The National EMS Management Association (NEMSMA) has spent the past two years developing a set of national EMS officer competencies to provide future leaders with the tools they need to be successful. In the interest of the profession, the competencies will be made available to the entire EMS community, not just NEMSMA members.

NEMSMA is a professional association of EMS leaders dedicated to the discovery, development and promotion of excellence in leadership and management of EMS systems, regardless of system model, organizational structure or agency affiliation.

The project was a significant undertaking with a laudable goal. “We are going to set a path for the future of EMS,” says Ryan Greenberg, division chief of Hackensack (N.J.) University Medical Center EMS and chair of NEMSMA’s Leadership Competencies Project.

The issues addressed by NEMSMA include a lack of measurable expectations for EMS leaders, plus the fact that there is no national standardized training for leaders and thus no clear path for advancement for future leaders. NEMSMA determined that what is needed is a definition of leadership duties to prepare new managers and allow those working their way up the ranks to decide if they really want to take a leadership job in the first place. If so, what core competencies are needed to achieve this goal?

The committee developed the competencies in two parts: First it identified the levels of leadership; then it developed the expected educational, performance and improvement requirements for each level. These include basic leadership skills and traits, augmented with specific EMS knowledge. Individual organizations can supplement the training with their particular needs.

The committee identified three officer levels:

• Supervising offcers who provide frstline supervision to EMTs and paramedics in the field.

• Managing offcers who are responsible for managing major components of EMS organizations, or serve as division or unit heads or staff specialists responsible for administrative and clinical functions in EMS organizations.

• Executive offcers who provide general management and top-level leadership to an EMS organization.

As part of the oversight process, the committee presented its work to another NEMSMA committee for review. “We felt we needed a second—and in some cases third—set of eyes to meet the various needs of the people in our profession,” Greenberg says. The feedback was rewarding. “Reviewers stated it was more comprehensive than they expected,” he says.

Next steps

Now that the leadership competencies are in the final preparation stages before release, the committee’s next step will be to work on a credentialing process. “That’s down the road,” Greenberg says.

The EMS officer leadership curriculum will be built around the competencies while taking into account EMS leaders’ often busy schedules. “Part of the beauty is that we are not limiting where they get that training, as long as it meets the credentials. What we are hoping for is a variety of curriculum and a variety of learning applications—not just classroom-based, but a blended learning environment,” Greenberg says. “We don’t see people replacing education. We see a standardization occurring.” He hopes that the first course will be ready to launch by fall 2014.

Greenberg acknowledges that the work of developing the competencies and curriculum will never be wholly complete. “The expectations of an EMS leader will change in the next five to ten years. We want this to be a living, breathing document,” he says.

According to Greenberg, the impetus for the project was NEMSMA’s Management and Leadership Development in America: An Agenda for the Future. “We felt this is a critical part of the development of our profession. Many times managers don’t even know what is expected of them. We are really excited to provide this. Hopefully, it is only step one in helping [EMS] move forward,” he says.

Additional information about this project, including the competencies once released, can be found at the NEMSMA website (www.nemsma.org).

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The authors of the study concluded that the increase was due in part to inflation, the transition to a national fee schedule for Medicare ambulance transports and the continued growth in utilization of ambulances services.

Although the total number of Medicare fee-for-service beneficiaries increased just 7% from 2002 to 2011, the study found that the number of beneficiaries who received ambulance transports jumped 34%, increasing from 619 to 830 transports per supplier. The number of ambulance providers varied by state, from a decrease of 25% in Mississippi to an increase of 207% in Virginia. Nationally, the average number of transports per beneficiary increased 26%.

In addition, the number of ambulance suppliers increased 26%, up from 14,087 in 2002 to 17,776 in 2011. The most noteworthy increase was seen in ambulance suppliers that provide BLS nonemergency transports. That number nearly doubled from 2002 to 2011.

Dialysis-related transports increased most significantly, compared with transports to or from other origins and destinations. The number of dialysis-related transports during the study period increased 269%. They represented 9% of the total number of ambulance transports in 2002 and 19% of all transports in 2011. The report indicates that beneficiaries with end-stage renal disease (ESRD) “who received transports accounted for an increasing percentage of all ambulance transports,” even though the percentage of beneficiaries with ESRD who required transports remained relatively consistent from 2002 to 2011. The greatest increase in dialysis-related transports by state occurred in South Carolina. In 2002, 2% of all South Carolina’s transports were dialysis-related. By 2011, dialysis-related transports represented nearly half of the total ambulance transports for that state.

Although transports to and from hospitals represented a larger proportion of all ambulance transports, these increased at a considerably slower rate than did dialysis-related transports—just 55%. The number of transports from a residence to a hospital increased 51%, accounting for approximately half of all transports to a hospital. ALS emergency transports to a hospital increased 69%, while BLS emergency transports to a hospital increased 60% during the same time period.
The authors noted an increase in transports to nonhospital facilities. In particular, there was an 829% increase between 2002 and 2011 in visits by beneficiaries who received transports to community mental health centers.

According to the report, ambulance suppliers billed for greater average transport distances in 2001. The average trip length increased 1.6 miles (from 7.8 to 9.4 miles). Furthermore, suppliers billed for longer-mileage transports. At the same time, Medicare beneficiaries were no more likely to live in a rural location in 2011 than in 2002.

The authors noted that, while transports from 2002 to 2011 increased throughout the United States, utilization changes varied widely by state. Ambulance transportation utilization was the lowest in Utah (8%) and the highest in California (289%). Other states reporting exceptionally high increases included Virginia, South Carolina, Georgia and New Jersey. Ten states had increases of 100% or more.

How the study was conducted
To determine the extent to which the utilization of ambulance transports changed from 2002 to 2011, Medicare Part B claims for ambulance transports from 2002 to 2011 and the Medicare Part A and B claims that were associated with these transports were reviewed. The authors also examined enrollment data for all Medicare fee-for-service beneficiaries. The characteristics of beneficiaries, suppliers and transports were analyzed and the percentage difference between 2002 and 2011 was calculated. Changes in utilization were also calculated by state.

Only transports for which mileage was also billed were reviewed. Transports billed by institution-based ambulance providers were excluded.

The authors did not review the medical records of beneficiaries who received transports. Therefore, no determination was made whether the transports were medically necessary or met coding and documentation requirements for coverage.

Conclusion
The report does not contain recommendations. However, the OIG plans a subsequent analysis of ambulance suppliers that exhibited “characteristics of questionable billing in the first half of 2012, as well as geographic areas with high numbers of these suppliers.”

The speculation among EMS leaders is that, while the report primarily focuses on the potential for fraud and abuse in the area of BLS transports—and more specifically, dialysis transports—all ambulance transport providers should be aware that the additional scrutiny from the OIG may generate increased ambulance audits throughout the industry.

Not everyone sees this as a bad thing. “Although I know this report will be discussed at many levels of the EMS industry, I see it as a positive sign,” says Don Lundy, BS, NREMT-P, president of the National Association of EMTs. “EMS has entered the world of healthcare and that is a good thing. We are becoming an integral part of the process, instead of—dare I say it?—ambulance drivers. With that comes great responsibility from all of us in the ambulance industry to ensure that how we approach our patient care and business practices are, at all times, both ethical and moral.”

The OIG is accepting comments or questions about this report. However, they must be received within 60 days of the September 24 publication date. Refer to report number OEI-09-12-00350 in all correspondence.

The entire report can be downloaded at the Document Repository at www.emsinsider.com.

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Although there were no related studies involving out-of-hospital medication errors, one could extrapolate that the error rate was at least as bad, if not worse, according to Sedgwick County (Kan.) EMS Director Scott Had-ley. He points to the additional risks of practicing medicine in the field:

• Emergency situation;

• No external crosscheck;

• No electronic decision support;

• High-risk medications; and

• Drug shortage issues and substitutions.

As a result, Hadley and his Sedgwick County colleagues began to look for ways to decrease medication errors. They started by trying to understand the frequency of medication errors in their system. In an internal survey, 100% of the 107 EMS providers who responded said they always verify for accuracy before giving medication. Yet, 60% admitted to making a medication error, and 40% said they didn’t make an error that they know of—“that’s critical,” Hadley says.

Survey results were supported by evidence collected during the systems credentialing process: Some providers were unknowingly making medication errors. Significantly, they found that 31% of those committing a medication error had no idea that they had made a mistake. Even though they verbalized the correct medication and dose, they administered the incorrect dose.

Identifying the scope of the problem was a good start, but how to address it? Sedgwick County’s EMS Quality Improvement Manager, Paul Misasi, reached out to other systems, conducting a survey to determine if other EMS agencies had found the same problem. Of the 178 respondents, he learned that 96% use a verification process before administering medications. The majority use the “Five Rights”—the right patient, dose, medication, route and time. Interestingly, only 30% of the agencies said the verification process is done verbally. The majority of the time, the EMS provider ticks off the five rights mentally. Seventy percent said that’s how they were taught to perform the task.

Of those who said they used the Five Rights, only 60% said they follow it exactly. When asked if a one-person, mental checklist is adequate to prevent medication errors, slightly better than half said it was. Eight out of ten agreed or somewhat agreed that a two-person verbal process would be more successful.

After reviewing the results of the two surveys and other information, Sedgwick County EMS, in collaboration with its medical director, Sabina Braithwaite, MD, MPH, FACEP, developed a process to help identify and correct for system errors. The Medication Administration Cross-Check (MACC) is a one-page, easily remembered, standardized method for administering medications every time for every medication. Error traps, written into the process, help to create “pause points” that ensure safety. The MACC requires two providers to verbalize the procedure in a feedback loop.

It’s similar to asking someone else to proofread your own work: The second person often catches errors inadvertently caused by what was intended versus what was actually accomplished. “The second person is actually authorizing the medication,” Hadley says. “For the majority, it does a good job.”

The MACC doesn’t require a paramedic partner for it to work. “Even though an EMT cannot deliver the dose, he or she can read,” Hadley says.

Beta testing

There were some initial objections to using the MACC. Some providers were concerned that it would delay treatment. “Is it better to give the wrong dose faster or the right medication slower?” Hadley asks. Internal studies demonstrated that the two-person process takes approximately 20–25 seconds. “Not a lot of time,” he says.

Other concerns identified during the beta testing included a perception of a lack of professionalism or competency on the part of the paramedic, if the MACC is used in front of the patient. To combat this, EMS providers were instructed to explain to the patient what they were doing, telling them they are going to converse with their partner on a safety check regarding the medication they are about to administer. “How many people intervene and tell a pilot not to do a safety check?” Hadley says. They found that patients were receptive and didn’t think less of the provider’s abilities, he reports.

Success helped breed compliance. “Those who use the verbal verification process report 50% fewer errors than those who verify mentally,” Hadley says.

Results

Identifying errors that do not occur is a challenge. Sedgwick County began tracking medication errors prior to implementing the MACC in order to establish a baseline. By comparing historical data to data collected after the MACC was implemented, Hadley says they estimate the MACC has prevented about 15 potential errors so far. Since March 2012, when the program was implemented, the average number of errors pre-MACC was 1.63 per month. Post-MACC errors dropped to 1.33 per month. “The power is in finding the events that didn’t cause harm,” Hadley says. He admits that determining the exact number of errors that were avoided is difficult because the medication errors prior to using the MACC were self-reported and could be under-represented.

Using the category index developed by National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP), Sedgwick County can see that the majority of the errors that occurred (45%) fell into Category C, meaning the wrong medication reached the patient, but no harm was caused. Three percent fell into a more serious category, contributing to temporary harm or requiring intervention. None of the errors resulted in permanent harm or death of the patient.

To help track medication errors both internally and nationally, Sedgwick County enters its data into the EMS Voluntary Event Notification Tool (E.V.E.N.T.) at http://event.clirems.org. The online tool is a program of the Center for Leadership, Innovation, and Research in EMS with sponsorship provided by the North Central EMS Institute, the National EMS Management Association, the Emergency Medical Services Chiefs of Canada, the National Association of Emergency Medical Technicians and the National Association of State EMS Officials.

The purpose of E.V.E.N.T. is to improve the safety, quality and consistent delivery of EMS, through the collection of data submitted anonymously by EMS practitioners. The data is used to develop policies, procedures and training programs to improve the safe delivery of EMS. The developers say that a similar system used by airline pilots has led to important airline system improvements based upon pilot-reported “near miss” situations and errors.

Mitigating errors

In the past, identifying an error usually resulted in some form of punishment for the provider. Typically the severity of the punishment was based on the degree of harm to the patient. As a result, few providers were willing to report an error and few systems could identify areas of improvement.

“We cannot keep blaming and shaming people who make an error. We have to fix it,” Hadley says. That’s why Sedgwick County subscribes to the Just Culture philosophy. “People must feel confident reporting errors,” he says. “[Self-reporting is] critical to making system-level improvements.” If the mistake could happen again tomorrow, it is probably not the fault of the individual.

Just Culture uses a system of peer review. However, Hadley notes that peer review protection laws differ from state to state, and need to be taken into account when developing a medication error reporting system. “Some [peer review programs] are discoverable,” he says.

Since implementing Just Culture at Sedgwick County, Hadley says that more and more providers are coming forward to report medication errors. “Employees don’t come to work to make mistakes. Mistakes will happen. We want to know what happens in our system so we can improve,” he says.

For those interested in the MACC and supporting documents, please contact Hadley at shadley@sedgwick.gov or Misasi at pmisasi@sedgwick.gov.

The post Tracking Medication Errors appeared first on EMS Insider.

EMS Insider has launched an all-new website, combining news, exclusive articles, an archive of back issues and a handy repository for supporting documents, all into one location. As with the printed publication, the focus of the website is news and articles that EMS managers, supervisors, chiefs and medical directors can use, including in-depth reports, research, legislative updates, announcements and industry news. But the website allows us to add value to your Insider subscription through immediate updates to developing issues, breaking news alerts and one-click access to related content.

Because news never rests, the Insider website will always be a work in progress, with content added frequently, including ongoing updates and breaking news stories. Nearly all of the content will be exclusive to EMS Insider subscribers, accessible via a one-time quick login process. Subscribers will be able to access a digital version of the current issue and back issues as well as perform various other functions. All subscribers will continue to receive the printed version of the newsletter unless they opt out.

The new site correlates with the launch of an e-newsletter, EMS Insider: Update, which features a summary of the most relevant stories and related links and resources. A Facebook page and Twitter account round out the Insider’s new digital footprint.

The value of subscribing to the EMS Insider is that it takes the reader deeper into the topic than popular newscoverage, with links to related websites and documents that give EMS managers the tools to quickly and efficiently implement changes within their own organization.

With the new website, readers have an added benefit—a repository of archived documents, PDFs, spreadsheets and PowerPoint presentations provided by your colleagues as supporting documentation to Insider articles. These documents, available for subscribers to download and use, include a variety of protocols, checklists, guidelines, presentations and procedures to something as specific as a letter from OSHA outlining hospitals’ responsibility to decontaminate backboards before returning them to EMS agencies. Readers will also find white papers, analysis tools and research. Searchable by date and subject, these documents are available to help busy EMS leaders and medical directors quickly and easily find and use what has already been developed—saving precious time and money.

Putting news in context is what the EMS Insider does best, especially as it relates to healthcare reform. Only the Insider keeps EMS leaders current with the various challenges and opportunities provided by the changing healthcare landscape, offering insightful articles on how to contract with accountable care organizations (ACOs), legislative concerns and how to resolve them, and much more. The website consolidates all of the healthcare reform articles published in the monthly issues of the Insider—an invaluable resource for prehospital managers and directors.

Since its acquisition by James O. Page and his company, JEMS Communications, in 1988, the EMS Insider has been the premier publication for EMS leaders who wish to remain knowledgeable about the business side of EMS. The publication has sought to help EMS managers and supervisors tackle the unique—and not so unique—issues facing them on a daily basis.

Content for the Insider is written by Insider staff who continue their commitment to the EMS community. Specialty articles are provided by industry experts. Regular columnists include Allison J. Bloom, Esq.; Jerry Overton; W. Ann Maggiore, JD, EMT-P; Jay Fitch, PhD; R. Michael Scarano, JD; Dave Williams, PhD; Doug Wolfberg, JD; and Matt Zavadsky, MS-HSA, EMT. Special features from additional EMS experts offer specific how-to information for busy professionals who need more than just an overview of an issue.

The EMS Insider is owned and operated by PennWell Corporation, of Tulsa, Okla. PennWell also publishes the Journal of Emergency Medical Services (JEMS), FireRescue Magazine, Law Officer Magazine and Public Safety Communications, among others. PennWell is also the producer of the EMS Today Conference & Exposition.

Visit the new Insider website at www.www.emsinsider.com, “Like” us on Facebook at facebook.com/emsinsider  and follow us on Twitter at @emsinsidernews.

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