We all know federal privacy regulations limit the use and disclosure of patient information by EMS agencies that are “covered entities” under HIPAA. But how does HIPAA apply to the mass casualty incident (MCI) where there are multiple victims, our resources are taxed and the situation isn’t as controlled as with a traditional EMS patient situation? HIPAA was never intended to interfere with the provision of patient care and the “customary and essential communications” necessary for patient care in any situation—including MCIs.

First, HIPAA specifically allows for the sharing of protected health information (PHI) about a patient when it must be shared among healthcare providers for treatment purposes, even where the patient doesn’t give permission to do so. So it’s permissible to share PHI among fire and EMS agencies or others involved at the scene in the care of patients of an MCI.

Second, HIPAA also allows for “incidental” uses and disclosures of PHI in many healthcare situations—even in cases where other patients and those not involved in a patient’s care may hear or view a patient’s PHI. These incidental disclosures are recognized as a “byproduct of an otherwise permitted disclosure.”

The Office of Civil Rights, which enforces HIPAA, states it very well in a Q-and-A posted on its web site: “Many customary healthcare communications and practices play an important or even essential role in ensuring that individuals receive prompt and effective care. Due to the nature of these communications and practices, as well as the various environments in which individuals receive healthcare or other services from covered entities, the potential exists for an individual’s health information to be disclosed ‘incidentally.’” The OCR notes this can occur where a patient overhears conversations between and among healthcare providers and other patients that are unrelated to that patient’s care or sees PHI that’s about other patients.

Examples of incidental disclosures the OCR gives are a hospital visitor who overhears a discussion about a patient, or where one patient glimpses another patient’s information on a sign-in sheet or nursing station whiteboard. All HIPAA requires is that the covered entity have “reasonable safeguards” and minimum necessary policies and procedures to protect the patient’s privacy in place. This means that EMS agencies should take practical steps to limit the likelihood of the incidental disclosure and when there’s a disclosure, to only disclose the minimum amount of PHI necessary for treatment.

So how does this apply in an MCI? Use common sense, but don’t let HIPAA interfere with the standard practices used to manage the situation and to deal with the victims or treat the patients involved. There will be victims involved in the MCI (injured and uninjured) who are walking around interacting with EMS providers. You can’t usually keep them separated or set up “HIPAA safe zones” or go out and buy portable “cones of silence.” You do what you need to do to effectively deal with those involved and use common sense when it comes to on scene communications and information sharing. Follow your agency’s privacy policies, which should recognize that the likelihood of incidental disclosures of PHI are more likely and, in some cases, can’t be prevented in an MCI.

Another example of an incidental disclosure in an MCI is the use of a “multiple person refusal form,” when it’s simply impractical (and could interfere with patient care) to get a separate refusal form signed on every victim of the MCI. A.J. Heightman, MPA, EMTP, editor-in-chief of JEMS, has been using this type of form for years in his nationallyacclaimed MCI courses. This simple form has a refusal statement at the top of the form, and numbered rows below the statement where basic information about each victim is recorded, such as the person’s name, address, phone number and vital signs, the initials of the person processing the refusal, and the person’s signature acknowledging they’re refusing further treatment and/or transportation. It’s simple, easy to use, and keeps the paperwork to a minimum at a time when paperwork shouldn’t be the priority. Yes, the person signing the multiple refusal form may glimpse at the names of others listed and maybe some information about them, but the risk of PHI escaping is low since that person is unlikely to remember the names or retain the information seen. And in our view, the use of this form would clearly fit within the permissible incidental disclosure provisions of HIPAA. Can there be some reasonable safeguards to minimize this HIPAA risk? Sure, use a blank piece of paper to cover the names of other patients who signed the form when you present it for the next signature. If a patient later requests a copy of the form, you can redact the names and information of the other signers before releasing the copy.

The key point here is that HIPAA regulations are flexible and recognize that not every patient situation can be treated the same in terms of HIPAA. These regulations and OCR enforcement policy allow for unique situations like this and don’t set up strict limits. It’s also clear that those who wrote the regulations never anticipated the unique problems confronted by EMS in MCI responses.

It all comes down to common sense and what’s reasonable given the particular situation. With one or two patients, it’s certainly the reasonable approach to obtain separate refusal forms for each person refusing care and keep any identifable patient information separate. But by their very nature, incidental disclosures should be expected in an MCI more often than in a typical non-MCI situation and the multiple person refusal form may be a reasonable approach that shouldn’t run afoul of HIPAA. The key is to have clear privacy policies that make good sense. Educate your EMS staff on the practical steps to minimize the improper disclosure of patient information in all types of responses that they’ll confront, including MCI.

Attorneys Doug Wolfberg and Steve Wirth, founding partners of Page, Wolfberg & Wirth, LLC, a national EMS industry law firm. Visit the firm’s website at www.pwwemslaw.com. Check out the all new Fourth Edition of The Ambulance Service Guide to HIPAA Compliance recently released and now available from PWW.

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As supervisors, managers and leaders, we have a responsibility to participate in preparing our practitioners for practice. Likewise, we have a responsibility to participate in succession planning. We should be preparing practitioners who want to grow professionally to fill supervisory, management and leadership roles.

There are various classes available and although they’re a valuable component of professional development, most have high costs associated. In-house programs have costs as well, not the least of which is the time and expertise needed to design and develop them.

But there’s another resource we often overlook. We frequently use simulation to develop and assess only two domains: the psychomotor domain (i.e., skill) and the cognitive domain (i.e., knowledge). A third domain, the affective domain, is defined by behaviors that reflect and demonstrate attitudes and values. I suggest that, with careful consideration and well-designed scenarios, we can use simulation to develop and assess values and attitudes in addition to knowledge and skill. There’s still a cost, but the returns are worth the investment.

Role-Play & Scenario Design

Thinking of simulation probably brings to mind a sophisticated manikin that presents lung sounds and cardiac rhythms, with a blood pressure arm and an IV arm. Although an excellent tool for teaching, practicing, developing and evaluating clinical knowledge and skill, I’d like you to think of another aspect of simulation: the live actor. Patient actors have been used in medicine for some time, but how about using other sorts of role players to help us with developing supervisory, management and leadership skills?

It takes some thought and consideration when crafting the scenario, but using this methodology is a very productive tool. The National Fire Academy uses role-play to great effect during several of the classroom exercises in its Management of EMS course. The challenging and fun exercises allow people to experience the stress, uncertainty and immediacy of dealing with difficult employees in a “safe to fail” environment.

The first step in the scenario design process is completing a gap analysis. What does a supervisor need to know that’s different than an EMT or medic’s roles and responsibilities? What are the expected supervisory behaviors defined in your organization’s rules, regulations, policies and procedures? Are all the supervisors meeting organizational expectations? If not, why not? Once you’ve diagnosed the reasons, you can use education and training to address some of the gaps.

Enlist the assistance of training and education experts, both inside and outside your organization, to help with writing the performance objectives for the scenario that address identified performance gaps. Next, design the overall concept for the scenario and then develop the rest of the details, the scripts and various responses for your role players. Finally, beta test the activity, make any adjustments and implement your program. You should also be able to get the activity approved for continuing education.

Example Scenarios

Scenario for evaluating affective domain competency: A BLS ambulance crew responds to a report of a “sick person.” On arrival they find an elderly woman in a hospital bed in the living room of a small home. She’s clearly very sick. As they begin to examine the patient, a family member comes into the room and says, “You don’t need to do all that stuff, you just need to get my grandma out of here. You need to take her to the hospital right now!” The EMTs have to demonstrate compassion, empathy, caring and diplomacy—all areas of affective domain competency—in order to interact effectively with the family member.

In this scenario, the clinical component is important but it’s not only taking care of the elderly woman that matters. It’s equally, perhaps more importantly, about how the EMTs deal with the family member.

Scenario for evaluating clinical and supervisory, management and leadership skills: An ambulance staffed with a paramedic and an EMT responds to a report of a cardiac arrest in a supermarket with bystander CPR in progress. The ambulance arrives on scene and within a minute the ambulance calls for a second ambulance and a supervisor to respond immediately. When the supervisor arrives he finds the ambulance parked in front of the supermarket with the paramedic sitting in the front seat. The second ambulance arrives on scene.

In this scenario, the paramedic in the first ambulance is a role player and part of the scenario. The EMT and the second crew are being evaluated on their ability to run the cardiac arrest. The supervisor is being evaluated on his supervisory, management and leadership skills in dealing with the EMT, the responding crew, and the paramedic who is just sitting in the ambulance.

In these two scenarios, your design and your role players are the keys to an effective learning experience and performance evaluation. With well-thought-out and carefully designed scenarios and some willing role players, you’ll be able to demonstrate that simulation isn’t only about skills and knowledge. You can contribute to creating three-dimensional practitioners and prepare new supervisors, managers and leaders for success.

Michael Touchstone, BS, EMT-P, is the regional director for the Philadelphia Regional Office of EMS and president of the National EMS Management Association.

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The unfortunate situation exists today that if you were to go out into any crew room and ask the average paramedic whether they would ever aspire to be a supervisor or an officer one day, they would probably laugh out loud. We have to ask ourselves why that is. Although most, if not all, paramedics entered the profession to treat the sick and injured in a pre-hospital setting, why is it that many very qualified paramedics, who are also great leaders in their own right, do not want to get promoted?

Let me ask you this: What would happen if the senior leaders in your agency all bought into a lottery ticket and won big? While some might stay for the thrill of the job or the dedication to their sworn duties, my guess is that most of them would be off to St. Somewhere Hot. So this begs the question: Who would step into their boots? One tragic real world example of this was 9/11, when FDNY lost a large amount of its senior command structure in one major incident.

It is important for EMS agencies to develop a culture in which employees want to move up into leadership ranks. Employees need to see the short- and long-term rewards of preparing themselves for advancement. Employees need to know that they will be rewarded for their actions in developing their agency.

Leaders today have to plan for their organization’s tomorrow. While there are some EMS agencies that have great succession plans already in place, many still have work to do in this area. When it comes to developing a strong succession strategy, EMS is not isolated in its lack of planning; succession planning is something many professions have difficulty with.

Unfortunately, succession planning is either not a priority in many EMS organizations or it occurs too late, after key people have already left.¹ Many agencies have too many contingency plans to count, yet they do not have a plan in place to replace leadership ranks. It is incumbent on current leaders to prepare their successors for when they move on. If you are in a management or leadership position, you owe it to your organization, your community and our industry to develop a succession plan for your role, but day-to-day operational commitments often keep organizations focused on the present with little thought toward the future.²

The National EMS Management Association (NEMSMA) has suggested that, as the current generation of EMS managers ages, there is growing concern about how the experience and knowledge of leaders will be passed on to the next generation. The concept of succession planning is foreign to many EMS organizations. One key informant said, “We have no idea where the next generation will come from. We’re not developing them. We’re not passing on our knowledge. Are they going to have to start all over again?”³

In EMS, I have found the topic of succession difficult to research due to the fact that there appears to be little in the way of literature on the specific subject. Part of the reason for this is that, as a profession, EMS is relatively young. Modern-day EMS as we know it has only been around since the late 1960s or early 1970s. This means that many organizations are hitting their first major loss of staff, which includes a number of current leaders as well as those who are in a position to be promoted.

The trend has been for senior executives to retire at an increasingly younger age, expanding their chances for career revivals or consulting work. A survey conducted in 2003 showed most hospital and health system CEOs expected to retire within 10 years, and about a third planned to retire within five years.⁴ Several of those leaders who were planning on leaving did not believe that there was anyone equipped to replace them in their positions:

Building a strong succession plan in EMS is difficult for a number of reasons, including the fact that staff members who started in this profession when it was in its infancy are retiring or resigning due to their age and the toll the job has taken on their bodies.⁵ Indeed, NEMSMA research has found that, over the last decade, EMS leaders have expressed concerns about EMS manager development with growing urgency. That urgency is being fueled by the aging of the first generation of EMS managers, a lack of uniform management development and succession planning, the need to manage growing system complexity and the general lack of attention, coordination and leadership in the area of management development.⁶

Another issue is the fact that continued education has not been effectively pushed in EMS. EMS is a young industry lacking formal education programs for EMS management. EMS professionals who wish to pursue an actual degree in EMS have very limited choices, and programs with Bachelor’s or Master’s level programs are still quite difficult to find.⁷

Another reason that has been suggested for the lack of qualified managers and leaders is the fact that, traditionally, promotions have been based on street experience or clinical skills, rather than management skills or business acumen. Due to the fact that many of today’s senior managers were promoted in such a way, or merely belonged to the “old boys club,” a number of them do not believe that formal education is important and therefore do not encourage their junior staff to take courses other than those technical ones required for their licence or certificate levels.

Many of those who started their careers in the ’70s have begun leaving the profession in recent years, creating a brain drain that is sure to affect the future of EMS. In order to sustain organizational performance, EMS agencies should start planning now for the need to systemically replace key management positions.⁸ Agencies can no longer simply wait until there is a vacancy, put out a posting or an expression of interest, and fill it with the best out of those who applied. We must develop potential leaders from day one of their careers to ensure that members of the next generation are adequately prepared to step into these new roles as they become available.

Developing staff from day one allows organizations to prepare the next generation. Career development and succession planning go hand-in-hand, and when they are linked to the organization’s vision, employees can align their personal aspirations to the organization’s current and future needs, creating a mutually beneficial environment.⁹ Through inclusion in the organization’s planning and development means, staff members are part of the organization and have a sense of ownership as opposed to simply following the corporate direction. When employees understand what the organization needs and how their personal career aspirations ft into the overall plan, they become personally invested in the long-term health of the agency. And as employees grow within the organization, they continue to contribute to its evolution. When a strategy of grooming employees for future roles is implemented, the company can keep the people it needs to succeed.

Succession planning not only is a way of sustaining an organization, but it also decreases the amount of external recruitment that will be required in the future, allowing organizations to deal with staffing levels by looking in a broader fashion at what they currently have. Succession planning initiatives can help organizations address the seemingly separate issues of recruitment, retention and planning an organization’s future.¹⁰ In these tough financial times, it would appear that after investing in an employee for several years, an organization would want to keep him or her for as long as possible.

It is incumbent on the current leaders of today to prepare their successors for when they move on; thus protecting their agency, their stakeholders and ultimately their communities. With this in mind, my hope is that one day staff will be coming to us to ask how they might move up within their agency as opposed to the crew room full of laughter when we pose the question to them.

PASCAL RODIER has more than 25 years of service in Canadian EMS. He has worked as a front-line paramedic in Metro Vancouver, B.C., and has held various leadership ranks over the last 12 years. Pascal’s focus in recent years has been on the national development and expansion of responder interoperability. He holds a Master of Arts degree, with a focus on health leadership, from Royal Roads University. Reach him at pdrodier@gmail.com.

REFERENCES

The post We Just Won the Lottery, We’re Out of Here! appeared first on EMS Insider.

I thought it was a bit odd when I first saw name of this publication: EMS Insider. I was wondering what A.J. Heightman was thinking when he asked an “outsider” (I have only been a recipient of EMS services, not a provider) to write something to be read by the “insiders.” But I do understand the way his mind works. Outsiders tend to look at things differently than insiders do and sometimes the outside perspective might make you think about things a little differently.

Over the years I have been accused of throwing around four-letter words, and that is true. In fact, here is a favorite four-letter word that many people do not think about often enough. Are you ready for it? Bias. Years ago I wrote a piece on this word with the kick off statement “everyone has a bias!”

Holy moly! (Two more four letter words). I get the occasional “nastygram” after I write things, but this particular article got me quite a few negative comments, including my favorite of the group, which read, “Dear Mr. Graham. How dare you say I have a bias? I can assure you that I do not have a biased bone in my body!”

So I typed a response, but I did not send it because these emails seem to have a life after initial transmission. But had I sent it, it would have read, “Not only are you biased—you’re stupid!”

Now before you send me a nastygram of your own regarding this comment, let me explain. If you salt your food before you eat it; that is a bias. If you prefer Ford over Chevy; that is a bias. If you prefer home fries over freedom fries; that is a bias. And there is nothing wrong with being biased, so long as that bias does not negatively impact anyone else.

The bias that I see almost daily involves another four-letter word: Risk. If you have been to any of my live programs over the last 35 years, you know I talk about risk (and specifically how to manage risk) a lot. The bias that many people have is that too many people think risk and risk management are solely related to “the safety stuff.”

To be fair and accurate, if you have this view you are partially right. Understanding the importance of safety and building control measures (policies) to keep people safe is part of an overall risk management strategy. But risk management is bigger than the safety stuff. It is bigger than the ergonomics stuff. It is bigger than the insurance stuff. It is bigger than the subrogation stuff.

Risk is ubiquitous. Everything you do in life, and everything you do in EMS operations, involves a level of risk. If you are hiring people, there is a level of risk involved. If you are firing people, there is a level of risk involved. If you are writing a report following a mass casualty incident, ambulance accident or patient transport, there is a level of risk involved. Even when you are driving an ambulance there is a level of risk involved.

So what can you do with all of these risks? You can eliminate some risks. You can share some risks. You can avoid some risks. And you can transfer some risks. When all of these are considered, you have a risk management program.

The one thing that I don’t want you to do is to run from risk. In the early ’80s, early on in my career as a young lawyer, I got into this discussion with some chiefs and sheriffs. There were two major lawyers who defended police agencies around California, and I wanted to get part of that market. So I sent out a flyer to a group of law enforcement executives to come to my program at a law enforcement conference where I promised I would should them how to eliminate police civil liability. They showed up and I told them the secret. If you don’t want to get sued, don’t do anything. Don’t answer the phone. Lock the front doors on your station. And whatever you do, don’t roll on any calls.

Some of them got the joke, some did not.

The point is we cannot eliminate risk. All jobs in public safety involve risk, but running from risk will cause your agency nothing but greater problems.

All of us in the high-risk profession of EMS response and public safety must understand the breadth and the depth of real risk management and recognize how much can be done to manage the real risks you face.

Here is a definition that I will be using in all future writings, and I hope you will use this in your high-risk job in EMS operations:

Risk management is any activity that involves the evaluation of or comparison of risks and the development, selection and implementation of control measures that change outcomes.

Or more simply stated: It all gets down to what I call “RPM.” You must be able to recognize the real risks you face, personally and professionally. After recognition, you need to be able to prioritize these risks in terms of frequency and potential severity. And then you must mobilize (act) to do something to address the given risk. It all gets down to RPM: Recognize, Prioritize, Mobilize.

Well, that wraps it up for this initial piece. I look forward to the next opportunity to give you some further thoughts on risk management. Until then, you can take a look at some of my Tips from Lexipol at www.Lexipol.com. Some of those might be of some value to you as an EMS Insider.

Gordon Graham is a 33-year police veteran and the president of Lexipol. He is a risk management expert and a practicing attorney. He is one of the most sought-after speakers in public safety and has presented a common sense approach to risk management to hundreds of thousands of law enforcement professionals around the world.

The post Managing Risk appeared first on EMS Insider.

Hi, nice to meet you. I was just elected to your local board of commissioners. In just a few weeks I’ll be making decisions that affect whether your department grows and prospers, struggles to hold onto status quo, or degrades and actually starts slipping backwards.

I’m the new guy, and I’m holding your department’s purse strings. But don’t worry. I think public safety is just as important as the next guy does. I mean, who isn’t proud of our police cars? Who doesn’t think fire engines are neat? An ambulance? Ugh. That’s a little different. No one wants to face their own mortality, but I guess people need them.

Now keep in mind, I didn’t get elected on a public safety platform. Maybe I was elected on concerns about local zoning issues and commercial development on the north end of town. Maybe I was elected over a bond issue or protection of a watershed. Maybe it was all about education, local transit or simply reducing government to its smallest possible size.

But hey, like I said, everyone thinks public safety is important. Everything should be just fine, right?

So what would you say to this newly elected leader? Does it matter if he or she knows anything about your department and what you really do? Does it matter if they have more than just a casual understanding of EMS and the unique needs and challenges of your service as compared to police and fire?

Let’s assume it does matter. Let’s assume that the more thoroughly they understand your department and EMS in general, the more likely they are to support you in the ways that you need them to.

How then, do we talk to them? How do we help them understand? Is it their responsibility to come to us and learn? Should we sit and wait for them or should we drive the process? Do we lean on our post-9/11 hero status to exert our importance and relevance? We can certainly tell them how important we are, and we probably will. But every other entity that looks to them for funding will be saying the same thing.

In EMS we have some unique ways to communicate not just what we do and how we do it, but more importantly, the impact that we have on the very people we’re all ultimately here to serve. We don’t just have to tell them. We can show them. And we can do it in several powerful ways.

There are a number of tools we can use to achieve this goal. An added benefit to each method is that we’re not only showing our elected officials, but also our collective community members as well. And when we talk to our community members, we’re strongly reinforcing our message to our elected officials. And if there’s anything elected officials pay attention to at election time, it’s what the voters are talking about. Have you given those voters a reason to talk about the importance of the service you provide? Simply put, if you’re talking to your community, you’re also talking to your elected leaders.

Method 1: Engage Local Media

Emergency responders have a long history of putting up a wall to media when they arrive on scene to cover an event. That could be one of the biggest tactical errors we make as public safety entities. There are undoubtedly reasons why some may feel resistant to media coverage of a scene. Maybe there’s an assumption that they’re just there for exploitation. Certainly we’re inclined to protect the dignity of our patients. Maybe we’re concerned about their safety, or maybe it has more to do with not wanting to subject ourselves to the scrutiny of our peers.

Regardless of the reasons for resistance, let’s look at the benefits of cooperative engagement with media. Keep in mind that just like us, the reporter was dispatched to the scene of the call to do a job. The best case scenario for them is acquiring a few facts from the authorities on what happened and what’s being done about it. That equips the reporter to provide his or her audience with the most accurate narrative on the incident with information directly from the people in charge. That gives their media outlet credibility, which drives viewership. And viewership drives advertising sales. That’s their motivation.

Our motivation? That’s easy. By cooperating, we allowed them to portray us as capable professionals who care about the community, and we demonstrated that we are on scene and mitigating the problem. We have instilled confidence in our community by carrying ourselves in a knowledgeable and professional way. By showing our community, we have also shown value and worth to our elected officials. You could never even begin to buy the commercial time you just got on the 6 o’clock news.

It’s surprisingly easy to engage media in an effective way, but there is also plenty to learn. Search for Public Information Officer (PIO) courses that may be offered by your state emergency management offices or other local entities.

Method 2: Engage Social Media

Let’s make this a two-step process. Step one: turn off the urge to aggressively run off the citizen with the cellphone, camera, tablet or drone. Everyone has a right to record anything out in the public domain. It’s not a HIPAA issue, and it’s not for us to stop. So what if someone posts a clip of us on Facebook? At least that clip shows us taking care of our patient instead of letting our emotional and aggressive reaction become the story. If you want to advocate for your patient, minimize their exposure instead of fighting the photographer.

Step two: create social media channels for your department. There are thousands of department examples to draw from. Reach out to your community. It’s how people communicate now. Show them who you are, what you do and why you do it that way.

Method 3: Put On a Survivor Celebration

Cardiac arrest resuscitation with good neurological outcome has increased dramatically in many areas of the country. Now that’s certainly good for a variety of reasons, but included in that list is the fact that it provides a unique opportunity to demonstrate value to your community in a way that’s easy to understand, yet has very dramatic impact.

Think how moving it would be to have a survivor speak to your board. Here we have a person who was clinically dead, but is now standing there talking about how much your staff means to them. And they’re not using charts, facts and figures. They’re speaking from their hearts in a way that connects from human to human. They personify the value of EMS, and they want your elected officials to hear them.

There are a variety of ways to conduct a survivor celebration. It can be as simple as a survivor and family speaking alongside their responders at a council meeting. Or it could be a small media event that offers photo ops, interviews and maybe even hands-only CPR demonstrations for media.

For larger systems with higher numbers of survivors, the celebration may take the form of a larger community event that stands on its own. An important component to such an event is inviting elected officials, including having the mayor or chair of the commissioners serve as a host or speaker.

There’s another reason to have them speak. Elected officials typically make a lot of appearances. Make sure you coordinate with their staff members so that you can provide talking points for them prior to the event. This actually gives you a method to help shape the script that your elected officials will use to talk about your department. How many other opportunities do you have to tell the people who fund your budget what they should be saying to the public about your department?

Granted, cardiac arrests represent a tiny percentage of our everyday calls. And there are some responders who may find it disingenuous to prop up a cardiac arrest survivor as representation of an entire EMS system’s work. That sentiment is well understood, because there are so many positive impacts made every day by more routine interactions, and it’s important we find ways to cite those accomplishments. But cardiac arrest survival is worth consideration for a public celebration because of the powerful impact that their stories have. People can relate, and those people include elected officials.

Method 4: ‘State of EMS’ Address & Ride Along

National EMS Week is a really good time to request 15 minutes to address your local board. Ask them to declare a local EMS Week. Then spend 10 minutes reporting your system’s performance. Show them some data points that are important for EMS to measure and that benchmark your department’s performance. Help them learn that there are some really important measures beyond simple response times. Then show them some things you’re working on. Next year remind them about those things and show how you’ve made them better. It’s a data-driven world. Collect it and use it.

Don’t forget to offer a ride along. Nothing speaks to the multitude of challenges and objectives in EMS more than those elected officials seeing it firsthand.

Using these combined methods, we have spoken to both the heads and hearts of our community and elected officials. We didn’t just tell them we’re important, we demonstrated value through both objective and subjective means. When that newly elected official sits down for the next budget process, ensure that he or she has a good understanding of what you do and why it matters.

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Four years ago, I wrote an article for the IAFC called, “Time for a Truce.” This article addressed the constant in-fighting that was going on between fire-based and non-fire-based EMS organizations and associations. This in-fighting was preventing EMS as a whole from moving forward, and when I look at our situation today, it still exists and has actually gotten worse. Not only have some of the relationships between different national EMS organizations soured, we’re seeing a number of disagreements within fire-based EMS that are now causing issues at the national level.

Two examples of disagreements within fire-based EMS focus on the potential creation of a National Fire Protection Association (NFPA) Standard on EMS Officer Qualifications (which would be similar to NFPA 1021, Standard on Fire Officer Professional Qualifications) and the Recognition of EMS Personnel Licensure Interstate CompAct, also known as REPLICA.

With EMS officer qualifications, there are factions within the fire service who do not believe this standard is needed. Some have stated that we can simply use the existing fire officer standard, or that it simply isn’t needed at all. Why wouldn’t we want something in place that helps move EMS forward? More on this in just a minute.

REPLICA was developed by a working group of national EMS representatives at the request of the Department of Homeland Security through the National Association of State EMS Officials (NASEMSO). Both the IAFC and the International Association of Fire Fighters (IAFF) were represented at the table, and the IAFF was even involved in the drafting of the compact. However, once the compact was written and ready for adoption, the IAFF came out in opposition to REPLICA.

NEMSMA had previously put forth the “Seven Pillars of National EMS Officer Competencies,” and their position is that we don’t need a standard because their document outlining the competencies fills that void. While their document does address many of the needs, part of NEMSMA’s challenge is getting other EMS groups to accept their work as a national standard. As many EMS leaders already know, if we didn’t have a say in how it was developed, then we typically don’t want to adopt or endorse it. Maybe we should take NEMSMA’s work and use that as the basis to create an NFPA standard. We have other EMS standards within the NFPA framework, so why should this be any different? Part of the challenge here is the word “Fire” in NFPA.

REPLICA, too, has experienced challenges from other EMS associations, and there are concerns about states losing their ability to control their own EMS programs, interstate commerce issues, and oversight and funding of the compact and governing board. The interesting thing here is that NASEMSO, which is comprised of all of the state EMS officials, was the lead agency in having REPLICA developed, so you would think that they looked at all of these concerns (and by the way, they did).

Two other major EMS issues out there are NFPA 1917, Standard for Automotive Ambulances, and the National Association of EMTs (NAEMT) EMS Field Bill.

Again, the NFPA attempted to address a national level EMS problem by replacing the expiring KKK purchasing standard with a design standard on how ambulances are built. A multi-disciplinary group of EMS professionals developed the standard. Some EMS groups had initial issues with it, and once published, it immediately went into revision to try and address those issues. Fearing that the issues would not be adequately addressed, the Commission on Accreditation of Ambulance Services (CAAS) decided to develop its own standard. What are EMS agencies to do if there are two standards out there? Agencies will be forced to choose one to adopt, and manufacturers may have an even harder time trying to build ambulances to two different standards.

Finally, we have the EMS Field Bill. While I believe this bill, which has been re-introduced to Congress, has many components that would serve EMS well and move the profession forward, there are a number of challenges with it as well. Specifically, funding and leadership of EMS at the federal level are two big points of contention that have caused this bill to stall. The IAFC and others have concerns about these challenges and opposed the bill as previously written, which lead to the current bill under consideration. However, this “new” version is essentially the same as the previous bill with all the same challenges. The IAFC and others have attempted to reach out to NAEMT to try to address these challenges, but these attempts have been unsuccessful to date. So, sadly, this bill will continue to languish and probably eventually die in the halls of Congress.

These are just a few examples of the contentious issues that plague our field. We have great leaders in the EMS profession; we have visionaries who are doing great things and pushing us to be better, and we all want the same thing: to provide outstanding patient care in the most efficient manner possible. All EMS providers, whether third service, volunteer, private, hospital-based, fire-based or otherwise, have a vested interest in the outcomes of the above standards proposals, and yet we can’t seem to come together to find workable solutions. Broken? Yes. Unfixable? I truly don’t believe so. But, it is going to take a commitment, along with some give and take, by all of us to resolve our differences, solve these challenges and continue to work to elevate EMS to the professional level that we all desire.

Norris W. Croom III, EFO, CEMSO, CFO, is the Deputy Chief of Operations for the Castle Rock (Colo.) Fire and Rescue Department. He currently serves as International Director for the IAFC’s EMS Section, and as Vice Chair and EMS Representative on the CPSE Commission on Professional Credentialing.

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Every once in a while, you’ll run across a patient care report that causes your blood pressure to spike, your pulse to double and your “I’m going to fire someone” trigger finger to get itchy. We were reviewing some charts last week when one launched my sympathetic nervous system into overdrive. A 34-year-old woman was awakened in the middle of the night with a fast heartbeat and “anxiety.” Her vitals were pulse 112, respirations 24, and bp 134/90.

The paramedic crew was kind, compassionate, reassuring and clinically incompetent. It was clear from the patient care report that they heard the word “anxiety” and decided that she did not have a significant medical problem. When we hear the word “anxiety” in a chief complaint, pulmonary embolism is the first thing that pops into our minds along with a host of other serious or potentially life-threatening conditions. We’ve been around long enough to know that some people who complain of anxiety need nothing more than to attend a Tony Robbins seminar, but there are others—more than many paramedics realize—who will die quickly without proper diagnosis and intervention.

The problem is that the tools to make that differential diagnosis have yet to make it to the prehospital world. Heck, even in the hospital one-third of pulmonary embolisms are misdiagnosed or missed completely. Most of the people who die from pulmonary embolism were never treated for it.

One of the first considerations in both quality management and the Just Culture framework is, “How much influence did system issues have on the situation you’re investigating?” During the interview with the paramedics involved in this case, they made it clear that they were kind and compassionate with the patient as they talked her down, but that they did not believe that she might have a serious medical issue. Their anxietybased report to the receiving hospital set the triage nurse up to place the patient in the waiting room rather than a bed in a monitored room.

After some coaching by our medical director, the crew came to the realization that they can be kind while they do a full work up. During our conversation with them, they indicated that everyone treats these patients this way. We checked with a several other medics in our operation who confirmed that we may have a culture of underappreciating the full spectrum of serious medical conditions that a complaint of anxiety or hyperventilation should have.

Disciplining or providing individual employees with education will not solve system-level culture problems. The system and culture must be changed. To be successful, a full performance improvement project needs to be chartered. In this case the medics involved are taking the lead by providing system-wide education on the appropriate differential diagnosis and treatment for complaints involving anxiety, panic attacks and hyperventilation. This will be followed up by creating a system-level performance indicator that measures the percentage of patients with an anxiety-like chief complaint who are fully worked up. Cases in which care was inadequate will be followed up with individual coaching until the overall percentage of patients receiving appropriate care is sustainably high.

Paul LeSage, former fire chief and fight medic, is with Critical Decision Partners LLC (cdm-hro.com) and conducts post-incident analysis using the “Just Culture” framework.

Mike Taigman, lifelong student and general manager for AMR’s Ventura County (Calif.) and Gold Coast operations, is a certified improvement advisor with the Institute for Healthcare Improvement.

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Specialty certifications are prevalent throughout healthcare. When you think about different areas of healthcare, consider how much exists outside the realm of initial education. EMS is no different. Since we have strayed so far from our trauma roots of the ’60s, the profession has branched in several directions. In the U.S., we have EMS providers that are operating in critical care transport, helicopter air ambulances, tactical medicine, mobile integrated healthcare/community paramedicine, wilderness medicine and more. Let’s take a moment to look at specialty certifications and the status of specialty certifications in EMS.

About Specialty Certifications

Specialty certifications are the formal recognition of specialized knowledge, skills and experience, demonstrated by the achievement of standards to promote optimal health outcomes.¹ The American Board of Medical Specialties differentiates board certification from medical licensure. Medical licensure describes the minimum competency required to diagnose and treat patients, as opposed to board certifications, which demonstrate expertise in a particular specialty. Furthermore, licensure is a credential that is issued by a governmental entity, sometimes by using the established certification. If a state has a statutorily or regulatorily defined scope of practice for the profession, regardless of what the state chooses to call it, then authorized individuals are licensed.²

Specialty certifications exist in nursing, radiology, respiratory therapy, medical laboratory sciences and many other healthcare professions. The American Board of Nursing Specialties identifies more than 60 certifications from more than 20 certifying agencies. These specialties range from emergency nursing to wound care nursing. Depending on the type of nursing and department the nurse is employed in, certification may be required. For example, if a helicopter air ambulance program is accredited by the Commission of Accreditation for Medical Transport Services (CAMTS) and employs a nurse or a paramedic, the providers must obtain their specialty certification as a certified emergency nurse, certified fight nurse, certified transport nurse, certified critical care nurse, certified fight paramedic or certified critical care paramedic within two years of hire.³

One may argue that many of the skills and knowledge can be obtained through on-the-job training. This is true, and often a crucial component of specialty certifications. In fact, many of the specialty certifications encourage healthcare providers to work for a certain amount of time prior to being eligible for the specialty certification exam. Experience has a huge benefit to clinical performance and knowledge. However, even with on-the-job training, a minimum bar must be set to ensure everyone has achieved a set level of competence as determined by the industrial standards of the certifying agency.

In EMS, we are overwhelmed with dozens of certifications that are made available to the industry from a variety of continuing education sources. It’s important to realize that there is a significant difference between assessment-based certifications and professional certifications. Assessment-based certifications are awarded after successful completion of a proprietary curriculum followed by a content assessment exam.⁴ A professional certification is used to validate an individual’s competence and knowledge through an established confirmatory system. A prime example of this can be found in critical care transport. Programs such as the Critical Care Emergency Medical Transport Provider at University of Maryland, Baltimore County (UMBC) or the Cleveland Clinic’s now defunct Certified Intensive Care Provider certification were achieved after successful completion of those respective educational programs. These certification exams, however, were written specifically for those proprietary educational programs and are more accurately classified as final course exams. In EMS, these programs are often treated as specialty certifications, but they lack some of the core components of specialty certification, which include psychometric validity and the legally defensible foundations of specialty certification exams. Existing specialty certification exams are offered by the Board for Critical Care Transport Paramedic Certification (BCCTPC), such as Certified Flight Paramedic (FPC) or Certified Critical Care Paramedic (CCP-C). The FP-C and CCP-C are true EMS specialty certifications in critical care transport that meet the criteria for professional certifications.

Throughout the healthcare field, agencies exist for the sole purpose of validation of competency. There are some fundamental components that allow these entities to function in a thorough and unbiased manner. The agencies and certifications must have a defined scope of practice that separates it from initial certification, along with a researchbased body of knowledge that supports the scope. The certifying agency must be an autonomous, non-governmental entity. While government entities may be consulted for the development of standards and content, accreditation is considered a non-governmental process.⁵ Eligibility criteria must exist for the certifications. The examinations must be valid, psychometrically sound and secure. Lastly, a recertification process must be established by the certifying agency to ensure continued competency.

Each certifying agency has set standards for its certification process. Content of the exams is based upon the standards developed from a job analysis that is distributed and evaluated by the certifying agency. The job analysis evaluates the knowledge that the providers within the profession feel are the most important. Exam validation is a multifaceted process. First, the certifying agency makes a request of subject matter experts (SME), who are actively involved within the specialty, to submit items (test questions) to the certifying organization through a predetermined process. Afterward, a group of SMEs meet as a committee to review all of the submitted items and make alterations to ensure there is no regional bias, terminology complications or other issues with each item. Then all of the items are sent to a psychometrician to ensure that there is no inherent discrimination. After the items are deemed psychometrically sound, the questions must be pilot tested by certification applicants. Lastly, the items are reviewed by the certifying agency and analyzed for weighted scoring depending on the test method construction. Tests methods can include Angoff, modified Angoff, Beuk, Hofstee or a variety of other methods.

Current Status of Specialty Certifications in EMS

In February 2015, the National Association of State EMS Officials (NASEMSO) released a report titled A National Strategy for EMS Specialty Certifications.⁶ This document discusses the need for specialty certifications in EMS and makes recommendations on how to achieve this goal. NASEMSO declares that the certifying entity cannot be a governmental entity because government entities are responsible for licensure. However, it describes how government entities can implement specialty certifications into their EMS system without developing a new level of licensure for each specialty.

The NASEMSO document identifies several key points about EMS specialty certifications. First, it recognizes the need for a board to manage specialty certifications within EMS. A board must exist that is comprised of industry representatives. Each specialty must be backed up by evidence that the specialty necessitates knowledge that exceeds initial certification. The content must be developed by a job analysis identifying core knowledge expected by certified clinicians working in the specialized industry. Furthermore, each specialty certification must have an accredited examination.

Currently, there are two major certifying entities in EMS. The most well-known entity, the National Registry of Emergency Medical Technicians (NREMT), is responsible for initial certification. The NREMT is comprised of a board of EMS professionals from across the country, and its examinations are developed by committees that include SMEs, state officials and physicians involved in EMS. The examinations are reviewed by a psychometrician and validated through an extensive process. Eligibility for the examination is defined by the state, but must include graduation from an accredited paramedic program or state-approved EMR, EMT or AEMT program. Once a provider is certified, there are defined criteria for recertification through continuing education or retaking the cognitive examination. A large portion of the U.S. utilizes the NREMT for initial certification, and this process is written into many revised statutes and/or administrative codes.⁷

The other certifying entity, the BCCTPC, has been in existence since 2000 and was created because a need for certifying fight paramedics that was identified.⁸ As the Critical Care Transport (CCT) and Helicopter Air Ambulance (HAA) industries grew, providers working in the profession received on-the-job training and experience, but lacked the validation of a professional certification. Requests for certification grew when accrediting agencies required certified personnel in order to obtain or maintain organizational accreditation. While CCT and HAA are generally regulated by states, some states require accreditation by the Commission on Accreditation of Medical Transport Systems (CAMTS). On top of some states requiring CAMTS, the three largest HAA providers also have many of their bases accredited. Since the current CAMTS standards state that paramedics who operate as a critical care paramedic or fight paramedic must obtain their CCP-C or FP-C within two years of hire, these certifications have been in high demand.

As a specialty certification board, the BCCTPC is comprised of SMEs who are involved within the specialty industries. The board is comprised of providers from across the country, physicians who are involved in the various EMS specialties, and representatives from other agencies who share the same vision. Together they vote on specialty certifications that should be added and collaborative efforts that the BCCTPC should become a part of, and they participate in item writing for the BCCTPC.

The BCCTPC currently offers the Certified Flight Paramedic exam, Certified Critical Care Paramedic exam and Certified Tactical Paramedic exam (TP-C). Later this year, they are also releasing the Certified Community Paramedic exam (CP-C) under contract with the North Central EMS institute, an EMT/AEMT version of the TP-C that will be known as the Certified Tactical Responder exam (TR-C), and the Certified Medical Transport Safety Professional exam (MTSP-C) that is in partnership with the Association of Air Medical Services. These specialty certification exams were developed after industrial representatives of the specialties presented to the board the need for specific knowledge that exceeds initial certification. Each examination is developed by SMEs, paramedics (several of whom hold licenses as a paramedic, RN or nurse practitioner) and physicians, in conjunction with board representatives. The SMEs contribute items and the Item Writing Committee meets to review each item to ensure the questions’ validity and remove any regional bias. Afterward, the questions are sent to a psychometrician, piloted and reviewed. The examinations are given an Angoff Cut Score based on the difficulty of the questions to determine a passing grade for each individual exam.

Once specialty certification is acquired, the BCCTPC has set standards for recertification. Each certification has a set amount of continuing education hours that must be obtained within that specialty during the certification period. Along with the designated hours, an approved renewal course must be completed. Usually, the hours acquired for specialty certification can be used for NREMT & state recertification as long as it meets all other distance requirements and other standards set by the state and/or the NREMT.

In EMS, the pathways for upward mobility are limited. Many providers end up leaving the industry early due to issues with pay, fatigue, injuries and a variety of other reasons. As EMS providers begin to work in specialty settings, doors open up. This can help providers who feel as though they have nowhere else to climb, but desire more knowledge and opportunity. Specialty certifications can also help administrators justify an increase in pay due to recognized, externally validated achievements. Some of the specialties can provide pathways for providers who were injured but still have a desire to work in the field. By incorporating specialty certifications into EMS, we provide options for our workforce to help retain, challenge and compensate great providers who want to grow within the industry.

Summary

Specialty certification is needed for healthcare providers who work in areas that exceed the knowledge of their initial education. In EMS, we have a group of providers who regularly work in a specialty area outside of their initial education. These providers often receive on-the-job training, however, external validation is imperative to ensure that clinicians have met and maintained a set bar as determined by the certifying entity.

The need for specialty certifications has been identified throughout allied healthcare. Within our own industry, a need has been identified by NASEMSO. EMS providers are currently operating in specialty settings where the knowledge base exceeds their initial education. The BCCTPC has several specialty examinations in place that help validate the EMS provider’s competency in that body of knowledge. They are also expanding beyond the realm of critical care transport, at the request of other industrial entities to help provide specialty certifications in a variety of other areas.

As EMS grows beyond our traditional roles, specialty certification will help validate the knowledge that providers have as well as their commitment to achieving competency. As it has in other professions, specialty certifications allow the specialized sections of EMS to improve its professional appearance, potentially increase pay and meet the requirements of national accrediting bodies. This step forward shows other healthcare professions that we identify specialties in our industry as well. Within these specialties, EMS providers with specialty certifications have the knowledge to work alongside other healthcare providers with specialty certifications at a comparable level for the greater good of patient care.

KEITH WIDMEIER started his career as a firefighter/EMT in high school, obtaining his paramedic certification shortly after. Since then, he has operated as a paramedic in urban, suburban and rural settings. He has also served as a critical care paramedic for aeromedical and ground critical care transport teams. Currently he works for the University of Cincinnati College of Medicine in the Department of Emergency Medicine teaching a variety of continuing education courses as well as coordinating their critical care transport educational programs. He can be reached at micuparamedic@gmail.com.

REFERENCES

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The MIH-CP Performance Measurement project was initiated to develop and describe performance measures that encourage achieving the optimum sustainability and utilization of patient-centered mobile resources in the out-of-hospital environment and achieves the Institute for Healthcare Improvement’s Triple Aim initiatives—improve the quality and experience of care; improve the health of populations; and reduce per capita cost.

Together, this group reviewed and refined the measures project based on four domains:

• Structure: The acquisition of physical materials and development of system infrastructures needed to execute the service delivery model, such as executive sponsorship, organizational readiness assessment, plan for integration with healthcare systems, and community health needs assessment.
• Outcomes: How the system impacts the values of patients, their health and well-being, such as quality of care, utilization, cost of care and experience of care metrics.
• Balancing: How changes designed to improve one part of the system are impacting other parts of the system, such as impacts on other stakeholders like payers, employees or community partners such as primary and specialty care utilization, public and stakeholder engagement, and partner and practitioner satisfaction.
• Process: The status of fundamental activities associated with the service; how the components in the system are performing, progress toward improvement goals such as clinical and operations metrics, referral and enrollment metrics and volume of contact metrics.

The measures project addresses pay-for-performance and program performance measurement in the area of community health services provided in the MIH-CP models. It offers a universe of measures from which an agency (or a state that’s sponsoring MIH-CP pilot projects) can choose to describe the outcomes of the suite of services that it provides. The document provides a data dictionary for, and descriptions of, outcome measures that will produce meaningful data that can be compared from program to program across the country.

The core team members for the project are:

• Brenda Staffan, Regional EMS Authority (Reno, Nev.)
• Dan Swayze, University of Pittsburgh Center for Emergency Medicine (Pittsburgh, Pa.)
• Gary Wingrove, Mayo Medical Transport (Minnesota and Wisconsin)
• Brian LaCroix, Allina Healthcare System (Minneapolis, Minn.)
• Brent Myers, Wake County EMS (Raleigh, N.C.)
• Matt Zavadsky, MedStar Mobile Healthcare (Fort Worth, Texas)

Attending the national rollout was also nearly every EMS-related association or advocacy group such as the American Ambulance Association (AAA), the American College of Emergency Physicians (ACEP), the National Association of EMS Physicians (NAEMSP), the International Academies of Emergency Dispatch (IAED), the National Association of EMTs (NAEMT), the National Association of State EMS Officials (NASEMSO), the International Association of Fire Chiefs (IAFC), the International Association of Fire Fighters (IAFF), the National Fire Protection Association (NFPA), the Academy of International Mobile Healthcare Integration (AIMHI) and many others.

Finally, the rollout was also attended by key federal partners and groups invited by the core team that have a unique insight into performance measures for healthcare such as the Agency for Healthcare Research and Quality (AHRQ), the Institute for Healthcare Improvement (IHI), the National Committee on Quality Assurance (NCQA) and the Commission for the Accreditation of Ambulance Services (CAAS).

During the rollout, proposed outcome measures for the community paramedic programs were discussed and consensus was reached on 17 core measures from all measure domains that the operating agencies felt were meaningful, trackable and reportable. These are all marked with a star of life symbol. The group also established work groups to establish measures and metrics for three additional areas:

• Process measures for the community paramedic intervention;
• Outcome measures for 9-1-1 nurse triage interventions; and
• Outcome measures for ambulance transport alternative interventions.

Next Steps & Additional Participants

Everyone involved in this project understands this will be an evolving process that will require continuous refinement and participation from stakeholders. We invite other participants to become involved in the process, participate in the various work groups and review teams, and help us establish reasonable and effective measurement strategies for the evolving MIH-CP service delivery model.

If you would like to download the current measures document, the list of participating agencies and associations, notes from the various stakeholder meetings, or volunteer to become part of the team, please visit www.medstar911.org/mih-cp-outcome-measures-project.

Invited Participating Agencies:

Acadian Ambulance

Ada County Paramedics (Idaho)

Allina Health System

Arlington Fire Department (Texas)

AMR—California

California EMS Authority

Carlsbad Fire (Calif.)

Chandler Fire & Medical Department (Ariz.)

Christian Hospital EMS (Mo.)

Dallas Fire Department (Texas)

Eagle County Paramedics (Colo.)

Humbolt General Hospital (Nev)

Lifeguard Ambulance Service (Ala.)

Louisville EMS (Ky.)

McKinney Fire Department (Texas)

Medic Ambulance (Calif.)

MedStar Mobile Healthcare (Texas)

MedEx Ambulance (Ill.)

Mesa Fire & Medical Department (Ariz.)

Mt. Sinai Hospital (N.Y.)

Nature Coast EMS (Fla.)

North Memorial Hospital (Minn.)

North Shore University/LIJ Health System (N.Y.)

Prosser Health District (Wash.)

REMSA (Nev.)

San Diego Medical Enterprise (Calif.)

UPMC/Community Connect (Pa.)

Wake County (N.C.)

Yale New Haven Hospital (Conn.)

Invited Associations & Stakeholder Participants:

American Ambulance Association (AAA)

American College of Emergency Physicians (ACEP)

Agency for Healthcare Research and Quality (AHRQ)

Academy of International Mobile Healthcare Integration (AIMHI)

Association of State and Territorial Health Officials (ASTHO)

Commission on the Accreditation of Ambulance Services (CAAS)

CMS Quality Improvement Organization – Health Insight

Hennepin Technical College

International Academies of Emergency Dispatch (IAED)

International Association of EMS Chiefs (IAEMSC)

International Association of Fire Chiefs (IAFC)

International Association of Fire Fighters (IAFF)

Institute for Healthcare Improvement (IHI)

National Association of EMS Educators (NAEMSE)

National Association of EMS Physicians (NAEMSP)

National Association of EMTs (NAEMT)

National Rural Health Association (NRHA)

National Association of State EMS Officials (NASEMSO)

National Committee for Quality Assurance (NCQA)

National EMS Information System (NEMSIS)

National EMS Management Association (NEMSMA)

National Fire Protection Agency (NFPA)

University of California—Los Angeles (UCLA)

University of California—San Francisco (UCSF)

University of Nevada—Reno (UN-R)

Matt Zavadsky, MS-HSA, EMT is public affairs director for MedStar Mobile Healthcare, the exclusive emergency and non-emergency EMS provider for Fort Worth and 14 surrounding cities in North Texas. He holds a master’s degree in Health Service Administration and has 32 years of experience in EMS, including volunteer, fire department, as well as public and private sector EMS agencies.

Zavadsky has helped guide the implementation of Mobile Healthcare programs at MedStar and several other agencies across the United States. He also chairs the NAEMT Mobile Integrated Healthcare/Community Paramedicine (MIH-CP) Committee and EMS Data Committee.

On April 8, 2015, the MIH-CP measures project took a major leap forward with the hosting of a national rollout of the draft measures tool via webinar with over 50 participants. Invited participants included more than 25 agencies currently operating EMS-based MIH-CP programs representing diverse system design models (public, private, fire, and hospital), and MIH programs (community paramedic, 9-1-1 nurse triage, ambulance transport alternatives, station-based clinics).

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Threats can turn into opportunities with strategic planning. A potential threat to your ambulance reimbursement rates needs your action now.

Recently, there has been much talk regarding the impact of the Patient Protection and Affordable Care Act (PPACA; P.L. 111-148) on pre-hospital care and EMS. Many have said there will be little impact. Others, of which I am one, believe the PPACA will have significant impact and will usher in a new era in EMS delivery, similar to the way paramedicine changed the fire service in the early 1970s.

Although EMS wasn’t included in the original language of the PPACA, there’s been considerable focus on the fact that EMS drives huge costs based on where we transport patients. Fire-based EMS providers must look to the Centers for Medicare and Medicaid Services (CMS) and federal government statements to understand the changes the PPACA will bring to pre-hospital care providers.

One major policy statement came recently from U.S. Department of Health and Human Services (HHS) Secretary Sylvia Burwell. Secretary Burwell announced that by 2018, 90% of all Medicare fees-for-service payments will be linked to quality or value. Furthermore, those payments will be tied to quality or value through alternative payment models. Those alternative models include Accountable Care Organizations (ACOs).

Quality programs mandated by HHS have traditionally been referred to as value-based purchasing. HHS ties reimbursement bonuses or penalties to a medical provider’s performance in areas such as key performance indicators (KPIs) and patient satisfaction scores.

Burwell’s statement that 90% of Medicare payments will be linked to such programs should catch the attention of every fire-based EMS provider, as it will most assuredly impact your ambulance transport revenue.

Burwell’s statement and the fact that the federal government, through the National Highway Traffic Safety Administration (NHTSA), awarded a grant to the National Association of State EMS Officials (NASEMSO) to develop KPIs for EMS should make us all pay attention. This project may look similar to NHTSA’s 2009 effort to develop KPIs, which ultimately stalled because the developing partners couldn’t agree on all the elements.

Burwell’s intent was highlighted in the recent passage of the Medicare Access and CHIP Reauthorization Act of 2015 (P.L. 114- 10). This bill was passed with strong bipartisan support and signed into law on April 16, 2015.

According to Kaiser Health News, P.L. 114-10 “transitions to a new system focused on quality, value and accountability. Existing payment incentive programs would be combined into a new Merit Based Incentive Payment System.” This concept is clearly describes the idea of value-based purchasing.

Burwell’s statement about the increasing use of ACOs should also cause our ears to perk. It implies that in years to come, most payers will be ACOs, not insurance companies.

ACOs will receive a capitated, or preset, amount of money for each of their patients. They will coordinate a patient’s care with all providers with the goal of avoiding duplication and improving quality of care.

If an ACO spends less per patient than they receive, they’ll be financially rewarded. If they spend more, they’ll be financially penalized.

Since ACOs will be paying the ambulance transport fees for their patients, will they be concerned if you continue transporting their patients in a very expensive ambulance to a very expensive emergency department? Or will the ACOs prefer treating their patients much less expensively in outpatient clinics, freestanding emergency centers or with alternate methods of transportation?

Kaiser Health News further describes P.L. 114-10 as “reward[ing] providers who receive a significant portion of their revenue from an alternative payment model or patient centered medical home with a 5 percent payment bonus.” This concept describes an ACO.

Call to Action

Secretary Burwell’s statements, the passage of P.L. 114-10 and other CMS actions show a clear need for three actions from fire-based EMS providers:

• Review the 2009 NHTSA work on KPIs, begin measuring your system and make improvements where needed. This review should expose the mindset and direction of this newest effort. The first KPI to be released this year will address EMS care of patients with suspected strokes. Note that some KPIs in the 2009 effort measured organizational financial-efficiency indicators and ambulance vehicle crashes along with expected clinical measures.
• Talk with the ACOs in your area and help them understand how you can help them solve their problems.
• Regularly review the IAFC ACA webpage for our white papers and other information about the Affordable Care Act.

Remember, the future isn’t hard to predict when those molding it are standing on the mountain top and telling us what that future will look like.

^?Editor’s note: This article originally appeared in On Scene, the digital publication of the International Association of Fire Chiefs (IAFC), and is reprinted with permission.

Mike Metro was Chief Deputy for the Los Angeles County Fire Department until he retired in January 2015. He has nearly 40 years of experience in America’s fire service, including five years for the City of El Cajon, a four-station fire department in San Diego County. In his last role with LAFD, he provided executive oversight for the emergency operations of the department’s 170 fire stations protecting 58 cities and 4.5 million citizens. He was Chief of Emergency Medical Services for L.A. County Fire for seven years as well as the president of the California Association of Fire Chiefs–EMS Section for four years. He currently serves on the Executive Board of the IAFC–EMS Section, as the vice chair as well as chair of the IAFC’s Affordable Care Act Task Force.

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