Superior North EMS Strategic PlanNorth+EMS+Strategic+Plan+2… · I’m proud that through this strategic plan, ... developing a 5-year strategic “change” program to ... increasing

Strategic Plan2013-2017

Superior North EMS

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ContextIn 2010-11, the Superior North Emergency Medical Service (SNEMS) undertook a strategic planning process within the context of a dynamic emergency medical services environment. This was necessary as EMS and its environment are changing rapidly: increasing call volumes, aging populations, more complex patient calls, the centralized delivery of health care, gaps in service delivery, and increased skill sets of paramedics are all contributing to our need to adapt.

Indeed, the political, economic, environmental, and technological landscapes are changing exponentially. Concurrently, stakeholder expectations are evolving. To remain vibrant, to remain relative, and to continue to deliver great patient care, Superior North EMS and its paramedics must embrace and adapt to change; we must transform.

This plan was developed with the interests of patients as the primary focus and concern. To this end, we used an evidence-based philosophy to come to the most appropriate conclusions. Key input was provided by internal and external stakeholders, whom I thank for eagerly contributing to the plan’s development.

As a relatively young entity, Superior North EMS has never undergone a “forward looking” strategic process. I’m proud that through this strategic plan, we are positioning Superior North EMS to be the vibrant health care and emergency service needed in today’s complex environment.

We exist to serve people. Through this plan we strive to improve.

Norm GaleChiefFebruary, 2013


1. Strategic Planning Intro: Organizing Ourselves to Transform SNEMS & Safeguard Patient Outcomes

SNEMS Strategic Plan

The Superior North Emergency Medical Service undertook in 2011-12 the development of a strategic plan.

To facilitate the plan development, Performance Concepts Consulting was engaged.

www.performanceconcepts.ca

Both external and internal stakeholders played important roles in the development of the plan.

This plan is a “living document”; indeed, some obvious system changes were implemented as the plan developed.

Guiding Principles: How We Made Decisions

Patient outcomes are PARAMOUNT.

The SNEMS Strategic Plan will identify sources of internal/external patient risk and mitigate this risk

accordingly. Patient interests will trump individual stakeholder interests.

The “change” agenda that is part and parcel of the SNEMS Strategic Plan will be evidence-based.

Performance measurement data and evidence-based analysis should support the rational deployment of SNEMS finite resources - to protect the health and safety of ALL pre-hospital emergency patients in the City and District.

The SNEMS Strategic Planning Model

ProjectSponsor: Chief Gale

PerformanceConcepts Project SupportTeam

Project Team leadTodd MacDonald

Strategic PlanGovernance Committee MayorThunder Bay Council reps (2)District municipal council reps (3)City ManagerSuperior North EMS ChiefHealthcare stakeholders rep (1)

Superior NorthStrategic PlanInternalWorking Group

Management & Frontline Paramedics

The Internal Working Group providedevidence-based analysis & expert advice,while the Governance Committee provided a Community-based perspective to difficult restructuring / redeployment issues

Actors & Decision-making Framework: Who Did What

SNEMS Project Component

Advisory or Decision-making Role

Internal Working Group

Evidence based research, analysis & development of technical recommendations

SNEMS Chief

Bring forward evidence-based recommendations & advocate for positive SNEMS change management

planning (from a patient-centric clinical perspective)

Governance Committee

Provide a forum for external stakeholder input & diverse City/District government perspectives - while developing a 5-year strategic “change” program to

safeguard patient outcomes in the face of operational, demographic and intergovernmental

challenges

T-Bay Council Final decision makers – the buck stops here

We have a successful strategicplan due to the clear roles &responsibilities of these variousactors…each exercising leadership to serve our community

Mission, Vision & Values

The SNEMS Mission, Vision & Values Statements

…were crafted by our frontline and leadership paramedics… a team based collaboration

These have meaning…they define who we are and how we serve!!!

AND they indicate where we want to go

Photo: Sandi Krasowski


MISSION

To provide timely and effective pre-hospital emergency patient care. To save lives and reduce pain and suffering from medical emergencies for every patient. To promote public education and wellness through expanded community paramedic roles.


VISION

The Superior North EMS will be an organization that embraces continued learning and evidence-based practises to provide skilled, effective, and efficient patient care to people in the City and District of Thunder Bay.


VALUESRespect.

Empathy, Patience and Understanding.

Integrity and Honesty.

Continued learning.

Excellence.

Fun, teamwork driven work culture.

Leadership.


2. Situation Analysis: Understanding Service Demand & Current SNEMS System Characteristics

The SNEMS “At a Glance” Profile

25,000 service responses per year…mostly 9-1-1 emergencies210 dedicated personnel (190 front line)

17 stations Governance by Thunder Bay Municipal Council

Service delivery relationships with 15 municipalities

SNEMS Operational Reality: Distinct City & District Models

Upsala

Conmee

Thunder Bay

Nipigon

Red Rock Schreiber Terrace Bay Marathon

Manitouwadge

Beardmore

Longlac Geraldton

Nakina

Armstrong

Shuniah

City model driven by response time performance imperatives within the context of ever-increasing demand.

District model drivenby geographic coveragechallenges…core realitiesrecognized in this Strategic Plan

Population Forecast Does NOT Reflect Service Demand

This Statistics Canada population forecast does not capture temporary / seasonal populations.

These populations are sources of additional demand for service.

The Thunder Bay “Age Tsunami”: Driving Demand for Service

An aging population “tsunami”Is driving demand for Thunder Bayhealth care services– including EMS.

Population cohorts age 65+ are the “super users” of EMS, and these cohorts are going to grow in size over the next ten years as the baby boomers continue to age.

This “age tsunami “explains whyEMS demand in Thunder Bay is going to increase faster than population or assessment growth – year after year after year.

Age Cohorts

Imminent 9-1-1 Demand Growth The blue bars (2009) represent current service demand. The red bars (2020) denote the expected increase in service demand coming in just a few years.

This graphically shows the “age tsunami”.

The SNEMS must ensure that necessary paramedic resources are in place on a “just in time” basis in order to meet this demand spike and continue to respond in timely fashion to 9-1-1 emergencies.

City Performance Snapshot: Preview of Future Challenges

Blue bar 90th percentileresponse times are now beginning to erodein the face of escalating 9-1-1 emergency call volumes (the red line).

This is the “canary in the coal mine” signaling future response time challenges in the City!

Non-urgent patient transfers erode the ability of the SNEMS to deliver timely responses to mission-critical 9-1-1 emergencies

SNEMS System Utilization: “Busyness” City and District

City based paramedics have a unit hour utilization (UHU)* rate of > 40% - a level of system busyness well above EMS peer best standards.

District paramedics are utilized at 10% or less -this excess capacity is a reality of the geography based coverage model in the low population, low call volume district communities.

*the amount of staffing time actually spent on a

paramedic call

Paramedics are making a difference…

In 2011, paramedics assessed and treated 44 patients with congestive heart failure (CHF).

After treatment by paramedics, patient status improved dramatically. 31 of 44 patients reported improvement in how they felt, which was evidenced by changes in vital signs and physiological response.

Three of 44 patients worsened.

nb: not all medical / traumatic emergencies show patient improvement after intervention by paramedics.

Paramedics are making a difference (but not all of the time)…

In 2011, paramedics assessed and treated 1199 patients complaining of abdominal pain.

After treatment by paramedics, patient status was virtually unchanged. Only 140 (or 11%) of the patients reported improvement in how they felt, which was evidenced by changes in vital signs and physiological response.

1044 of the 1199 patients experienced no change in their condition while 6 patients felt slightly worse.

Potential

SNEMS paramedics are a skilled, empathetic workforce who work in two silos

In the District, their utilization rate* is typically <10%*the amount of time actually spent on a paramedic call

In the City, their utilization rate is typically > 40% and increasing, but there is some limited excess capacity

Paramedics represent a “force multiplier” with respect to the delivery of health care

In a holistic view, they are a largely under-utilized part of the fabric of health care delivery… paramedics have more to offer


3. Situation Analysis: SNEMS System Performance Challenges/RisksDrivers of Strategic Plan Resourcing Strategy

Provincial Dispatch Performance is Problematic

The Province operates EMS dispatch for the SNEMS.

The key to high performance EMS dispatch is to triage emergency calls into useful patient acuity “buckets”that allow the SNEMS to deploy finite resources against thetruly life threatening & serious calls first, while less seriouscalls are placed in a queue.

The provincial dispatch model (DPCI II) is failing this test: ~60% of all emergency calls are assigned to the high priority “lights and sirens” category.

In essence the current dispatch system does not triage patient acuity – it simply transfers risk to SNEMS by assessing the majority of 9-1-1 calls as life-threatening.

There are other dispatch models (Toronto and Niagara) –where the EMS operates dispatch. These systems utilize patient triage tools (AMPDS) that are considered the “best practice” standard across North America

Dispatch (continued)

The current dispatching model:

Provides no opportunities to the SNEMS to assess and implement system improvements

Provides no opportunities to the SNEMS to proactively address operational issues in real time

Inhibits the SNEMS’ ability to proactively implement system re-design

Potentially increases risks (to the patient and public) by failing to appropriately prioritize calls for service.

“Silos” SNEMS’ operations from EMS communications

2011 Dispatch Performance (continued)

~60% of 9-1-1 calls are assigned as “urgent” (highest priority) by EMS dispatch

while

Only 7% of 9-1-1 calls are found by paramedics to be “urgent”

*“urgent” normally necessitates a high risk “lights and sirens” response

City Hospital Offload Delay –Ongoing Risk to SNEMS Performance

Patient offload delays caused by patient flow “clogs” (GRIDLOCK) inside the TBRHSC.

Internal hospital solutions are not working (i.e. offload nurse program)

Offload delay incidents occur multiple times each day…approaching 300 incidents per month; approximately 16 lost paramedic hours daily

Duration(avg 48 mins) of each offload delay worsened in 2011

Strategic plan success is jeopardized by this ongoing, persistent erosion of SNEMS resources…a healthcare SYSTEM problem

Non-Emergent Transfers Erode SNEMS Capacity Re. Code 4 Emergencies

Non-emergent patient transfer calls consume budgeted/deployed Emergency medical vehicle hours funded by local taxpayers

Results in reduced supply of available emergency medical services in already over-burdened City system

Results in frequent removal of units from District emergency deployment zones

Annual loss of 4,602 SNEMS hours funded & deployed to address emergency service demands; but these hours are expended performing non-emergent transportation requests!

Service Demand Overwhelming SNEMS Resources

City SystemTime of Day

Frequency of Hitting Paramedic

UnitResource Ceiling

Average Duration When Hitting Ceiling

Weekday Days(7 Units typically

deployed))

178 Occurrences 10 minutes

Weekday Nights (5 Units typically

deployed)


Weekend Days (6 Units typically

deployed)


Weekend Nights(4 Units typically

deployed)


1,062 Annual Occurrences

In 2010, more than 1000 times, there were no ambulances available in the City.

Zero unit availability is a significant indicator of SNEMS system performance risk in the City.

It reflects the reality that historic system funding/resourcing has not kept pace with “age tsunami” driven call volumes…

…it also reflects the negative impact of hospital offload delays and the erosion of deployed resources caused by non-urgent patient transfer workload

Impact –Zero Ambulances Available

259

511

231

59 No additional calls

1 additional call

2 additional calls

3 additional calls

0.05.0

10.015.020.025.0

AV

G…

90%

T1-

T2A

VG

…90

% T

2-T3

Avg

T3-

T490

% T

3-T4

AV

G…

90%

T2-

T4

All Availablity14321.0

Zero Available801.0

Second Call231.0

Third call 59.0

Risk associated with the “zero units available” problem translates into a gap for actual 9-1-1 emergency calls received when paramedics are occupied – 801 such calls annually.

About 300 of those 801 calls are second or third 9-1-1 calls (see pie chart).

The response times for these calls are longer –stretching well over 20 minutes (90th P T1-T2 plus 90th P T2-T4, see bar chart).

The SNEMS Strategic Plan must address this continuing trend of potential negative patient impacts.

4. Situation Analysis: Recognizing SNEMS City Vehicle Hours Deficit

SNEMS Resource Requirements

2011 2012 2013 2014 2015

Code 3-4 Service Requests 21,938 22,035 22,156 22,296 22,422

Av Time on Task 0.92 0.92 0.92 0.92 0.92

SNEMS Unit Responses 27,423 27,544 27,695 27,870 28,028

Workload Hours 20,183 20,272 20,384 20,512 20,628

Utilzation Rate 0.35 0.35 0.35 0.35 0.35

Required SNEMS 57,666 57,921 58,239 58,607 58,938Emerg Resource Hours

The key to improving SNEMS system performance in the City is to reduce the current system “busyness” (45% UHU) down to an industry standard (35% UHU).

This 2013-18 five year forecast setsout the resources required to address growth in emergency requests and the resulting SNEMS responses.

SNEMS required deployed resource hours (59,938 in 2015) translates into 3-3.5 new ambulances to progress towards a 35% UHU.

*This may be mitigated by reducing call volume (either 9-1-1 or non-urgent transportation).

Impact of Adding Forecast City Resources

Before City system unit hour utilization

approaching 45%...this erodes deployment performance & emergency response times

No budgeting/planning to account for the “age tsunami” demand growth

>1,000 annual incidents of “zero unit availability”

Ongoing erosion of SNEMS capacity from offload delays at TBRHSC

After UHU stabilizes & progresses towards

35%

“age tsunami” accounted for in budget/planning cycle

Significant reduction in annual zero availability incidents

Unclear impact re offload delay…these new resources must not be “swallowed up” in a TBRHSC off-load “trap”

Dividend from Restructuring the Non-Emergent Patient Transfer Model

1644

797517

1998

945618

0.0

500.0

1000.0

1500.0

2000.0

2500.0

0 1 2

749 749 749

Transfer effort hrs. Count

Roland Station Beck Station Selkirk Station

Non-emergent transfer effort across the three city bases (pre-2013) equates to a 12-hour city ambulance deployed for one year (approximation)

Summing Up: Resource “Add” Essential to Turn Around City EMS Performance

The modeled paramedic resource requirements (to achieve 35% UHU) + a non-emergent transfer restructuring dividend will generate 3-4 new 12-hour ambulances…the key conclusion from the Situation Analysis

Potential Redeployment: From where Should the New City EMS Resources Come?

Strategic Direction A

Redeploy low-utilization ambulances from each of the “twinned” North Shore Bases into the City (correcting current sub-optimal

overlapping coverage patterns at Red Rock/Nipigon & Schreiber/Terrace Bay)

Implement a non-paramedic model of non-urgent patient transfers in the District, thereby ensuring remaining ambulances on the North Shore are anchored to their coverage areas

Strategic Direction B

Seek new $.5M* property tax funding from Council for 2 new 12-hour City EMS units…requiring a significant multi-year property tax increase & assuming matching Provincial cost-sharing

* Presuming the Province pays 50%

Avoids immediate District rationalization & re-deployment of community-based ambulance resources into City EMS

In late 2012 Council selected this option – no further discussion with District stakeholders concerning future palatable District restructuring options is to be held

5. Strategic Plan Recommendations Bundle #1

Theme: Major EMS System Restructuring & Injection of City Ambulance Resources

Injection of Council Approved New Vehicle Hours

Implement Restructuring Option 5 from Thunder Bay Municipal Council report 2011.130

Endorsed by Council November 14, 2011 2 new 12-hour ambulances for the

City…implemented in 2012 at a local taxpayer cost of $400,000 to Thunder Bay & $100,000 to 15 District municipalities

Future examination and monitoring of the need for EMS expansion in the City given projected demand increases, on a “just-in-time” basis

No immediate restructuring for District deployment

Action Item: the SNEMS to secure required new paramedic capital assets & paramedic personnel resources to implement the injection of 2 x 12-hour ambulancesAction Item: Projected expansion to be reviewed and monitored; proposed implementation on a “just-in-time” basis

Renewed EMS Deployment (City)

In 2012, the new SNEMS HQ opened. It is projected that this will provide better EMS response to Thunder Bay North.

It is recommended that EMS deploy from six stations (the HQ and five satellites) on a move forward basis.

Before 2012, City EMS deployment was problematic.

The three EMS stations were not ideally located given geography, population, and call demand.

Action item… increase the number of EMS satellite stations from two to five.

Action item… leverage existing fire halls to reduce costs in EMS expansion.

Renewed EMS Deployment (City)

Headquarters 4 add City of Thunder Bay

Pre-strategic planning… 3 stations

Post-strategic planning… 6 stations

* 6 minute response zones

Restructuring Non-emergent Patient Transportation

Council direction to work with the NW LHIN & the TBRHSC to develop a new model for governance, funding & delivery of non-urgent patient transportation

Action Item…Provide project leadership in collaboration with LHIN & City/District hospital stakeholders to develop a new non-emergent transportation model during 2012-2013

Action Item…Develop non-emergent transportation models for two over-arching scenarios

→ City→ District

Action Item…Secure annual city EMS reduction in non-emergent transfer workload

Pursue Dispatch Alternatives

1. The SNEMS to work with the OAPC & AMO* to advocate for municipal operation/control of EMS dispatch under a service contract with the Province.

2. Provincial service contract to focus on required results while offering maximum flexibility

ie examine whether AMPDS should be utilized rather than DPCI II

Action Item: Design & execute an intergovernmental advocacy strategy to secure dispatch responsibility/control from the Province… Province to retain funding obligations for a transferred system.

*OAPC: Ontario Association of Paramedic ChiefsAMO: Association of Municipalities of Ontario

Review & Refine Tiered Response

In collaboration with the Northwest Region Base Hospital Medical Director and program personnel and other community first responders, conduct an EVIDENCE-BASED review of the medical tiered response model to ensure a timely, cost-effective model is in place; ensuring that the right responders are deployed appropriately to 9-1-1 calls

Action Item…the SNEMS to lead an emergency medical tiered response review project in 2013…ensure project charter notes importance of establishing medically justified tiered response protocols…ensure that the project charter recognizes the opportunity to identify cost avoidance/savings among first responders in a rationalized model


6. Strategic Plan Recommendations Bundle #2

Theme: Improving Operational Efficiency & Promoting Organization Renewal

Building a SNEMS Scorecard

Create and implement a SNEMS Scorecard based business planning model, including an on-line performance dashboard tool and performance targets.

Action Item…secure Council & SNEMS frontline paramedic “buy-in” to the SNEMS Scorecard quadrants and key performance indicators (KPIs) developed during the strategic planning process

Action Item…integrate annual SNEMS Scorecard reporting, target setting and budgeting process…resulting in a results based business planning model

Action Item…link any future decisions on District deployment restructuring and non-emergent transportation restructuring to SNEMS Scorecard performance data trends & insights

Measuring System Performance

The SNEMS to use data to make evidence-based decisions on EMS deployment and the provision of patient care.

Action item… existing data to be consolidated into a single platform (QlikView)

Action item… platform to be accessible to SNEMS leadership, paramedics, and the public by using easy to understand graphics reflecting KPIs and providing secure access points

Measuring Response Times The Superior North EMS will measure Council endorsed response times in

accordance with new standards legislated by the Province.

Response times will be measured in accordance with patient acuity, providing better information to patients and administrators.

New response time targets (RTPP) will be established annually and replace the 1996 90th percentile response time standard as historically imposed by the Province.

EMS response time performance varies as a result of many factors: call volumes, station locations, staffing patterns, non-urgent transportation, EMS off-load delays, and in the District low call volumes (thus only a few extraordinary responses can impact on the annual performance).

Therefore separate standards for both the City and District of Thunder Bay would best address potential validity and reliability issues brought by a single standard encompassing urban, rural, and remote areas.

The RTPP will be publically accessible

EMS Off-Load Delays

1. The SNEMS to work with the OAPC & AMO to advocate for alternate strategies to deal with EMS off-load delays.

2. The SNEMS to work with the Thunder Bay Regional Health Sciences Centre on operational and staffing issues germane to off-load delays.

Action Item: Design & execute an advocacy strategy to reduce EMS off-load delays at the ED.

Action item… work collaboratively with the TBRHSC to reduce EMS off-load delays at the Emergency Department.

Promoting Community Paramedicine

Initiate a community paramedicine initiative to improve paramedic utilization (in the District)& deliver community health benefits

Action Item…Strike an internal community paramedic initiatives project team to develop specific targeted community medicine activities for phased implementation beginning in 2013; will include SNEMS leadership, paramedics, and the NW Region Base Hospital Program Medical Director.

Action item…Ensure consultation with health care community stakeholders (LIHN, CCAC, district hospitals) to identify appropriate target activities.

Action item… Work with the OAPC and Ministry of Health and Long-Term Care to address advocate for legislative / regulatory support.

Saving More Lives Initiative

Achieve significant progress in the rollout & evaluation of the Saving More Lives initiative

Action Item…once established, report on projected increases in Bystander CPR rates towards achieving overall 60% Bystander target rates…complete rollout of training and equipment provision across City & District

Using Social Media

The SNEMS will use social media to transparently communicate internally and externally… to promote our evidence-based accomplishments and organizational initiatives… to ensure that good information is disseminated

Action Item…strike a SNEMS social media project team to establish appropriate tools, processes and codes of conduct… supporting a culture of high performance, and providing staff with a “line of sight” to service delivery issues and success for our patients and communities

Infection Control Program Paramedics work in difficult situations: these are often uncontrolled environments

that may have poor (or absent) lighting, inclement weather, frequent distractions and other complicating factors such as upset family members or violent people.

Despite the use of best practises, paramedics may not immediately see the risks of exposure they face, nor may they immediately recognize risks of exposure to patients and bystanders, nor may they be enlightened to emerging infections

Action item… The SNEMS to create and implement an “infection control” program… using paramedic based “best information” and engaging personnel… goal to mitigate disease transmission… share information and best practices with other emergency responders

Action item… The SNEMS to evaluate disease rates, absenteeism due to illness, and disease exposure; program adjustments to be made accordingly

EMS Research EMS / paramedicine is a relatively new profession. Only

recently has genuine research into the efficacy of paramedic interventions occurred, with the landmark Ontario Pre-Hospital Advanced Life Support study being a paramount example.

As EMS evolves, changes to paramedic interventions must be evidence-based. Therefore, EM Service and paramedic involvement in research is crucial. Superior North EMS paramedics are now involved in important research being conducted by the Ottawa section of the Resuscitation Outcomes Consortium (ROC). Thunder Bay firefighters also participate in certain clinical trials on CPR.

The focus of the ROC is to conduct multiple collaborative trials to aid rapid translation of promising scientific and clinical advances to improve resuscitation outcomes. These are not limited to “vital signs absent” patients.

Action Item: SNEMS to collaborate with the Northwest Regional Base Hospital Program on research efforts.

Action Item: SNEMS to include paramedics in decision making regarding participation in clinical trials

Action Item: SNEMS to work with the Thunder Bay Fire and Rescue Service in decision making regarding germane clinical trials

Dedicated Paramedic Skill Review Program (District)

District paramedics have relatively low call volumes

This reduces opportunities to practise the paramedic skill set

Action Item: SNEMS to develop a dedicated paramedic skill maintenance program.

Action Item: SNEMS paramedic instructors to deliver and maintain the program.

Action Item: SNEMS to collaborate with the Northwest Regional Base Hospital Program.

Succession Planning

Leadership and management development opportunities for paramedics are lacking.

It is difficult to identify paramedics with leadership potential due to the lack of opportunity.

Action item… strike a joint committee (SNEMS leadership and paramedics) to develop a succession planning program.

7. Strategic Plan Implementation

Implementation

Strategic Plan Internal Working Group to take the lead on design & execution of implementation critical path

Time stamped action items of both bundles of recommendations

Annual progress report on plan integrated with SNEMS scorecard & business plan target achievement reporting

Acknowledgements

Internal Working GroupDeputy Chiefs Wayne Gates, Don Stokes, and Ernie KadikoffOperations and Budget Analyst Brent ClineParamedics Paula Verin, Mark Mannisto, Andrew Dillon, and Kyle Stamler

Governance CommitteeMayor Keith HobbsCouncillors Ken Boshcoff and Rebecca Johnson (Thunder Bay), and Terry Fox (Marathon), Gino LeBlanc(Terrace Bay) and Bev Dale (Neebing)City Manager Tim CommissoAndree Robichaud, President; Rhonda Crocker-Ellacott, Vice President, and Lisa Beck, Director, TBRHSC

Performance Concepts and Interdev TechnologiesTodd MacDonald, Principal, Performance Concepts ConsultingBrian Field, President, Interdev Technologies

Superior North EMS paramedics

Documents

Superior North EMS Strategic PlanNorth+EMS+Strategic+Plan+2… · I’m proud that through this strategic plan, ... developing a 5-year strategic “change” program to ... increasing