy on safety infractions. Schertz, Texas EMS Page 24 Fitch & Associates, LLC

29 PREPAREDNESS September 11, 2001 and several large-scale natural disasters in the United States have stimulated increased funding for all facets of emergency preparedness. SEMS preparedness efforts are above ambulance industry norms. SEMS has been proactive, making staff preparedness training a priority ensuring that they have basic safety and security knowledge of the communities they serve. Records indicate that all of the SEMS staff has been certified in National Incident Management System (NIMS) Incident Command System 100, 200, 700 and 800 levels and in HAZ-MAT Awareness Level. SEMS leadership has had additional training in NIMS 300 and 400 levels. The clinical department should consider taking the HAZ-MAT training up to the Technician level. EMS systems should have an all-hazards preparedness approach, combined with knowledge of the unique risk factors faced by the communities they serve. By weighing likely and less likely risks, it s possible to strike a balance in preparedness efforts. Clearly, EMS systems must maintain focus on dayto-day operations, while considering system enhancement for the far more frequent events they encounter. Interagency training is of utmost importance. Recent media reports have indicated that in multijurisdictional operations, the Incident Command System (ICS) procedures failed. After-action reports demonstrated the lack of practice made ICS cumbersome and awkward. Our experience indicates that the success of a large-scale event is predicated upon policies, activities and practices that are used daily. Based upon the fact that SEMS and the local hospitals will be the recipient of any major disaster, expanded, fully integrated training should be a priority. The unique integration aspects of EMS and the larger system merit a separate evaluation of how to better integrate planning, exercise, risk mitigation and staffing those functions within the larger healthcare delivery system. Such an evaluation was beyond the scope of this study. Recommendations 30. Continued joint training with other agencies such as fire and police, as well as PSAPs and hospitals, should be conducted at defined intervals. 31. Expand education to include a HAZ-MAT requirement for the Technician certification. 32. Evaluate the EMS role and the opportunities associated with risk evaluation and mitigation planning for the larger healthcare system. 33. Once a year, SEMS, along with their respective hospitals, should practice a combined community disaster drill. CREW CONFIGURATION AND STAFFING The following section discusses workforce-related issues including staffing, crew configuration and shift structure. Schertz, Texas EMS Page 25 Fitch & Associates, LLC

30 CREW CONFIGURATION Schertz EMS provides only emergency 911 responses and an occasional non-emergency response to a local hospital for a transport. Ambulances are staffed with two paramedics. Studies attempting to determine the best staffing model (i.e. one paramedic and one EMT or two paramedics) have resulted in no clear conclusion and no demonstrated improvement in patient outcomes with more than one paramedic. Based upon the lack of evidence and the expense difference in cost between a paramedic and EMT, the Consultant cannot support the additional expense for the service to provide two paramedics on each ambulance. A secondary and equally important consideration is the low call volume and patient contacts by some field providers. A single paramedic system will allow for additional opportunities for each paramedic to utilize and retain proficiency in providing advanced skills such as intubation. SEMS unscheduled overtime costs are significant. The Consultant estimates that the cost of unscheduled overtime could be decreased by more than 50% or more per year with more efficient labor allocation. The service budgets for 30% part-time personnel to cover overtime shifts. Several of those positions are currently open, specifically in the EMT-I category. The preferential use of part-time personnel can significantly reduce overtime. Part-time Paramedic and EMT employees should be utilized first in filling open shifts due to illness or vacation of full time personnel. Some services the size of SEMS will hire an additional full time employee to work scheduled time off, such as vacation or those shifts that have an injured employee assigned to the slot. This position is difficult to keep filled, as EMTs and paramedics like consistency as the same schedule of workdays and the same partner and station. TECHNOLOGY UTILIZATION DESCRIPTION OF BEST PRACTICES Technology supports interface between 911, medical dispatch functions and administrative processes. Data collection facilitates the analysis of key service elements and these data are routinely benchmarked and reported. Key personnel are available to support the analysis of operational data. Observations and Findings The following section discusses technology utilization including epcr and CAD related issues. Schertz, Texas EMS Page 26 Fitch & Associates, LLC

31 ELECTRONIC PATIENT CARE REPORTING The epcr is a point of care data entry for EMS crews. The information about the patient s condition, assessment and interventions is documented at the patient s side through a hand-held device. This information is electronically linked with the dispatch information to develop a record of the entire event. SEMS utilizes Zoll s RescueNet TabletPCR as its epcr system. Appropriate technology needs to be completely utilized by integrating data collected by patient care reports, billing and regional computer aided dispatch (CAD) into a single consolidated information resource. Without such consolidation, SEMS will be unable to fully participate in the mobile integrated healthcare practice that will drive EMS in the next five years. A desired feature for future implementation would be to broaden the epcr capability to include the information collected and documented by first responders during medical events in real time (immediately after completion of a call). COMPUTER-AIDED DISPATCH SEMS is part of Bexar Metro 911 Dispatch, a multi-jurisdictional service covering Schertz, Live Oak, Universal City and the counties of Bexar, Comal and Guadalupe. The CAD is a regional project between San Antonio, Bexar County and Schertz and has additional capabilities and capacity. Live Oak, Universal City, and Comal and Guadalupe Counties are not part of the CAD network. SEMS reports difficulties in getting response data specifics due to IT and reporting issues between TriTech CAD and Zoll RescueNet and are unable to provide detailed information on response specifics. Employees report interrupted radio/wireless coverage and inaccurate response mapping directions in some rural areas. Some field providers believe the Automatic Vehicle Locator (AVL) system is not accurate. Recommendations 34. Begin recruiting part time personnel to fill open shifts 35. As attrition occurs, hire EMT - Intermediates instead of paramedics as full time staff 36. Expand internal expertise to include data analysis and deployment capabilities. 37. Consider expanding epcr to capture Medical First Responder patient care, assessment and AED download. 38. Resolve the IT and reporting issues between RescueNET and TriData to obtain the needed response data. 39. Prioritize the technical issues with Bexar Metro 911 Dispatch CAD to improve wireless coverage, AVL status and response directions. Schertz, Texas EMS Page 27 Fitch & Associates, LLC

32 RESOURCE UTILIZATION AND DEMAND DESCRIPTION OF BEST PRACTICES In a best practice EMS system, a mechanism exists to identify and assure adequate deployment of ground and air transportation resources meeting specific standards of quality, to assure timely response scaled to nature of event. The systems are capable of monitoring safety and response time issues. There are defined response time targets to help rank severity of calls. The individual response components are measured by using both mean and 90th percentile metrics. Observations and Findings 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 Ambulances should be placed in areas with access and close to areas with higher demand. Post placement is often based on demand analysis. In the SEMS system, ambulances are fix based, also called static based, which means each ambulance has a permanent station and they observe fixed geographical boundaries of their own districts. EMS responds out of this station and return to this station. In the event the system drops to a level one, there are two street corner posts that the one ambulance may be assigned to. A review of the response time compliance indicates that the system is not responding well within its response time goals. The map below indicates a nine-minute (lighter shade) drive time from each of the SEMS stations and the call demand (red dots) in the service area. Data supplied did not differentiate demand locations by geographical base (similar addresses in multiple cities). It appears from this charting that Stations 3 and 4 have periods of time in which coverage from these locations could be reduced. Schertz, Texas EMS Page 28 Fitch & Associates, LLC

33 Figure 4. Drive Time Map DEMAND COVERAGE NOTE: Due to limited fields in the demand data, the analysis could not discern which unit ran a call from which station; therefore, it was not possible to isolate demand by station. Consequently, with the present data, Fitch could not determine low or peak demand times by geographical locations. In many systems, ambulance resources are scheduled statically or with some minor increase of resources during the core workday. Demand, however, is dynamic (see Figure 5) and often steadily increases throughout the day and is reduced in the late evening and overnight hours. When resources are not based on demand, there are blocks of time each day when the system wastes unit hours and peak periods where demand exceeds resources and response times are extended, calls are held, and crews are run hard. The SEMS system functions on 24-hour shifts. This type of staffing does not take into account demand, nor does the system add resources during the peak time of the day or reduce surplus capacity in the off hours. In communities such as those in the SEMS system, a core of base 24-hour shifts can make sense when supplemented with additional short shifts driven by demand. Based on demand charting, a reduction in the number of 24-hour shifts may be necessary and the inclusion of several shorter shifts may be of benefit. During crew interviews, several comments were made about crews experiencing sleep deprivation due to intensity of call volumes in several stations. Schertz, Texas EMS Page 29 Fitch & Associates, LLC

34 Figure 5. Chart of Demand Requests Schertz, Texas EMS Page 30 Fitch & Associates, LLC

35 Schertz, Texas EMS Page 31 Fitch & Associates, LLC

36 Schertz, Texas EMS Page 32 Fitch & Associates, LLC

37 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 eight minutes and fifty-nine seconds (8:59) in urban areas, within 11:59 in suburban areas and within 19:59 in very rural areas. For non-life-threatening emergencies [e.g. Medical Priority Dispatch System (MPDS), Charlie and Bravo], the typical urban response time is 11:59 and 14:59 respectively. SEMS management reports a 14:00-minute time at 90% reliability response time on emergency responses during FY The Consultant team was unable to verify response time compliance due to the manner in which call data is submitted. Table 3 reflects the Consultant s best efforts based on times for the system overall, acknowledging the time variances with calls originating with Live Oak and Universal City s PSAPs. Table 3. Response Time Chart (8 minutes 59 seconds) Response Times % % % % % Response time records are maintained within the Tritech CAD system in Schertz. There is no written protocol defining how these reports are to be constructed or validated. Schertz, Texas EMS Page 33 Fitch & Associates, LLC

38 Recommendations 40. A Data designation denoting contractual geo-fences should be established so demand activities by contract can be monitored. 41. Based on Demand Coverage charting, the creation of shorter shifts with hours based on demand would make the system more efficient. 42. Response times to contracted agencies must be reported by fractile method for responses occurring within their geographical boundaries. SYSTEM FINANCES AND FUNDING Ensuring Optimal System Value Benchmarks Clinical and customer satisfaction outcomes are enhanced by the EMS system. Unit Hour Utilization (UHU) 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. Costs by service line are verified, controlled and represent good value. Capital asset planning supports the organizational mission. Local tax subsidies are minimized. DESCRIPTION OF BEST PRACTICES In best practice systems, the governing body has identified and appropriated sufficient infrastructure funding from general funds, insurance recoveries and other non-lapsing sources for the EMS system to function in a manner consistent with its legislated mandates. Unit Hour Utilization (UHU) is measured and resources are deployed in a manner to achieve efficiency and effectiveness. Cost per unit hour, per transport and per capita is measured and the measurements document good value for money. Financial systems accurately reflect system revenues and document both direct and indirect costs. Financial data are routinely derived from the EMS data, insurers, emergency department, hospital discharge, death certificate and rehabilitation data and, along with data on general EMS infrastructure costs and are used to assess cost/benefit of the system. A method exists to investigate, diagnose and intervene in problems identified. Observations and Findings This review focused on two areas: reimbursement and system finance. A brief overview of funding is provided. Summaries of the findings are discussed in more detail in each of the following sections. Schertz, Texas EMS Page 34 Fitch & Associates, LLC

39 Funding for most EMS services is secured from two primary sources patient fees and subsidies. SEMS receives (via inter-local agreements) cash subsidies (subsidies from each jurisdiction calculated on a percapita basis) and relies additionally upon net collected funds available from system users. SEMS rates are set to include its cost of providing uncompensated care, but do not fully cover the cost of providing services. As a result, the City of Schertz is required to subsidize these costs by reallocating other city revenue. There are four major categories of payers for ambulance services: Medicare, Medicaid, private insurance, and patients. Medicare and Medicaid are fixed-fee payers and both, on average, pay less than the fully allocated costs of ambulance services. Medicaid pays significantly less than Medicare in Texas. Typically, patients are responsible for co-insurance, deductibles, or the full cost when they have no insurance coverage to reimburse for ambulance services. Nationwide, only a small percentage of billed charges are recovered from self-pay patients. This leaves the insurance companies to make up for the under-funded governmental programs, indigent care, and low percentage of patient payments. The ambulance industry mimics the rest of the healthcare industry by including the costs of uncompensated care in its commercial rates. While there is a limit to the amount that can be charged and reasonably reimbursed by insurance companies, non-subsidized ambulance services will continue to do so, as they have few other options. BILLING AND REIMBURSEMENT Section 4531b2 of the Balanced Budget Act of 1997 added Section 1834l to the Social Security Act (the Act), which mandated the implementation of a national Ambulance Fee Schedule (FS) effective for Medicare Part B ambulance services claims with dates of service on or after April 1, The Ambulance FS applies to all ambulance services. Section 1834l of the Act also required mandatory assignment for all ambulance services, which means that the provider or supplier will be paid the Medicare allowed amount as payment in full for these services. In addition, the provider or supplier may bill or collect only any unmet Part B deductible and coinsurance amounts from the beneficiary. The federal government and healthcare systems are linking compensation with quality measures. This is in place for hospitals and physicians and is being implemented for skilled nursing facilities and home health. It is only a matter of time before quality measures will determine reimbursement levels for ambulance services. Many of the recommendations in this report are in preparation for value-based reimbursement specifically the quality improvement and customer service components. Three primary sources fund the city s paramedic program general fund revenue from taxes, the Inter- Jurisdictional agreements, and user fees associated with ambulance transport. Table 6 shows SEMS FY 2012 average charge and mileage for each type of transport. Note that the emergency and non-emergency rates are the same. Under the CMS Fees Schedule, providers are Schertz, Texas EMS Page 35 Fitch & Associates, LLC

40 authorized to charge more for emergency transports than non-emergency transports. In review of other Texas EMS agencies, charges between emergency and non-emergency rates differ approximately $100. SEMS should consider increasing emergency rates by $100. Table 4. Averaged Base Charges Base Rate Mileage Charge BLS Non-Emergency $ $15.00 BLS Emergency $ $15.00 ALS Non-Emergency $1, $15.00 ALS-1 Emergency $1, $15.00 ALS-2 $1, $15.00 Specialty Care Transports $N/A $N/A REVENUES AND COLLECTION PROCESSES SEMS performs patient-billing services internally. This process appears to be working very well and collection amounts seem to be within industry standards. The key measure to determine the effectiveness of a collection agency is focused on the percent of billed charges collected. SEMS collects 39.1% of the total billed charges (before contractual). This is an industry norm gross collection rate and is reflective of good process and procedures for obtaining reimbursement, a favorable payer mix (which entity pays the bill, i.e., Medicare, Medicaid, commercial insurance), and below market charges. Another indicator is the net collection rate where the total charges are reduced by contractual allowances. The contractual allowances are those amounts that the service is precluded from receiving. For example, the service has to accept what Medicare allows as payment in full and this amount is significantly below the retail patient charges. The gap is larger for Medicaid recipients where the Medicaid reimburses a small fraction of the charged amount. At SEMS, Medicare and Medicaid contractual allowances represent 19% of the total amount billed. Bad debt and uncompensated care represents 41% of the total amount billed. Finally, the time it takes to collect from an account is analyzed. This is measured from the date of service until the account is considered satisfied in full. It may include a contractual allowance being applied, a payment by a third party source and/or payment from the patient. This is called an account s days in A/R. SEMS billing department has a days in A/R rating at 60.7 days, an accounts receivables rating which is well within industry standards for a similar patient mix and service base. Additional patient care charges will be realized as the healthcare system changes. In the future, EMS systems will receive dollars for not transporting, but caring for patients at home or work. This concept is discussed in a subsequent section of this report under Community Paramedicine. Schertz, Texas EMS Page 36 Fitch & Associates, LLC

41 SEMS mileage charges are low. The Consultant review found that SEMS charges are basically designed to cover the current cost of operations and uncompensated care and to be comparable within EMS agencies in Texas. The Consultant was unable to compare charges of competitors; however, they appear otherwise reasonable given that the system receives government subsidies. Mileage charges can typically generate a substantial amount of revenue. Although over 38.6% of revenues are fixed by government accounts, an increase in the mileage charge would realize a significant amount of income from private insurance and private pay accounts. The City of Schertz contributes any overall losses between net fees and expenses. SEMS does not consistently follow safe harbors billing practices. In FY 2012, $50 was subtracted from each resident s base rate by virtue of being a resident. This is not a safe harbors practice. Government accounts (Medicare and Medicaid) are required to receive the lowest possible pricing. If any special group receives a gross price reduction, that same deduction must be afforded to government payers. This practice should not be repeated. There is no system-wide compliance program in place. During the interview process, and in reviewing the bank deposit process, it was noted that the same person handles monies received from the point of pick up to point of deposit. It is recommended that a different person pick up monies received, tally a total of funds, and separate the money for deposit. Backup documents for deposits should be forwarded to a processing clerk and re-tallied for verification. These balances should be reviewed and verified before the end of each day. The billing and collection practices should be documented and verified for consistency and validation with job descriptions and responsibilities for compliance purposes. Facilities Consultants observed staff working in an environment too small for efficient productivity. Several Staff members perform multiple roles such as receptionist as well as processing claims and collecting money. There is no privacy for customers or patients who may want to discuss HIPAA protected information and the handling of money is accessible at the point of public entry into the building. Medical and billing records overflow into boxes stacked along corridors thus making the efficient retrieval of documents difficult and time consuming. The interior has evidence of redesign in the past, but today, just appears to be out of physical space. Consideration of moving the billing and collection functions into larger space which will afford privacy, accountability and adequate record storage and retrieval capable space. Recommendations 43. Discontinue the $50 base rate deduction for Schertz residents. 44. Increase both ALS and BLS Emergency base rates by $100. Schertz, Texas EMS Page 37 Fitch & Associates, LLC

42 45. Raise the mileage charge to realize an increase in private insurance and private pay accounts. 46. Document the billing and collections processes for compliance purposes. 47. Consider additional space for billing and collections activities. SYSTEMS COST AND FINANCE Once direct expenses and revenue are analyzed by service type, management will have the information to correct issues or improve operational and financial performance. This is especially important as management will want to track these expenses as they relate to pricing service contracts. Historically, the system was not able to operate on a break-even basis. The pressures of rapid community growth, coupled with a change in service territory, have increased losses incrementally. Contracted communities pay a per-capita fee annually for EMS. The per-capita is the same for each community, except Guadalupe County, which has a different fee schedule. This fee should be based on the cost to provide services offset by the revenue produced by geographical base. Observations and Findings SEMS overall combined FY2011 expenses approximate $3,796,406 1 and cash revenue of $3,253,826. Normally, each contractual operation would be analyzed independently. The data presented in Table 5 characterizes the data that was available during the Consultant s review. For example, analyzing the amount of revenue deductions and resulting net revenues can provide an insight into payer mixes and the collectability of the different localities. SEMS was only able to report consolidated numbers for revenue deductions and net revenues by counties. The inter-jurisdictional agreements generate approximately $1.4 million per year and ambulance fees approximately $1.8 million. Another $100,000 is generated from the Passport program, the training academy and other miscellaneous revenues. The expenses for the program exceed $3.2 million, leaving a shortfall of approximately $500,000 to be made up from the City s general fund. Table 5. Overall Combined Expenses FY 2011 Funds Gross Revenue billed (+) $ 4,715,522 Contractual deductions (-) $ 919,116 Net patient Charges (=) $ 3,796,406 Charity Care/Bad Debt (-) $ 1,949,798 Net Operations cash (=) $ 1,846,608 Inter-jurisdictional Fees (+) $ 1,406,218 Total operations funds (=) $ 3,252,826 1 Based on FY 2011 City of Schertz Audit Report Schertz, Texas EMS Page 38 Fitch & Associates, LLC

43 FY 2011 Funds Operation Expenses (-) $ 3,796,406 Deficit (=) $ 543,580 SEMS costs expressed on a combined per transport basis are $818 against benchmarked mean cost per transport of $265. The benchmark cost represents a system achieving high levels of clinical and financial performance. While this is the most current benchmark available, it is comparable to other EMS systems in Texas. UNIT HOUR UTILIZATION UHU is a calculation that measures the amount of time a unit is staffed, on duty, and prepared to respond to a call. This is measured as a percentage and it is the total amount of hours a unit is staffed and available for response. A 24-hour unit consumes 8,760 unit hours per year. When compared to transports, the UHU measures the percentage of on-duty time engaged in call activities. The specific formula used to calculate the UHU for each unit is: ( Number of calls) x (average call duration in hours) UHU= X,XXX hours per year Other time that is not included in the UHU calculation includes time for training, maintenance, and other preparedness-related functions. Stand-by services and public education efforts also are not included in the UHU calculation. UHU Benchmarks in high performance systems range between 0.35 and In systems more closely compared to SEMS, the Consultants have observed UHU ranges between 0.24 to Based on FY 2012 data, SEMS averaged a UHU of Overall, the service is increasingly losing larger amounts of money due to unsubstantiated staffing and payroll costs. An alignment of effective utilization of unit hours based on demand should help improve payroll costs. By remaining fiscally responsible and continuing to aggressively pursue reimbursement, the costs of required improvements can be offset to the maximum extent possible. Recommendations 48. Planning and budgeting to facilitate cost effective operations and sustainability should be a priority for the system, in light of the needs identified and recommendations made throughout this report. 49. Regular investments in capital must be given priority and growth opportunities must be explored and evaluated. Schertz, Texas EMS Page 39 Fitch & Associates, LLC

44 50. Continued infrastructure investment and programs to improve the system s ability to measure results (on a financial basis) of fleet and deployment of EMS units (e.g. Key Performance Indicators and tracking call demand) to insure efficiency within the operations. 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 The City of Schertz operates Schertz EMS as an Enterprise Fund. An enterprise fund establishes a separate accounting and financial reporting mechanism for municipal services for which a fee is charged in exchange for goods or services. Under enterprise accounting, the revenues and expenditures of services are separated into separate funds with its own financial statements, rather than commingled with the revenues and expenses of all other government activities. Enterprise accounting allows the community to demonstrate to the public the portions of total costs of a service that are recovered through user charges and, if any, the portion that is subsidized by tax levy or other available funds. Contracts are in place with each community served. The contracts reflect standard format and appear to address typical contract topics. These contracts enable SEMS to engage with several communities besides Schertz, for the purposes of providing EMS. User fees, as well as a per capita availability fee are paid annually by those communities. ACCOUNTABLE CARE Healthcare is shifting the manner in which reimbursement will be paid. In the future, it will be important to demonstrate patient satisfaction with your services. Organizations unable to demonstrate how the public perceives their service could receive a lesser reimbursement to no reimbursement, compared to those organizations that are committed to quality and can demonstrate patient satisfaction. SEMS recently implemented sending out patient satisfaction surveys. This information will be of great value in the future for justifying payment levels as well as the opportunity for expansion. Patient satisfaction postcards are sent to most patients asking: Did we arrive in a timely fashion? Were you treated in a respectful professional manner? Did we meet your overall expectations? Schertz, Texas EMS Page 40 Fitch & Associates, LLC

45 Did we explain the treatment you required? Were we able to make you comfortable? The postcards are addressed and mailed daily. The billing department staff originally addressed and mailed them, but as activities increased, the responsibility was passed on to a field supervisor, who also struggles to make this a priority. It may be more efficient to have the field crews complete this process because they readily have the run number, employee IDs and address available. INTERNAL CUSTOMER SATISFACTION Labor cost represents the largest portion of a financial statement. In EMS, the workforce is the most important aspect of the organization. A study of why employees leave an organization 2 indicates that employees do not leave an organization, they leave their immediate supervisor. The cycle of asking, answering, listening, taking action for improvement and assessing the impact of actions need to be repeated regularly and ingrained in the organizational culture. The internal customer satisfaction within SEMS can be labeled as guarded. The workforce enjoys highquality clinical care, the latest, greatest tools and a good patient base in which to practice. Interview after interview revealed that the supervisors are reported to be glorified administrative clerks. They cannot make decisions and when sharing information, it is apparent they are just doing as they are told. When asked questions, the reply is always, I will have to go ask... Responses typically take over two weeks to return or the topic ends up being forgotten. Recommendations 51. Publish monthly reports of first responder and ambulance services activities, as stipulated by contract. Fractile response times of all system participants and units should transparently be reported. 52. Develop a routine mechanism to benchmark and follow up staff issues and suggestions within the service. 53. Transfer the Customer Satisfaction Survey responsibility to the field crews to complete. 54. Expand ambulance service quality improvement plan and evaluate annually. 55. Supervisors must be empowered to make decisions to reinforce value within the workforce. 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. 2 First Break All the Rules by M. Buckingham & C. Coffman Schertz, Texas EMS Page 41 Fitch & Associates, LLC

46 Observations and Findings SEMS personnel present a positive image in the community. Employees maintain a casual uniform look. Uniforms observed were clean and in good order. The public views the staff as helpful and professional. STAND-BY SERVICES SEMS provides paid stand-by for a large number of community and city functions, as well as the EMS Extravaganza that is part of National EMS Week. Stand by for five high school football teams, played at three stadiums, motocross, dog racing, cycling events and softball tournaments keep a team busy year round. Stand-By services are charged at $135 per hour to most every event, including City sponsored activities. The regional Medical Ambulance Bus is used by EMS to provide rehabilitation services at working fire incidents. COMMUNITY EDUCATION SEMS developed a new staff position this fiscal year for a Public Training and Community Outreach Coordinator (PTCOC). PTCOC will grow existing community education programs in CPR, First Aid, EMT and Paramedic, and develop the pilot Schertz Community Paramedic program. The proposed Community Paramedic plan will develop local partnerships focused both on preventing hospital readmissions and to assist high-frequency EMS callers to appropriate services. Recommendations 56. Prepare and distribute an annual report to elected officials and community stakeholders describing the accomplishments of the ambulance service. 57. Explore implementation of a Community Paramedic Program with hospital partners. GOVERNANCE, GROWTH, ORGANIZATIONAL STRUCTURE AND LEADERSHIP Organizational Structure and Leadership Benchmarks A 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. Schertz, Texas EMS Page 42 Fitch & Associates, LLC

47 DESCRIPTION OF BEST PRACTICES In best practice EMS systems, a single lead agency is legislatively charged with the comprehensive leadership, development and regulation of the Emergency Medical Service System. Organizational governance, structure, and relationships are well defined. Human resources are developed and otherwise valued. Internal processes are designed to facilitate achievement of performance, with due regard for effective development, involvement and motivation of personnel at multiple levels within the organization. The agency assures ongoing needs assessment for areas of personnel shortage, trends in personnel utilization, and generalized health or safety issues. The agency has either documented actions to address human resources needs or, alternatively, has documented that no significant workforce needs or provider agency management issues exist as a result of the needs assessment. Agency leaders have established measurable program goals and outcome-based, time-specific, quantifiable, and measurable objectives that guide system effectiveness, performance and growth. Clinical outcomes and patient experience are clear drivers in the organization. Business planning and measurement processes are defined and utilized. An internal or external examination of EMS, including a performance and needs assessment, is performed every three to five years. Operational and clinical data is used to guide the decision process. Comprehensive annual reports on the status of the EMS system, including the effectiveness of all subsystems routinely report information system data and performance measures. A structured performance/quality Improvement (QI) system exists and addresses administrative as well as clinical issues. The EMS lead agency maintains clear procedures for enforcing personnel compliance with laws, regulations, and policies pertaining to provider licensure/certification. Observations and Findings Each of the following sections describes the findings related to governance, growth, organizational structure, human relations and leadership. GOVERNANCE AND REGULATORY COMPLIANCE In general, state EMS legislation aims to establish criteria for advance life support providers and ambulance service that is applicable across the state. Traditionally, regulations focus on basic guidelines for the licensing of ambulances, fleet and equipment standards, certification and continuing education requirement, and medical direction. SEMS has the necessary licenses and permits to operate at the State level. Schertz, Texas EMS Page 43 Fitch & Associates, LLC

48 At a local level, ordinances and regulations vary throughout the nation. Cities or counties typically have the responsibility to determine how EMS is provided and local ordinances are in place to assure service quality. This allows the local body of government to set the local standard for EMS delivery for its citizens and provides local control over the services provided and who provides those services. Locally, SEMS has contracts with the communities it serves. These contracts are well written and enforceable. Local communities have the structure to engage such services and provide subsidies in support. GROWTH OPPORTUNITIES AND COMPETITIVE ISSUES Healthcare delivery systems nationwide are re-evaluating the roles, opportunities and financial impacts of EMS initiatives under an accountable-care delivery model. The Enterprise Fund allows the City of Schertz to engage in competitive practices to sell EMS services to other communities. Over the years, SEMS has added communities and lost communities to their plan. Careful consideration should be given to revising service pricing structures. While costs may be consistently expensed, the billed patient fees are reflective of transport levels and populations. It may be necessary to increase the per capita charge in localities that produce less patient transports. Stakeholder interviews with representatives of contract communities were positive. Comments such as I could probably find services cheaper, but not better than with Schertz. ORGANIZATIONAL STRUCTURE AND HUMAN RESOURCES Management team structures vary from organization to organization and are typically based on system model, coverage area, and call volume. Traditionally, an organization the size of SEMS will have a management team that includes a director, operations supervisor, business manager, and a clinical quality and education manager supported by a single supervisor on each shift. Designated specialty support, or supervisory level administrative personnel (e.g. fleet, deployment specialists, etc.) are common. The titles and specific responsibilities vary. Organizational charts are used to provide insight and an understanding of the reporting relationships. Having a formal organizational chart provides clarity of the reporting structure to the staff and other departments. SEMS current organizational chart is shown below. Schertz, Texas EMS Page 44 Fitch & Associates, LLC

49 Figure 6. Current Organization Chart Observations and Findings SEMS executive leadership, supervisory functions and communication of organizational vision and values to achieve alignment within this organization can best be informally described as detached. This is based on stakeholder comments expressed in recent interviews with more than a dozen members of the leadership team, non-directional interviews conducted with frontline caregivers and interviews with leaders of other affiliated programs within the SEMS system. Consistent themes that emerged from stakeholder interviews include: There is positive affinity with the City of Schertz. Statements included, This is a good place to work. Our staff includes many great care givers. The standard of care is high. The school work schedule is accommodating and employee friendly. Schertz, Texas EMS Page 45 Fitch & Associates, LLC

50 Organizational communication is inadequate. Caregivers and other stakeholders clearly articulated that communication is severely lacking follow through. Supervision in the field needs to be empowered. They have to ask permission to do anything. It takes two or more weeks to get a response from administration. The inventory and supply process is frustrating and a waste of time. The inventory and supply system utilizes a commercial product called Ambu-Track. The program falls short for tracking expiration dates on products. This requires staff to frequently inventory for expiration dates, which causes frustration and aggravation for the crews. The result is inventories that are not accurate resulting in expired or about-to-expire products still on the ambulance. Due to the size of the organization, the consultants believe inventory control would just be better handled manually. EXECUTIVE LEADERSHIP EMS Director Dudley Wait, BS, LP, reports to City of Schertz Executive Director of Operations John Bierschwale. The executive director typically has a hands off approach letting Wait provide the primary direction for the organization. Wait has served as the Director for Schertz EMS since 2001 and has extensive EMS leadership experience for the past 15 years. Jason Mabbitt, BS, LP, is the operations manager and reports to the EMS Director. Originally hired as the clinical manager, Mabbitt has been operations manager for the last year. With the Director s extensive involvement in regional and state EMS, Mabbitt functions as the second-in-command. Survey results and staff interviews document staff communications as a significant concern. The Director is actively engaged at the regional level in providing support and leadership in the Southwest Texas Regional Advisory Council (STRAC). The Director is well respected within the various communities and is regarded as a thought leader for his vision. Within the SEMS organization, he is viewed as knowledgeable and engaged. Delegation does not come easily and he finds himself micromanaging processes. Decisions become drawn out and are viewed as indecisive. Those perceptions were consistent among peer leaders and others interviewed within EMS. OPERATIONAL LEADERSHIP The operational management of SEMS is made up of an operations manager and three field supervisors who operate 24/7 and are not assigned to an ambulance. Besides field supervision, each supervisor is assigned additional administrative responsibilities, such as supplies and inventory, training, and new hire orientation. Sometimes the administrative assignments conflict with field management. The supervisors are required to respond with crews on selected incidents. Rounding with staff, as well as other common leadership communications tools are not recognized concepts among this team. Each Schertz, Texas EMS Page 46 Fitch & Associates, LLC

51 supervisor expressed frustration with the inability to make independent decisions. They do not feel empowered to act without first consulting with the operations manager, who then needs to consult with the director. Many times, simple decisions get delayed as much as two weeks or just get lost in time and not addressed. A professional development program for members of the leadership team needs to be formulated with specific goals. Aligning job responsibilities with similar City roles would be useful. Encouraging minimum education requirements as appropriate with the role should be implemented. Utilizing an external program such as the Ambulance Service Manager (ASM) development program offered by the American Ambulance Association may provide the larger industry context and specific skills needed by this supervisory staff. Much of the information presented at interview was subjective in nature. To quantify the information, the Consultant utilized a matrix of the Twelve Common Benchmarks and Indicators of Satisfaction within EMS Agencies. On five of the twelve items, the Consultant could not document that these common factors were present, and on six of the factors partial documentation was identified. The Twelve Common Benchmark descriptors, along with criterion and SEMS observations are provided in Attachment B. An EMS system of only four 24-hour ambulances and a hierarchy of six non-system administrative staff, field supervisors might not be necessary. In other communities responding to less than 10,000 responses a year, a leadership team of a director, operations manager and clinical manager typically manages a system this size. However, with growth as envisioned by the City Manager and our recommendations to add unit hours based on demand statistics, the use of field supervisors may have a place. Regardless of the configuration utilized to oversee field operations, those persons must be empowered to make decisions in real time and be productive. The leadership team should develop a detailed actionable plan incorporating the recommendations of this report. Recommendations should be prioritized for a staged implementation over a three-year period. Attachment C provides a sample template for an implementation plan. LEADER DEVELOPMENT EMS has been evolving as a profession over the last 40 years. Traditionally, good EMS caregivers were promoted to supervisor positions and ascended the management ladder with little or no EMS specific training or academic preparation. While managing an EMS operation has grown exponentially more complex and EMS management degree programs now exist even online, management training and college level education are still undervalued. While not uncommon for an EMS organization this size, managers do not have the insights gained from a formal college education or the specific industry know-how gleaned from EMS management programs. Schertz, Texas EMS Page 47 Fitch & Associates, LLC

52 There are two primary avenues for achieving increased EMS specific leadership development: online EMS degree programs and industry specific management training. Several universities are now offering public safety and EMS management coursework online for undergraduate and graduate degrees. One example is The George Washington University, which offers a degree completion program completely online. In addition, the American Ambulance Association provides an industry-specific leader development program known as the Ambulance Service Manager Certificate Program. Schertz EMS should encourage managers and supervisors to achieve undergraduate education in EMS management and support them in participating in one or more of these management-training programs. Recommendations 58. Align EMS leadership positions with similar ones in the City and corresponding education requirements. Allow present staff the opportunity to use tuition assistance to upgrade credentials to meet standards. 59. Key members of the leadership team should, as a group, observe identified best practice sites in their orientation to operating a high performance, high-value EMS program. 60. Managers and supervisors should be encouraged to achieve undergraduate education in EMS management and/or participation in one or more of these management training programs. 61. Develop a clear action plan to address the recommendations made throughout the report and communicate the timeframes and results to staff at regular intervals. 62. The director should focus and develop SEMS global mission and path, while allowing the Operations staff to focus on day to day processes. Schertz, Texas EMS Page 48 Fitch & Associates, LLC

53 Community Paramedicine Aligning for the Future SEMS is in a premier position to lead EMS in Texas by evolving into a system founded on the principals of Community Paramedicine. This concept was discussed previously in this report. It fundamentally involves the leveraging of the EMS resources for the benefit of community health. Some of the aspects of this community-focused approach envisioned for the SEMS service area include increased involvement in prevention and early recognition activities. Programs such as assessing homes that include elderly or children to reduce falls and accidents have had a great impact. Treat and release programs are those where the paramedics provide in-home treatment of patients that precludes the need for ambulance transport. Other activities could include follow-up on patients recently discharged from hospitals to avoid unnecessary readmissions, and regular visits to the chronically ill patients to assess current health status and to ensure compliance with physician instructions and medications. In essence, the EMS personnel would be more tightly integrated with public health and healthcare delivery systems. Ultimately, funding for these activities will become available from the healthcare systems and payers. First, it will be necessary to demonstrate the value of these services. The Consultant recognizes that the implementation of Community Paramedicine will require allocation of resources to training, and documentation of results, but believes that a portion of the savings recommended in this report could be well allocated to these activities. The trial study could also be partially funded by grants and solicitation of support from receiving hospitals (particularly those in Texas), and insurance payers that have funded such pilot projects in other parts of the United States. SEMS leadership is aware of resources and contacts that more fully explore the Community Paramedicine options the vision for the future of EMS. SEMS is well positioned to move in this direction. The focus of SEMS personnel should be directed to embracing the Community Paramedicine model as the organization s primary function. Initiatives such as direct involvement in community health through prevention, education, emergency support, and continued care demonstrate a commitment to the full continuum of care giving. Hence, the benefits to residents of the service area are numerous. In addition, this orientation holds many opportunities for those who have chosen EMS as their careers to feel productive and fulfilled. The Consultant understands that funding is difficult, due to the current economic conditions throughout the country, and certainly in Schertz. SEMS should work with the State of Texas to develop the direction and planning for SEMS to expand its scope of practice and develop a community-based paramedic system. Schertz, Texas EMS Page 49 Fitch & Associates, LLC

54 NON-EMERGENCYTRANSPORTATION (NET) Providing non-emergency transportation services (NET) represents a new revenue opportunity for SEMS and makes sense for an Enterprise Agency to pursue. Presently, this service is performed by several private providers under agreements with local facilities, and Interviews with several hospitals indicate they are happy with these services and find the providers capable and competent. NET operations are highly competitive. Although there is a potential for increased revenue for non-emergency transports, it also represents increased expenses and risk. Adjustments in our recommendations may be required if SEMS desires to expand their book of business. Some highlights to consider include access, staffing, response times, medical necessity and patient billing services. Access Unlike a 911 request, non-911 service requires a more detailed, upfront screening of the transportation request due to medical necessity rules from third-party payers, as well as State and Federal regulations. This will require additional education and training for call processing personnel. As stated earlier in the report regarding the need for standardized single control point for dispatching of ambulances. The Schertz PSAP will need to agree to take on additional duties associated with NETs, it might be time for SEMS to create their own medical dispatching entity. Staffing A fundamental operating assumption is to optimize the department s ability to flex staff with less than 24-hour shifts to add additional capacity. This will allow the department to capture additional revenue associated with non-911 ambulance transportation at a reduced expense, as compared to the current full-time cost structure. Ambulance Response Time Performance Reliable response times are considered a key benchmark of an EMS system s performance. This is also the case in a non-911 system. In many cases, the requesting facility is attempting to quickly move a patient from one location to another in an effort to accomplish through put. Through put is described as the ability of a medical institution to move patients though a facility (i.e. from the Emergency Room to a patient bed in the Intensive Care Unit and on to a recovery location, such as a rehab facility or nursing home). If a facility is unable to efficiently move patients though the facility, a physical back-up in available hospital beds will occur, resulting in ambulance diversion in the Emergency Room or direct admissions. A timely, efficient non-911 ambulance transportation service is critical to most medical institutions. Quality providers measure response times similar to 911 Medical Service response standards. An example will require a 30-minute response time, 90 percent of the time or the provider is required to respond within 15 minutes of the requested pick-up time with a 90 percent reliability standard. Schertz, Texas EMS Page 50 Fitch & Associates, LLC

55 Medical Necessity Unlike 911 requests for service, non-911 requests for service must include preliminary determinations of the patient s condition and the appropriateness of ambulance transport. Many patient transports require prior authorization by the appropriate insurance organization before transportation is provided. Failure to receive prior authorization will result in denial of payment for the transport. Additional paperwork is required for the determination of medical necessity. A Physicians Certification Statement (PCS) will be required to bill many of the transports. Field crews will be required to obtain these forms from the sending facility to be included with the Patient Care Report (PCR). Summary To pursue this line of additional work will require a detailed business plan outlining projected costs, revenues and a timeline for implementation. The following questions should be addressed; (a) Will NET represent an incremental cost or do they have to add fixed costs to do the work? (b) What is the reasonable percentage of calls (and net revenue) you would expect them to capture? (c ) The public provider entering a highly competitive NET market may becomes the dump as all the privates know that the public service will be required to take everyone so the privates become "not available" for indigent or other self pay transfers. NON-EXCLUSIVE AMBULANCE FRANCHISING The granting of an ambulance service permit by the State of Texas is easy and inexpensive. Communities must safeguard themselves against ambulance operators who may not have the best interest of the community in mind. In considering setting up a non-exclusive ambulance, franchise requires an act of the City council with defined criteria for service. Government agencies should require anyone operating an ambulance services in your service area to complete an application, pay a fee and hold a franchise. To operate an ambulance service without benefit of such a franchise would be unlawful and subject to strict penalties. Applicants for a franchise will need to demonstrate their ability to recognize an emergency situation and have a means to promptly transfer the call to the 911 service. Additional minimum standards will assure that back ground checks on staff are performed, participation in system-wide medical direction, age and physical condition of fleet and be subject to periodic inspections for compliance. The creation of a Non-Exclusive Ambulance Franchise may produce a small amount of revenue while maintaining a minimum standard of care for the community. The recommendations included in this report are designed to increase the focused planning and coordinating activities occurring within Schertz. The recommendations are also focused on maximizing Schertz, Texas EMS Page 51 Fitch & Associates, LLC

56 the benefit derived from the limited resources available and to provide a stronger safety net for the residents and visitors of SEMS service areas. PRINCIPLES OF EMS SYSTEM DESIGN There are over 20 common models of ambulance service delivery. The most common include: Exclusive franchise (private) Non-exclusive franchise Entirely volunteer Hospital based Fire service based (paid) EMS/third government service Not-for-profit community based Government Enterprise Fund Ambulance service is medically (physician) driven and is, therefore, primarily a healthcare service that is delivered in a public safety environment. To determine which model would serve well over time, the guiding principles for system design should be considered. These include: Ensuring performance accountability External oversight Full cost accounting and disclosure Design features ensuring efficiency over time Performance sustainability as central to the right to continue services From the Consultant s perspective, an optimal EMS system is best designed from the patient's point of view. In addition to responding to emergency and transportation requests, patients should expect the service to be engaged in community awareness and prevention programs, health education and early symptom recognition. 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. Standards, such as NFPA 1710 and the Commission on Accreditation of Ambulance Services, suggest an eight-minute response for ALS; however, current studies suggest proper first response of four to six minutes can allow for the arrival of ALS within 10:59 in urban areas and 19:59 in rural areas on lifethreatening emergencies with 90% reliability from the time the EMS center receives the call. Non-life threatening emergencies should receive a response within 19:59 in urban areas with 90% reliability. Patients should be transported to a hospital that can treat their specific condition, not just the closest receiving facility. The EMS system should be externally and independently monitored, with participants Schertz, Texas EMS Page 52 Fitch & Associates, LLC

57 held accountable for their responsibilities. Finally, the system should deliver good value for the resources invested. SEMS STATUS QUO IS UNSUSTAINABLE To continue to operate this system in the status quo is inefficient, expensive and is not a good example of an Enterprise Fund program. This report indicates that changes and improvements are necessary in many categories. STATUS QUO IMPROVED (ADDITIONAL COSTS OFFSET BY IMPROVED PRODUCTIVITY) By reducing costs and providing quality products, Schertz EMS can implement many of the proposed recommendations in order to be viable. Recommendations based on accountability, improved productivity, quality assurance in clinical care and Community Paramedicine are core values to SEMS ability to improve and grow. Basic fundamental infrastructure additions and improvements will require an infusion of capital, as well as operating design. Capital components, such as a vehicle replacement schedule, mobile vehicle monitoring systems, leadership accountability and dynamic staffing are just some of the key areas in need of attention. Schertz, Texas EMS Page 53 Fitch & Associates, LLC

58 SUMMARY OF RECOMMENDATIONS 911/MEDICAL COMMUNICATIONS 1. Live Oak and Universal City should transfer all calls for an ambulance directly to Schertz PSAP for EMD and dispatch. 2. Schertz PSAP personnel should follow the processes prescribed in MPDS, EMD, and dispatch based on type of call and emergency versus non-emergency. 3. Train selected 911 center staff to provide regular, medically supervised quality review of EMD activities consistent with NAED standards. 4. The PSAP dispatcher must be prepared to re-assign the alarm if an ambulance comes available and is closer, after the initial dispatch of the call. 5. Implement the AQUA QI processes to ensure that 95% of those requiring pre-arrival instructions receive them in accordance with nationally recognized standards. 6. Strengthen prospective and retrospective medical oversight of the communications function. This should include routine case reviews by the medical director. 7. Develop necessary training, enforce procedures, and engage in quality assurance activities to insure that data produced by and contained in the SEMS CAD is accurate to an acceptable community standard. MEDICAL FIRST RESPONSE 8. MFR leadership should take advantage of greater interaction with the Medical Director and actively participate in medical QI processes. 9. First Responder response times should be reported from call receipt until wheel stop on a fractile basis, based on NFPA standards. 10. SEMS crews should participate in initial and CEU level training with fire staffs to promote camaraderie and teamwork. 11. This system would benefit from pit-crew style patient care. AMBULANCE OPERATION AND CLINICAL PERFORMANCE 12. Key staff members assigned to the quality management function should be trained in quality improvement and statistical process control. 13. A scorecard should be developed and used on a monthly or quarterly basis so that data can be easily utilized to improve the patient outcomes. 14. Effectiveness of a quality improvement program is required to maintain modern practice standards. EMS participation in larger scale research projects within one of the hospitals, should be a focus for the department with associated resources identified. Schertz, Texas EMS Page 54 Fitch & Associates, LLC

59 MEDICAL ACCOUNTABILITY 15. Develop a long-term succession plan in order to recruit a medical director that is actively engaged in emergency medicine, preferably located at the medical control center. 16. Consider utilizing an EMS Fellow as assistant medical director. 17. Medical Director Contract should be expanded and hours increased. 18. Regularly measure both clinical and operational skills and use appropriate remediation processes to ensure all staff maintains required competencies. 19. Conduct a 100% audit of patient refusals to review and validate the decision to not transport. FLEET OPERATIONS 20. Maintain the proper ratio of correct vehicles in reserve for back up and special duty functions. 21. Develop a fleet replacement program in the budget and plan for regular replacements. 22. Calculate age, miles and cost per mile in determining when a vehicle is scheduled for replacement. 23. Acquire an electronic maintenance reporting process that allows for rapid review and recording of fleet issues. 24. Evaluate the cost benefit relationship of high performance logistics processes. 25. Ensure fleet maintenance processes are continuous. 26. Implementation of black box technology would enhance the service s ability to monitor and provide feedback on driving habits; reduce vehicle wear and tear and maintenance costs. 27. Immediately implement an Emergency Driver education program for SEMS drivers. SEMS should invest in both a quality control system and associated training to improve safety and reduce vehicle collisions. 28. Anytime a vehicle sustains damage or is involved in an accident, a report should be filed and a determination of preventability should be made. 29. Review driving policies to bring into line with EMS safety training and implement and enforce use of spotter when vehicle is in reverse. Have a no tolerance policy on safety infractions. PREPAREDNESS 30. Continued joint training with other agencies such as fire and police, as well as PSAPs and hospitals, should be conducted at defined intervals. 31. Expand education to include a HAZ-MAT requirement for the Technician certification. 32. Evaluate the EMS role and the opportunities associated with risk evaluation and mitigation planning for the larger healthcare system. 33. Once a year, SEMS, along with their respective hospitals, should practice a combined community disaster drill. Schertz, Texas EMS Page 55 Fitch & Associates, LLC

60 TECHNOLOGY UTILIZATION 34. Begin recruiting part time personnel to fill open shifts 35. As attrition occurs, hire EMT-Intermediate instead of paramedics as full time staff 36. Expand internal expertise to include data analysis and deployment capabilities. 37. Consider expanding epcr to capture Medical First Responder patient care, assessment and AED download. 38. Resolve the IT and reporting issues between RescueNET and TriData to obtain the needed response data. 39. Prioritize the technical issues with Bexar Metro 911 Dispatch CAD to improve wireless coverage, AVL status and response directions. RESOURCE UTILIZATION AND DEMAND 40. A Data designation denoting contractual geo-fences should be established so demand activities by contract can be monitored. 41. Based on Demand Coverage charting, the creation of shorter shifts with hours based on demand would make the system more efficient. 42. Response times to contracted agencies must be reported by fractile method for responses occurring within their geographical boundaries. SYSTEM FINANCES AND FUNDING 43. Discontinue the $50 base rate deduction for Schertz residents. 44. Increase both ALS and BLS Emergency base rates by $ Raise the mileage charge to realize an increase in private insurance and private pay accounts. 46. Document the billing and collections processes for compliance purposes. 47. Consider additional space for billing and collections activities SYSTEM COSTS AND FINANCES 48. Planning and budgeting to facilitate cost effective operations and sustainability should be a priority for the system, in light of the needs identified and recommendations made throughout this report. 49. Regular investments in capital must be given priority and growth opportunities must be explored and evaluated. 50. Continued infrastructure investment and programs to improve the system s ability to measure results (on a financial basis) of fleet and deployment of EMS units (e.g. Key Performance Indicators and tracking call demand) to insure efficiency within the operations. Schertz, Texas EMS Page 56 Fitch & Associates, LLC

61 CUSTOMER AND COMMUNITY ACCOUNTIBILITY 51. Publish monthly reports of first responder and ambulance services activities, as stipulated by contract. Fractile response times of all system participants and units should transparently be reported. 52. Develop a routine mechanism to benchmark and follow up staff issues and suggestions within the service. 53. Transfer the Customer Satisfaction Survey responsibility to the field crews to complete. 54. Expand ambulance service quality improvement plan and evaluate annually. 55. Supervisors must be empowered to make decisions to reinforce value within the workforce. PREVENTION AND COMMUNITY EDUCATION 56. Prepare and distribute an annual report to elected officials and community stakeholders describing the accomplishments of the ambulance service. 57. Explore implementation of a Community Paramedic Program with hospital partners. GOVERNANCE, GROWTH, ORGANIZATIONAL STRUCTURE AND LEADERSHIP 58. Align EMS leadership positions with similar ones in the City and corresponding education requirements. Allow present staff the opportunity to use tuition assistance to upgrade credentials to meet standards. 59. Key members of the leadership team should, as a group, observe identified best practice sites in their orientation to operating a high performance, high-value EMS program. 60. Managers and supervisors should be encouraged to achieve undergraduate education in EMS management and/or participation in one or more of these management training programs. 61. Develop a clear action plan to address the recommendations made throughout the report and communicate the timeframes and results to staff at regular intervals. 62. The director should focus and develop SEMS global mission and path, while allowing the Operations staff to focus on day to day processes. Schertz, Texas EMS Page 57 Fitch & Associates, LLC

62 ATTACHMENT A Ambulance Benchmark Summary

63 ATTACHMENT A: Ambulance Benchmark Summary SYSTEM COMPONENTS BENCHMARKS OVERVIEW KEY: D=Documented, ND=Not Documented PD= Partially Documented Communications Benchmarks Comments Public access through a single number, preferably D enhanced 911 Coordinated PSAPs exist for the system PD Live Oak, Universal City and Schertz PSAPs are disjointed and do not easily share information Certified personnel provide pre-arrival instructions and priority dispatching (EMD) and this function is fully PD EMD only present at Schertz PSAP. Neither Live Oak nor Universal City practice EMD medically supervised Data collection which allows for key service elements to be analyzed PD Data collected from Schertz only. LO & UC data was unsupported Technology supports interface between 911, dispatching & administrative processes PD Schertz CAD supports processes, no data available from LO or UC Radio linkages between dispatch, field units & medical facilities provide adequate coverage and facilitate communications ND Reception issues with Schertz CAD and AVL, observed ambulances and SEMS supervisor changing dispatch assignments Medical First Response Benchmarks First responders are part of a coordinated response system and medically supervised by a single system medical director Defined response time standards exist for first responders First response agencies report/meet fractile response times. AED capabilities on all first line apparatus Smooth transition of care is achieved D Comments Regional EMS protocols and single physician medical director PD SFD Goal: 04:59 < 90% None of the other 1 st Responder departments have response time standards ND None of the 1 st Responder departments report their response times D D Medical Transportation Benchmarks Comments Defined response time standards exist PD Everything is run emergency Agency reports/meets fractile response times PD LO & UC data unreliable for response time calculations Units meet staffing and equipment requirements D Dual paramedic staffing Resources are efficiently and effectively deployed PD Static rather than dynamic deployment. Still maintains District concept for call assignments. There is a smooth integration of first response, air, ground and hospital services D Schertz consistently identified as most competent/trusted in area Develop/maintain coordinated disaster plans ND SEMS not routinely included in exercises or drills Schertz, Texas EMS Page 1 Fitch & Associates, LLC

64 ATTACHMENT A: Ambulance Benchmark Summary KEY: D=Documented, ND=Not Documented PD= Partially Documented Medical Accountability Benchmarks Comments Single point of physician medical direction for entire D system Written agreement (job description) for medical direction exists PD Contract exists, but roles & responsibilities need expanding Specialized medical director training/certification ND MD is not board certified and no longer working as emergency department physician Physician is effective in establishing local care standards that reflect current national standards of practice PD Standard of care is high, protocols are reviewed annually. Proactive, interactive and retroactive medical direction is facilitated by the activities of the medical director PD Monthly dinner with the Doc that is a combination training/quality Control session open to all PCR/QI data transparency for MD review PD MD only reviews report sent to him. (4-5/month) Clinical Education/Development Effectiveness D Clinical Education Efficiency D Customer/Community Accountability Benchmarks Comments Legislative authority to provide service and written D service agreements are in place Units and crews have a professional appearance D Pending new uniforms Formal mechanisms exist to address patient and D Service surveys sent out to most of transports community concerns Independent measurement and reporting of system performance are utilized ND All data is obtained, analyzed and reported by Executive Director Internal customer issues are routinely addressed PD Internal issues not readily addressed Prevention & Community Education Benchmarks Comments System personnel provide positive role models D Programs are targeted to at risk populations PD SEMS is available on demand for civic organization & health agency for At Risk projects Formal and effective programs with defined goals exist PD AED program managed by EMS. Seems comprehensive, but not measured or goaled Targeted objectives are measured and met ND Although several projects in place, there are no goals or measuring performed Schertz, Texas EMS Page 2 Fitch & Associates, LLC

65 ATTACHMENT A: Ambulance Benchmark Summary KEY: D=Documented, ND=Not Documented PD= Partially Documented 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 ND Static deployment utilized with only 24 hour shifts. UHU is 0.14 to achieve efficiency and effectiveness Ambulance cost per unit hour & transport document PD $ per hour good value Service agreements represent good value PD Some clients object to per capita rate. Cadillac system Non-emergency ambulance effective & efficient D Non-Emergency calls are handled by several private companies Non-Ambulance but medically necessary (MAV) services are effective and efficient D Non-ambulance calls provided by several private companies System facilitates appropriate medical access D Financial systems accurately reflect system revenues and both direct and indirect costs PD Tracking is available. Patient mix is high towards private pay. Collection % is low Revenues are collected professionally and in compliance with regulations PD Depositing process needs higher level of compliance Tax subsidies when required are minimized ND Tax subsidiaries are collected on a per capita basis Organizational Structure & Leadership Benchmarks Comments A lead agency is identified and coordinates system D activities Organizational structure and relationships are well D defined Human resources are developed and otherwise valued ND Essential HR practices are absent and HR has minimal involvement Business planning and measurement processes are D defined and utilized Operational and clinical data informs/guides the D decision process A structured and effective performance based quality improvement (QI) system exists PD Structure exists, aspects of the QI process remain a work-in-progress Schertz, Texas EMS Page 3 Fitch & Associates, LLC

66 ATTACHMENT B Leadership Benchmark Summary

67 ATTACHMENT B: Leadership Benchmark Summary 12 COMMON BENCHMARKS AND INDICATORS OF ORGANIZATIONAL SATISFACTION WITHIN EMS AGENCIES KEY: D=Documented; PD=Partially Documented; ND= Not Documented Descriptor Criterion Score Observation and/or Staff Comments Strong Servant D Leadership Affiliation & Culture Training & Development Involvement A compelling vision of the future and senior management draws people in a common direction. Employees understand and are personally enrolled in the vision goals and objectives that support the vision. Action oriented. Individuals identify how they and their work fit in to the bigger mission of the organization. Relationship building that exchanges help & respect is understood and practiced. The organization is a learning organization. Personal development opportunities abound and participation is strongly encouraged. Strong ownership is expressed. People who do the work, shape the work and own the processes. People feel they make meaningful contributions organizationally. PD PD PD Senior city and EMS leadership share a common direction in establishing a high-quality regional EMS system. Some EMS managers and employees share vision. Schertz EMS is action oriented; its impact on the region is much larger than their organizational size. Employees report a gap between the regional and state activities by the EMS director and the day-to-day delivery of EMS services. Participants frustrated by an unusually long period of committee work (2 to 3 years uniforms, administrative SOPs and replacement ambulances) and perception that EMS leadership is not accepting committee recommendations. Some delays due to city deferring expenditures for one budget year (ambulance replacement) Operations manager, clinical educator and some paramedics own the process, not noted with any of the EMS supervisors. Service A clear commitment to external & internal customer service exists. PD Very clear commitment to external customers, mixed commitment to Schertz EMS employees. Frequent Recognition Employees are acknowledged for a job well done, not with extrinsic rewards but with genuine appreciation. Multiple strategies are employed to communicate formal and informal appreciation. Accountability Accountability is evident at all levels of the organization. 360 appraisal tools are used. The organization takes full advantage of staff potential. Communication Formal and informal mechanisms are used by management to ensure dialogue is forthright. In meetings, titles tend to fall away, opening the way to free flowing dialogue. There is little fear of recrimination among employees who talk straight. Opinions set aside to understand other perspectives. PD ND ND Employees crave informal, positive feedback from director and Operations Manager we only see them when we are in trouble. Accountability not observed at EMS Supervisor level towards paramedics. 360 tools not used. Fifteen percent of the field staff interviewed complained of retaliation and recrimination by senior EMS staff. Ops Manager micro-processes the supervisors who tell the crews, I can t make that decision, I ll let you know. Schertz, Texas EMS Page 1 Fitch & Associates, LLC

68 ATTACHMENT B: Leadership Benchmark Summary Descriptor Criterion Score Observation and/or Staff Comments Technology & PD Innovation Informality & Flexibility Opportunity for Advancement Non-Aggressive and Productive Relationships with Labor Technologically sophisticated equipment supports clinical mission. Risk taking in the name of innovation is encouraged. Mistakes are viewed as part of a fair price for learning. An open door policy is practiced. Leadership frequently interacts with crews at stations, hospitals and other settings. Good judgment is used in applying rules caregivers and leadership have a working understanding of fairness & application principles. The workplace encourages staff to stretch capabilities, reach full potential or achieve higher levels of certification. Relationships are direct, productive and lead to reasonable end results. Both management and staff own the outcomes of the process and their behavior in that process. ND ND ND Schertz EMS is an early adopter and enthusiastic implementer of technology. Some employee resentment at constant barrage of new toys (including mass casualty bus) that increase workload without apparent benefit to them. From paramedic perspective, infrequent interaction with leadership at any setting. Many paramedics demonstrate what s in it for me approach to flexibility Supervisors are not empowered. Some employees believe that promotion process is fixed, with the director s favorites getting the operational manager and clinical educator spots. No evidence found of paramedics preparing for manager or administrative positions. Process impeded by city financial conditions, current fiscal year is first in three where employees will receive a small raise. While administration shares the numbers some employees do not trust the information. Supervisors are micro-managed and not empowered to make decisions. Schertz, Texas EMS Page 2 Fitch & Associates, LLC

69 ATTACHMENT C Sample Service Clinical Indicators

70 ATTACHMENT C: Sample Service Clinical Indicators 2004 Operational Plan Initiative Summary Group Southern Pacific Business Retention Team Team Business Retention Managers Click to Go To GREEN YELLOW RED Initiative Owner Status Original Date or Ongoing 1 Develop Service Promise Plans for Targeted and Priority Customers BRM GREEN 11/1/ Establish Preferred Provider Contracts with BRM all Targeted Customers GREEN 11/1/ Achieve Transport Targets for each area BRM GREEN 11/1/ Implement Customer Service Initiatives BRM GREEN 11/1/ Develop Target Facility Account Plans BRM GREEN 11/1/2003 All actions on-track for successful completion Problems exist that may cause slip or minor miss of target Significant problems exist, substantial slip likely or overall target in jeopardy Revised Date (if required) Comment 2004 Operational Plan Initiative Actions Group: Southern Pacific Business Retention Team Initiative: Develop Service Promise Plans for Targeted and Priority Customers Owner: Business Retention Managers Click Here to GoTo Summary ID Date Opened GREEN YELLOW Key Action to Achieve Initiative Owner Status RED Revised End Date Comment (if required) 11/18/2003 Identify Business Retention Plan BRM/Director/Ops GREEN completed for all Territories 11/18/2003 Identify Targeted Customers BRM/Director/Ops GREEN ongoing Business Retention Manager to identify the targeted accounts that will initially be contacted and negotiated. This list will change only after agreements are in place. Each area will determine the number of simultaneous negotiations are taking place. Names of clients placed here during negotiations process 11/18/2003 Current Internal Assessment of Services: BRM/Comm/PBS GREEN Include data on existing contract, level of service ICU, CCU, ALS, BLS etc, network provider structure, time on task, payor mix, utilization data, scheduling patterns, issues with Customer (PCS compliance), receivables 11/18/2003 Evaluate Data with Internal Org BRM/Comm/PBS/OPS GREEN 11/18/2003 Determine Customers to implement BRM/OPS/PBS/Comm 11/18/2003 Customer Needs Analysis BRM GREEN Gather Customer Needs, Validate Internal Data 11/18/2003 Develop Survey for client needs BRM GREEN Diana has developed analysis 11/18/2003 Develop Metrics and Reporting for Comm Center/BDM GREEN customers 11/18/2003 Collect Survey Data BRM/Marketing Rep GREEN BRM assigns 11/18/2003 Validate Data with Senior BRM/Customer GREEN Management 11/18/2003 Sign Service Promise Plans BRM GREEN VPO and Director Sign 11/18/2003 Implement Pilot Program to ensure process implementation On-target for completion on original (or approved revised) due date Possible slippage or missed target - revised due date proposed Significant slippage or missed target likely BRM/OPS/PBS/Comm GREEN Pilot with customer to ensure both internal and external processes support promise plan. SPP may be revised based upon tweaks 11/18/2003 Implement Service Promise Plan BRM/OPS 11/18/2003 In-Service Review BRM/Ops/Customer Users/AMR Internal 11/18/2003 Conduct Service Review with Customer BRM/OPS Manager/Marketing Rep GREEN ongoing Review Scorecards with customer. Timing is defined with customer 11/18/2003 Daily Compliance Review BRM/OPS/PBS/Comm GREEN ongoing Schertz, Texas EMS Page 1 Fitch & Associates, LLC

71 ATTACHMENT C: Sample Service Clinical Indicators 2004 Operational Plan Initiative Actions Group: Southern Pacific Business Retention Team Initiative: Establish Preferred Provider Contracts with all Targeted Owner: Business Retention Managers Click Here to GoTo Summary ID Date Opened GREEN YELLOW RED Key Action to Achieve Initiative Owner Status On-target for completion on original (or approved revised) due date Possible slippage or missed target - revised due date proposed Significant slippage or missed target likely Original End Date or Ongoing Revised End Date Comment (if required) 11/18/2003 Identify Customers to develop contract vehicle BRM YELLOW Acute, SNF, Managed Care customers, Mix, to determine which accounts to contract 11/18/2003 Determine Payor Mix BRM/PBS GREEN 11/18/2003 Determine AT-Risk BRM/PBS YELLOW 11/18/2003 Determine control of Transports BRM GREEN 11/18/2003 Financial Pro-Forma developed BRM/Finance/Ops GREEN 11/18/2003 Develop Business Plan BRM/Dir Ops/Fin Resources identified and customer needs 11/18/2003 Review and Approve Business Plan VPO, VPAD,VP FIN,CEO, VPPBS 11/18/2003 Develop Contract Template BRM/Fin/Adm/Ops GREEN Legal Requirements determined based upon internal and external needs 11/18/2003 Develop Services and Pricing Exhibit BRM/OPS/Fin GREEN 11/18/2003 Internal In-Service BRM GREEN 11/18/2003 Contract Negotiated with client BRM GREEN 11/18/2003 Changes communicated to AMR BRM/VP adm GREEN 11/18/2003 Contract Signed BRM/Customer GREEN 11/18/2003 Conduct External In-Service BRM GREEN 11/18/2003 Contract Implemented Contract ADM GREEN 2004 Operational Plan Initiative Actions Group: Southern Pacific Business Retention Team Initiative: Achieve Transport Targets for each area Owner: Business Retention Managers Click Here to GoTo Summary ID Date Opened GREEN YELLOW RED Key Action to Achieve Initiative Owner Status On-target for completion on original (or approved revised) due date Possible slippage or missed target - revised due date proposed Significant slippage or missed target likely Original End Date or Ongoing Revised End Date Comment (if required) Develop Transport Targets for BRM/OPS GREEN 11/18/2003 each facility Ongoing 11/18/2003 Assess current trending BRM GREEN Ongoing Utilize formula to set Available BRM GREEN 11/18/2003 Transports Ongoing 11/18/2003 Internal Buyoff BRM/OPS 11/18/2003 Inservice Internal resources BRM GREEN Ongoing 11/18/2003 Develop Metrics BRM GREEN Ongoing 11/18/2003 Account Plan Implementation BRM GREEN Ongoing See Initiative 5 GREEN Ongoing GREEN Ongoing 2004 Operational Plan Initiative Actions Group: Southern Pacific Business Retention Team Initiative: Implement Customer Service Initiatives Owner: Business Retention Managers Click Here to GoTo Summary ID Date Opened Key Action to Achieve Initiative Owner Status Customer Satisfaction Survey 11/18/2003 Developed Diana GREEN On-target for completion on original (or approved revised) due date YELLOW Possible slippage or missed target - revised due date proposed RED Significant slippage or missed target likely GREEN Original End Date or Ongoing 11/1/ /18/2003 Determine Sales Force Utilization Diana GREEN 25-Nov 11/18/2003 Develop Metrics GREEN Ongoing 11/18/2003 Review Results GREEN Ongoing 11/18/2003 Corective Action Plan Development Division Specific GREEN Ongoing 11/18/2003 Establish OGL by Division Division Specific GREEN GREEN 11/18/2003 Training CES/BRM GREEN Ongoing 11/18/2003 Employee Orientation GREEN 11/18/2003 Mandatory Meeting Training GREEN Revised End Date Comment (if required) Schertz, Texas EMS Page 2 Fitch & Associates, LLC

72 ATTACHMENT C: Sample Service Clinical Indicators 2004 Operational Plan Initiative Actions Group: Southern Pacific Business Retention Team Initiative: Develop Target Facility Account Plans Owner: Business Retention Managers Click Here to GoTo Summary ID Date Opened GREEN YELLOW RED Key Action to Achieve Initiative Owner Status 11/18/2003 Develop Transport Data by Customer BRM/PBS GREEN 11/18/2003 Develop Service Mix GREEN 11/18/2003 Determine Census information BR GREEN On-target for completion on original (or approved revised) due date Possible slippage or missed target - revised due date proposed Significant slippage or missed target likely Original End Date or Ongoing Revised End Date Comment (if required) This information will help drive type and payor mix 11/18/2003 Develop baseline BR GREEN Current Transport volume 11/18/2003 Validate Data with Customer BRM GREEN 11/18/2003 Assess Transport GAP BRM GREEN Business Gap is determined 11/18/2003 Assess Customer needs to grow Meet with the customer to determine how we BRM/MR GREEN business become preferred provider 11/18/2003 Assess and Develop Value BRM GREEN Proposition Political, financial etc benefit 11/18/2003 Assess Organizational Alignment with AMR BRM GREEN 11/18/2003 Build Account Plan/Strategy BRM/OPS GREEN 11/18/2003 Get local buyin with all internal resources to BRM GREEN Review with Internal resources implement 11/18/2003 Education Initiatives BRM/MR GREEN 11/18/2003 Inservice to present capabilities GREEN GREEN 11/18/2003 Develop Service Recovery GREEN Initiatives BRM/OPS/Fin/ Define if applicable GREEN 11/18/2003 Positioning Initiatives BRM GREEN 11/18/2003 Define Positioning strategy GREEN Schertz, Texas EMS Page 3 Fitch & Associates, LLC

73 APPENDIX D NAED Accreditation 20 Questions Guide

74 ATTACHMENT D: NAED Accreditation 20 Questions Guide T he Accredi tati on Self-Assessment Study must formally document and descri be: NO 1 All medical dispatch call-taking, dispatching, and supervisory workstations. NO 10 C or r ect case review and QI procedures validated through i ndependent Academy review. NO 2 C ur r ent Advanced Medical Priority Dispatch System (MPDS ) li censi ng of each EMD position. NO 3 C ur r ent Academy certification of all EMD personnel. NO 4 H ow Academy certification and case review wi ll conti nue to be maintained. NO 11 H ow EMS field personnel were oriented to the proper use of the MPDS and feedback r epor t. NO 12 L ocal policies and procedures for implementation and maintenance of the E M D program. NO 13 Current Continuing Dispatch Education (CDE) and EMD recertification program functions. Schertz, Texas EMS Page 1 Fitch & Associates, LLC

75 ATTACHMENT D: NAED Accreditation 20 Questions Guide NO 5 Full activity of Quality Improvement (QI) committee processes. NO 6 EMD quality assurance and improvement methodology. NO 7 Case review at the Academy s recommended number and percentage of randomly reviewed cases. NO 8 EMD quality assurance and improvement database. NO 9 Consistent, cumulative MPDS case review at or above the following percentages: 95% - case entry protocol compliance 95% - chief complaint selection accuracy 90% - Key Question protocol compliance 90% - Post-Dispatch instruction protocol compliance 95% - Pre-Arrival instruction protocol compliance 90% - Final code selection accuracy 90% - cumulative overall score NO 14 H ow police and fire dispatchers were oriented to the proper use of the MPDS (S.E.N.D. protocol). NO 15 P r oper ly establi shed local configuration of all MPDS response assignments. YES 16 H ow MPDS response assignments will be regularly reviewed and r ecommended changes approved. YES17 Incidence of all MPDS codes and levels. YES 18 Specific medical director oversight and involvement in EMD activities. NO 19 Sharing of nonconfidential data with the Academy. YES 20 Support of the Academy s Code of Ethics and practice standards. Schertz, Texas EMS Page 2 Fitch & Associates, LLC

76 APPENDIX E Demand/Drive Time Maps

77 ATTACHMENT E: Demand/Drive Time Maps Schertz, Texas EMS Page 1 Fitch & Associates, LLC

78 ATTACHMENT E: Demand/Drive Time Maps Schertz, Texas EMS Page 2 Fitch & Associates, LLC

79 ATTACHMENT E: Demand/Drive Time Maps Schertz, Texas EMS Page 3 Fitch & Associates, LLC

80 ATTACHMENT E: Demand/Drive Time Maps Schertz, Texas EMS Page 4 Fitch & Associates, LLC

81 ATTACHMENT E: Demand/Drive Time Maps Schertz, Texas EMS Page 5 Fitch & Associates, LLC

82 ATTACHMENT E: Demand/Drive Time Maps Schertz, Texas EMS Page 6 Fitch & Associates, LLC

83 ATTACHMENT E: Demand/Drive Time Maps Schertz, Texas EMS Page 7 Fitch & Associates, LLC

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