Why High-Performance EMS Is Worth Your While – Doug Hooten & Jonathan Washko

First Published in EMS World Magazine  Dec 2016.

Demonstrating high performance and high value is becoming increasingly important to our evolving healthcare environment and changing community expectations. The financial sustainability—and perhaps even the very survival—of EMS may hinge on our ability to prove the services we provide are valuable.

Defining value in EMS has been relatively elusive, as clinical, operational and fiscal performance measures are often disparate from one system to another. But there are common hallmarks of high performance that any EMS agency can use to demonstrate value to stakeholders.

The Academy of International Mobile Healthcare Integration (AIMHI)—an association of EMS agencies committed to providing high-performance and high-value EMS and mobile healthcare services—is excited to partner with EMS World to produce a yearlong series of articles that will discuss the attributes of high-performance/high-value EMS system design and operations. The series will include topics such as:

  • Attributes of high-performance EMS;
  • International models of EMS system design;
  • Using data to maximize operational efficiency;
  • Financial analysis and new economic models;
  • IT trends and cybersecurity in EMS;
  • Managing a diverse workforce;
  • Working with elected and appointed officials;
  • Developing stakeholder relationships;
  • Case studies and lessons learned in remote deployment centers.

The goal of the series is to assist EMS agencies in creating high-performance EMS processes and help demonstrate value to local community stakeholders.

—Matt Zavadsky, MS-HSA, EMT, Chief Strategic Integration Officer, MedStar Mobile Healthcare, Ft. Worth, TX

EMS systems of today, regardless of their design, face unprecedented challenges. Changing stakeholder expectations and rising financial pressures are driving a need to demonstrate that they provide value. Recent local and national media stories illustrate this shift in expectations and challenge the value equation the EMS profession has used for years.1–7

“Police transport a good bet for shooting victims, study finds”

“Need an ambulance? Why you may not want the more sophisticated version”

“Think the ER is expensive? Look at how much it costs to get there”

“Modesto rejects $1M firefighter paramedic grant”

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“Lockport plans to auction off ambulances, cut fire staffing minimum”

“Kalispell voters reject extra taxes for EMS”

“Is the current model for public safety service delivery sustainable?”

EMS agencies that desire to be successful in this rapidly changing environment need to demonstrate value in new ways by delivering high-performance EMS (HPEMS) as the first step to proving high-value EMS (HVEMS). There are generally three main hallmarks of HPEMS: clinical proficiency, operational effectiveness and fiscal efficiency. These hallmarks must be leveraged in a way that balances what is known as the EMS success triad: patient care, employee well-being and long-term financial sustainability. The Academy of International Mobile Healthcare Integration (AIMHI) has articulated several key attributes of a high-performance EMS system that help achieve these three hallmarks:

1. Sole Provider

Clinical proficiency—As a sole provider, an EMS agency will generally be able to maintain a high utilization of the EMTs and paramedics operating within the system. Higher utilization provides the opportunity to refine critical clinical skills such as patient assessment and effective clinical care. Additionally, a single source of quality oversight for all emergency and nonemergency calls helps ensure every provider, regardless of the type of service they provide, shares common credentialing and quality improvement processes.

Operational effectiveness—A single provider can also maximize operational effectiveness for the system. A patient awaiting transport to a skilled nursing facility from Acme General Hospital can be efficiently transported by the ambulance that just brought a chest pain patient into Acme General’s emergency room. The same unit that transports the patient to the SNF can then be posted to provide temporal or geospatial coverage to that area. Having multiple ambulance providers operating in the same market generally leads to underutilized resources and makes the system less operationally effective.

Fiscal efficiency—The provision of 9-1-1 service is expensive, and the reimbursements more challenging. A sole provider can balance the generally lower-cost, higher-reimbursement nonemergency services to help offset high-cost, low-reimbursement 9-1-1 services. A single layer of utility-like cost structure minimizes the financial impact to the taxpayer and other payers. Further, the operational effectiveness of the sole provider, as explained above, helps reduce the overall cost of the EMS system by preventing multiple infrastructure costs and lower utilization.

2. External Accountability

Clinical proficiency—Holding yourself externally accountable for clinical care helps improve the care provided by identifying areas of potential improvement, coming up with a plan for improvement, implementing the plan and evaluating the results. Some EMS agencies are financially incentivized for demonstrating compliance with scientifically proven clinical bundles of care for conditions such as STEMI, stroke, trauma and hypoglycemia.

Operational effectiveness—External accountability for performance measures like extended response times, unit hour utilization, lost unit hours, employee turnover and mission failures encourages the EMS agency to continually improve these metrics.

Fiscal efficiency—Similarly, reporting and being held accountable for financial measures such as cost per unit hour, cost per call, cost per transport, revenue per transport and revenue per unit hour encourages EMS agencies to improve these measures, as well as benchmark their performance to other similar agencies.

3. Control Center Operations

Clinical proficiency—Controlling your own resources helps ensure your units are appropriately utilized, increasing the clinical proficiency of your field EMTs and paramedics. If another agency is controlling the placement and deployment of your units, it is more difficult to assure appropriate utilization.

Operational effectiveness—As with clinical proficiency, relying on another agency to control your assets may reduce operational effectiveness and make it harder to achieve the correct balance between supply and demand.

Fiscal efficiency—Relinquishing control of your assets to another control center operator may increase costs through less effective asset utilization and lost unit hours.

4. Revenue Maximization

Clinical proficiency—Employing system design and business practices that maximize revenue generation within the EMS system allows the provider greater ability to invest in training, equipment and medical oversight that improves clinical proficiency. For example, FirstPass, a valuable tool for near-real-time clinical quality metrics, requires a significant resource investment. The ability to invest in a system like FirstPass is enhanced when the agency maximizes revenue generation.

Operational effectiveness—The same is true for investing in tools and processes to achieve operational effectiveness. Examples could include an investment in software to predict call volume and locations; dedicated departments that stock, maintain and redeploy ambulances with a high degree of reliability; and sophisticated computer-aided dispatch systems designed to maximize resource utilization.

Fiscal efficiency—Clearly collecting the appropriate fees for the services you provide helps make the system more financially sustainable and could even reduce the tax subsidy burden. This is common in some EMS-based fire agencies that provide nonemergency transfer services as a way to increase revenues.

5. Flexible Production Strategy

Clinical proficiency—Effectively matching supply to demand helps ensure enough EMS resources are on duty to handle larger call volumes while minimizing the number of idle units and amount of nonproductive time. This again helps assure field providers are using their clinical skills regularly to maintain proficiency. It also helps prevent burnout (too many calls per provider) and rustout (too few calls per provider).

Operational effectiveness—Using a flexible production strategy helps maintain a healthy and manageable unit utilization through the day and year, making the system more operationally effective.

Fiscal efficiency—Matching supply to demand improves the financial efficiency of the system by minimizing the expense of excess capacity.

6. Dynamic Resource Management (DRM), System Status Management (SSM)

Clinical proficiency—As with the other attributes, moving resources within the system to cover anticipated demand helps enhance utilization and consequently improve providers’ clinical proficiency. It may also help reduce utilization in high call volume areas and prevent burnout.

Operational effectiveness—Having the right resources in the right locations can significantly improve operational effectiveness. If you know there are high-volume areas in your jurisdiction, dynamically deploying resources from low-volume areas allows for enhanced service delivery.

Fiscal efficiency—Matching supply to demand is a first step in achieving fiscal efficiency. The second step is to have those resources in the right places. DRM allows moving available resources throughout the system to meet anticipated call volume. Combining a flexible production strategy with DRM has a significant impact on effectively using your on-duty resources.

The EMS Success Triad

The EMS success triad is a philosophy and business compass that can be adopted within any EMS system type, and its importance is highlighted in any HPEMS system. The triad includes a constant balancing of:

Patient care—When we speak of patient care, we must think beyond the clinical aspects of care and also include the value aspects such as patient satisfaction, patient safety, customer service, response time and service reliability, and outcomes.

Employee well-being—EMS is a service business, and service businesses are founded on their people. EMS must acknowledge this and build systems and processes that acknowledge the impacts of lean design on its teams. Issues such as adequate breaks, workload balancing, employee engagement, just culture, trust, employee safety systems, work-life balance, schedules and scheduling, compensation strategies, organizational and mission passion and decision making involvement are just a few areas EMS must work to improve.

Long-term financial sustainability—Every decision made within an EMS organization has a cost that impacts the triad in some fashion. These costs must be accounted for and balanced. Cost is a relative term and not necessarily financial in nature (e.g., impacts on patient care and employee well-being). No matter the type of business structure or operational philosophy an EMS system has, the concept of “no margin, no mission” always applies. Long-term business, financial and other cost impacts must always be kept in check if an EMS system is to remain sustainable.

While not every EMS agency or community will be able to employ all the attributes of HPEMS, we are convinced many EMS providers can use some of these principles to demonstrate the value they bring to their community.

In next month’s column we’ll focus on providing high-value EMS.


AIMHI represents high-performance emergency medical and mobile healthcare providers in the U.S. and abroad who deliver care to more than six million people over more than 43,000 square miles and responding to nearly a million calls annually.

Formerly known as the Coalition of Advanced Emergency Medical Services (CAEMS), AIMHI changed its name in March 2015 to better reflect its members’ dedication to promoting high-performance ambulance and mobile integrated healthcare systems.

Member organizations include high-performance EMS systems in locations such as Oklahoma City and Tulsa, OK; Fort Worth, TX; Richmond, VA; Pinellas County, FL; Charlotte, NC; Niagara, ON, and the province of Nova Scotia, Canada; New York, NY; Little Rock, AR; Davenport, IA; Three Rivers, IN; and Reno, NV. Find more information on AIMHI at www.aimhi.mobi.


1. Avril T. Police transport a good bet for shooting victims, study finds. Philadelphia Inquirer, 2014 Jan 8.

2. Sun LH. Need an ambulance? Why you may not want the more sophisticated version. Washington Post, 2015 Oct 12.

3. Rosenthal E. Think the E.R. Is Expensive? Look at How Much It Costs to Get There. New York Times, 2013 Dec 4.

4. Valine K. Modesto rejects $1M firefighter paramedic grant. Modesto Bee, 2016 Oct 5.

5. Prohaska TJ. Lockport plans to auction off ambulances, cut fire staffing minimum. Buffalo News, 2014 Aug 27.

6. Loper B. Kalispell voters reject extra taxes for EMS. Daily Inter Lake.

7. Matarese L. Is the Current Model for Public Safety Service Delivery Sustainable? ICMA Publications.

Doug Hooten, MBA, is the chief executive officer of MedStar Mobile Healthcare in Fort Worth, TX. He has over 37 years of experience in EMS, having served as senior vice president of operations and regional director for American Medical Response, CEO of the Metropolitan Ambulance Service Trust (MAST) in Kansas City, and in a variety of leadership roles with Rural/Metro in South Carolina, Georgia, Ohio and Texas. He has expertise in change management, cost optimization, process improvement and clinical excellence. Doug is the president of AIMHI, serves as a board member for the American Ambulance Association and is a member of the National EMS Advisory Council (NEMSAC). 

Jonathan Washko, MBA, NREMT-P, AEMD, is the assistant vice president for Northwell Health’s Center for EMS and leads numerous innovation efforts to improve patient care, employee well-being and the long-term financial sustainability of EMS systems. He volunteers as a board member with the American Ambulance Association, NAEMT, AIMHI and NYMIHA and also serves as a member of the EMS Compass initiative, working to develop standardized industry measures, as well as an advisor to the Promoting Innovation in EMS (PIE) project. Reach him by e-mail at jwashko@northwell.edu


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