Performance Measures for EMS Performance Contracts and Service Level Agreements

Units of local government make substantial annual investments in their emergency medical service (EMS) systems. That investment is typically divided up between the 9-1-1 communications center, the fire department’s non-transport medical first response efforts, and the ambulance service. Ambulance services might be operated by the fire department, a separate government ambulance agency, a private ambulance company or perhaps a volunteer ambulance service. The ambulance service is usually able to collect fees for its services, but they often are not enough to completely cover their operating costs. In those cases, some degree of ambulance budget subsidy is needed.

In any of these scenarios, these various elements of the local EMS system come at a significant public funding cost to the communities they serve. It stands to reason that with that significant investment, there should be some level of accountability on these entities to report on the quality of their care. There is a broad range of measures that could be used for such public accountability purposes, but a fewer number of higher level measures would be more helpful and practical.

One of the main purposes of having this accountability is to encourage higher levels of performance. Therefore, choosing measuring what truly matters is key. The ability of the measures to positively influence EMS performance will also depend on the context in which they are reported. Measures that are only seen seven clicks deep into an obscure section of a local government website will be virtually invisible.

In contrast, these performance measures can be a prominent part of a service level agreement that is negotiated between the city manager or county administrator and the particular 9-1-1 manager, fire chief or ambulance director. For a private ambulance service, the contract that grants EMS market rights is a very appropriate place to establish these accountabilities. Commonly, government and private EMS providers are held accountable for response times, but little more. While response times are an element of EMS performance, they should not be the only measure. From a clinical standpoint, they are not really the most important measure either.

The measures suggested for public accountability fall into four general categories – satisfaction measures, process measures, outcome measures and value measures, although not all categories of measures are appropriate for all parts of the EMS system.

Satisfaction measures should ideally be based on the results of independently performed and compiled surveys of patient/family satisfaction. Families might be surveyed in lieu of patients when the patient had any sort of impaired mental status at the time of care.

Process measures are very helpful, because clinical outcomes are not solely dependent on the actions of any one element of the EMS system or just the hospital when the patient was cared for by EMS. Therefore, performance measures are often based on how well care was delivered at various stages of care. The parts of care to be measured should be ones that have the most influence on patient outcomes. For example, the fire rescue agency or ambulance service might report on how accurately they detected heart attacks or strokes and gave advance notice to hospitals. Correctly identifying heart attacks and strokes in their field allows patients to be taken initially to the most appropriate hospital – which saves time and improves outcomes. Advance notification from the field to hospitals allows specialty care teams  (e.g., cardiac catheterization team for heart attacks; surgical teams for trauma; neurology teams for stroke) to be ready to intervene by the time the patient arrives at the hospital – which saves even more time and further improves patient outcomes.

Outcome measures are more difficult to interpret. However, they can be helpful to public officials in comparing results from other communities when they are measured the same way. This is a big advantage to using nationally standardized healthcare performance measures. The nationally standardized measures are often calculated with statistical risk-adjustments to make comparisons between communities easier by compensating for the severities of patient illness and other factors that influence outcomes other than the quality and timeliness of care given by EMS or the hospitals.

Value measures are relatively new to EMS and much of healthcare. They are important to public officials because they are designed to measure the combined impact of quality and cost. They help assess how much benefit was received for the amount of money spent. This makes it an important measure related to sound stewardship of public funds. Communities might have good outcomes but at extraordinary expense. Other communities might have poor outcomes in spite of high costs. The desirable higher scores on value measures happen when good outcomes are achieved and lower total costs. This is indeed what tends to happen when organizations improve their quality – the quality improvement efforts often reveal opportunities to improve operational efficiency as well. Of course, the likelihood of improving value scores will go up when value is explicitly measured. The old saying, “what gets measured gets done” still has a lot of validity.

The performance measures listed below are a small sample of potential measures. They were selected for their importance and level of acceptance in the EMS industry.

9-1-1 Communications Centers

Satisfaction Measures

• Results of standardized caller surveys, viewed in comparison to local historical trends and national benchmarks.

Process Measures

• Time from first ring to call answered
• Time from call answered to first compression performed (on cases with suspected witness onset cardiac arrest)

Outcome Measures

• Not included

Value Measures

• Not included

Non-Transport Medical First Response Agency and/or Ambulance Service

Satisfaction Measures

• Results of standardized patient/family surveys, viewed in comparison to local historical trends and national benchmarks.

Process Measures

• % of time with chest compressions delivered in desired rate and depth range (for cardiac arrest patients)
• % of time with ventilations delivered in desired rate range (for cardiac arrest patients)
• % of stroke patients that received a field stroke assessment score (for stroke patients)
• % of patients where a ‘last known well’ was documented on the EMS report to the hospital
• % of cases where the hospital was notified within 10 minutes of completing the stroke assessment that showed the presence of stroke
• % of severe heart attack patients (STEMI) that were correctly identified in the field.
• % of cases where the hospital was notified of the severe heart attack within 10 minutes of obtaining the 12 lead electrocardiogram (ECG or EKG) that showed the heart attack was present.

Outcome Measures

• Not utilized

Value Measures

• Not utilized

EMS System (Collective performance of all the entities, including hospitals)

Satisfaction Measures

• Results of standardized surveys, viewed in comparison to local historical trends and national benchmarks.

Process Measures

• % of severe heart attack cases with EMS first medical contact to coronary artery open times less of than 90 minutes (if the patient was taken initially to a hospital with a cardiac catheterization lab)

Outcome Measures

• % of patients that survived to hospital discharge (for cardiac arrest patients)

Value Measures

• % of patients that survived to hospital discharge/community cost per capita for EMS (for cardiac arrest patients)

These suggested measures are not a definitive list. But, they can start an important on-going conversation with your 9-1-1 communications center managers, fire-rescue chiefs, and ambulance service managers about being accountable for their performance and operational efficiency – and that’s an immediate step forward for the community.

Mic Gunderson is a GovLoop Featured Contributor. He has been involved in emergency healthcare for over 40 years in various leadership, educational, and clinical roles. Currently, he is the President of the Center for Systems Improvement where he provides consulting and training services related to emergency systems of care and EMS systems. Read his posts here.