Accountability in EMS

Accountability in EMS is more than something that needs to come from the top, down…it needs to come from the bottom, up.

Accountability can be examined and categorized through a number of objective criteria, and also by a number of subjective benchmarks. Choosing what’s important to your individual service, moreover, is the important part.

While community leaders will often focus most of their attention on financial responsibilities, it’s important for them to understand that EMS shouldn’t be run solely like a profit/loss business…there’s much more to it than that!

Recently across the country, large numbers of states and individual services are beginning to look at performance benchmarks in the areas of cardiac arrest management, stroke care, and trauma care. We’ve seen a transition from simply transporting patients to the closest hospital, to now focusing on transporting patients to the closest appropriate hospital. This means transporting to facilities that can care for pediatric intensive care emergencies, cardiac catheterizations, and multi-system trauma injuries.

Aside from the traditional response-time data analysis, the concept of quality assurance is expanding beyond a simple focus on chart reviews and response times, to a broader spectrum of topics related to skills performance, protocol competency, and evidence-based training program development.

Again, there are a number of topics, sub-topics, and avenues that services can demand accountability…but here are a few that come to mind at the top of my priority list.

CREW RESOURCE MANAGEMENT

If you ask any firefighter what they think “accountability” means, they’ll likely mention something about “who’s in, and who’s out.” They may also mention something about “free-lancing,” and how it’s not tolerated in their field. While this is one aspect of crew resource management, another way of looking at this topic is related to your service’s organizational structure. Often viewed from the top, down; a service’s organizational structure is its backbone…its chain of command…its identity.

Without a structure in place, there is no accountability. Whether a service is a small, rural, volunteer agency; or a large, urban, career system; crew resource management (and some sort of span of control) is imperative to its functional existence.

In a smaller service, a single individual may be accountable for all of its members because of financial restraints, a lack of interest from others, or simply because of an “ownership” feeling by the person on the top. Are these, however, good reasons for a lack of structure? Even if a service can’t pay someone more (or anything) to oversee others, does it justify the added stress, risk, and accountability that another individual faces? What can they do to create some structure and disperse its accountability?

Develop a structure…it’s as simple as that. Give others titles, roles/responsibilities, and let them oversee the performance, documentation, or call-time of their peers. Give them “something” that warrants their title. Whether you call them crew chiefs, supervisors, captains, or crew leaders, give them a title that warrants respect, responsibility, and accountability for others.

TRAINING & QUALITY ASSURANCE

Along with physical accountability for your service members is their training, skills performance, and overall quality assurance. While many states will clearly define that an individual is responsible for his or her EMS license, not the service(s) that they are affiliated with, it’s still your service’s responsibility to assure that they meet your quality standards. It is still your service’s responsibility to assure that they are updated and able to meet your protocols’ expectations. It is still your service’s responsibility to assure that they are competent EMS providers…yes, your service is accountable for that!

Having taught a number of EMS refreshers throughout my career, I was often pulled aside by a Director that wanted to know if I could somehow fail a student because they were either a sub-standard provider, or they were simply just a pain in their ass. My responsibility as an instructor, however, wasn’t (and isn’t) to fail someone based on his/her actual performance in the field…I was only responsible for what happened in the classroom. This responsibility lays with the service…the Director.

Whether your service schedules a mass-refresher each license period for its members to attend, or if it does something more flexible by allowing them to attend continued education courses, training is still a part of your service’s responsibility to its members…remember the whole competency idea…that’s the service’s responsibility. Speaking of refresher training, is simply scheduling a mass-refresher, and then “calling it a day,” enough? Is what your local technical college or training center offers enough to keep your providers updated on their protocols and service requirements? (The answer to this should be “no.”)

The truth is, more is needed than what we (as EMS providers) obtain in our refresher training. We need assurance and oversight over our knowledge, skills, and abilities. We need a quality assurance program in place that involves chart reviews, skills performance evaluations, and protocol competency assessments. Remember, provider competency is the responsibility of the service…provider ability is the responsibility of the individual person.

FISCAL

It blows my mind when I hear that a service bought an ambulance that cost nearly $200,000; and that’s not only when a rural/volunteer service that only has 100 calls each year does it, but when an urban/career service does it as well! Why? Do we really need a huge box bolted to the back of a van or pick-up truck chassis? Can a service really afford 12mpg when they’re doing 100-mile long-distance transports (especially if they only have one provider with the patient!)? What’s wrong with this picture?

Budgets are tightening in the municipal realm, I couldn’t possibly believe that they’re abundantly fruitful in the private sector, so where’s the accountability? Where’s the justification? Do we not adopt a more European-style of ambulance because we’re afraid that the goofy siren will change our styles, our systems, our traditions? Or, are we just resistant to change and unwilling to compromise this facet of our identity?

When it comes down to keeping people on staff, providing additional training, updating to newer and better equipment, and simply adding to our capital improvement budgets, how can we not look at buying a different style of ambulance…especially if it’s significantly cheaper (and safer, too!)?

Now, surely fiscal accountability relates to more than just buying new ambulances, but when you don’t have much control to decrease personnel costs (which typically consume 80% of operational budgets), where else can you save money? It’s not like we can just put a special filter on our ambulances to allow them to get 17mpg; but we can buy a different style that offers this fuel efficiency, improved safety design, and more ergonomically-comfortable interior for our one or two providers that actually ride with the patient.

SAFETY

Safety, amongst all other forms of accountability, is something that can be embraced from both the top, down; and the bottom, up.  Whether it’s wearing the proper personal protective equipment while intubating, purchasing safer ambulances, using battery-powered cots, or simply keeping ergonomics in mind while lifting a patient, a concept of safety can be embraced through a variety of means by all members of an EMS agency.

From an insurance and liability perspective, how about safety while driving? Does your service have an ambulance operator training program in place? Do you require EVOC or CEVO? training for all drivers/providers before hitting the roads with lights & siren? What about a recording device in your ambulances…both in front and in back?

Speaking about lights and siren, do you have a policy in place for its proper and appropriate use?

Are there any penalties for unsafe behavior or practices in your organization? Related to that, if you already provide a variety of safety equipment for your members, are they compliant with their use; if not, what are you currently doing about it?

The fact is, relying on the hope that “it hasn’t happened to me (yet)” isn’t enough in our field. Back injuries occur, crashes happen, and exposures go unreported. Who’s responsible for your service’s safety…who’s accountable? Most importantly, what are you going to do to help keep yourself and your crew safe moving forward?