Ambulance contracts begin to measure what matters

By Jay Fitch, PhD

EMS systems often evolve slowly in the absence of a crisis. One needs only to look at the contracting and RFP processes utilized by many communities to see that the contracting processes for ambulance services have become stagnant. Without a scandal, bankruptcy or other red flag drawing scrutiny to the system, these agreements with ambulance services use antiquated provisions and often measure the wrong things.

Communities frequently rely on data and measures that are easy to find and calculate, rather than those that can be most effective in assessing performance and making improvements. Many communities focus almost exclusively on response time, subsidy amounts and the user fees charged by the contracted ambulance service.

Developing ways to effectively measure clinical performance and customer satisfaction is far more difficult. But with more communities focused on resident needs and the rise of patient-centered health care, building these metrics into ambulance contracts and budget cycles is critical to achieving the best outcomes for patients and the community.

Measuring what matters is key to that effort. In addition to baseline response time and service costs, RFPs must meaningfully delineate the expectations for clinical outcomes and improving the patient experience. To be minimally qualified to participate in a sophisticated procurement process, an organization needs to demonstrate its capabilities and experience measuring impacts on each of these dimensions.

Community leaders are beginning to appreciate that what they emphasize in the RFP shapes the expectations and performance of its provider. For example, clinical management in the call center is essential to begin making evidence-based decisions for safe and effective deployment and dispatch of resources.

In those systems where the response to every 911 call is "hot," leaders are not considering the risk versus the benefit. Any ambulance RFP that does not require utilization of an accredited emergency medical dispatch criteria quite simply is putting patients, caregivers and citizens at risk and should constitute culpable community negligence.

Because outcome data is often difficult for EMS agencies to access — and the EMS impact on patient outcomes is not always easy to determine — many of the clinical metrics being used in today's contracts focus on clinical skills and procedure success rates rather than patient outcomes. Process measures, such as intubation and intravenous access success rates and correct recognition of strokes and STEMIs, are a good start and can help an agency assess its own training efforts.

While the evidence base is growing, it still isn't always clear which processes are tied to good outcomes, although we're starting to achieve more clarity. At the same time, though, even our measurement of processes is limited.

The Cornerstone Survey, which last year asked more than 500 agencies about data collection and analysis, revealed that while most systems measure cardiac arrest return of circulation and STEMI and stroke recognition, only 53 percent track door-to-balloon time and only 47 percent track cardiac arrest survival to discharge [1].

In contrast, ambulance service contracts of the future will objectively report an expanded series of clinical process measures and ultimately will require linking those measures to actual outcomes as software tools facilitate improved data sharing — a few include these measures already. There is significant work that needs to be done to facilitate cost-effective data exchanges in a more integrated system of care. That said, several EMS software vendors have already created initiatives to meet this need.

The patient experience
Hallmarks of good system design and RFP processes were best articulated by the American Ambulance Association nearly a decade ago in its guide for contracting for ambulance service [2].

The five hallmarks are:

1. Holding the service accountable.
2. Objective and independent oversight.
3. Accounting for all system costs.
4. Requiring system features that ensure economic efficiency.
5. Ensuring long-term high-performance service through measurement.

Since the contracting guide was published, the health care community has widely adopted the Institute for Healthcare Improvement’s Triple Aim, placing an increased emphasis on the patient experience in addition to heath outcomes and costs. As they continue to advocate for value-based purchasing, federal agencies may well use an EMS agency’s patient satisfaction scores when determining reimbursement levels, as they do in the hospital setting by utilizing the Hospital Consumer Assessment of Healthcare Providers and Systems.

The HCAHPS survey is a very structured process, typically administered by a third party. Yet while nearly six of 10 agencies reported in the Cornerstone Survey that they are attempting to track patient satisfaction, only 18 percent are measuring it through a third party.

EMS agencies can expect that future professionally managed RFPs will likely require the independent measurement of patient satisfaction. This will be a significant factor used to differentiate the agency's performance under the contract.

While the state of performance measurement in EMS continues to evolve, traditional measures to report performance used in professionally managed RFP processes are clearly moving beyond response time to include increasingly sophisticated measures of clinical metrics and patient satisfaction. That trend will continue, and future ambulance RFPs and contracts will require more integration with local healthcare systems in order to truly measure what matters.

About the author
Jay Fitch is the founding partner at Fitch & Associates, which has managed procurements successfully in major U.S. cities and smaller communities. Contact Jay directly at jfitch@emprize.net.

References
1. Fitch, J. & Fuentes, G. (2016). The State of Data Use in EMS. Download the Cornerstone survey.

2. American Ambulance Association (2008). EMS Structured for Quality: Best Practices in Designing, Managing and Contracting for Emergency Ambulance Service.

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