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January 1999

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Emergency Quality Management

Mission Impossible: The Ultimate Facilitation Challenge

Do You Believe In Magic?

Remembering Root Cause Analysis



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by Peter Block

Fox Shows Employees It Has Heart
by Lynn L. Franzoi


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Emergency Quality Management
Redesigning 911 and EMS Services Wins Florida Team Trip to AQP’s National Team Competition

NFC: Tell me a little about how your team was selected.
Locurto: Our EMS team was not the only team involved. First there was a team developed to do a strategic plan to try and solve the EMS problem in the city- which is that there were a number of customer complaints. They said that basically we need to find a better way to provide EMS and we are going to do it ourselves. I was hired in August of 1995 as their “EMS expert” to run the division.
Shortly after I was hired, the city commission decided to put out a request for proposals (RFP). Our team was put together to develop the performance measures we wanted to have in the RFP—basically, what type of EMS system we wanted to have and what we wanted it to look like. The team consisted of individuals from accounting, the fire department and the manager’s office.

We developed the RFP and we became the team that developed the fire department’s bid as part of the RFP along with two other private services and Broward County. As part of the development phase of the RFP, we had to do a lot of research into best practices and some benchmarking to find out who performed the best service; what were their performance measures?

NFC: How did you find those systems to benchmark?
Locurto: Basically we read a lot of EMS journals. We contacted individual fire departments, private services and state agencies looking for what they had, what they could recommend as far as performance measures and whom they would recommend talking to. There are a number of departments locally, right here in Broward Count; one department won a national EMS award. We narrowed it down to probably four or five that were very similar demographically—that would be population, square miles, average age of the populous. We did a lot statistical gathering from there—how many EMS runs, how many patient transports, what were the response times, what training level were the individuals on the trucks, what equipment they carried. We went as in-depth to get as much information as we could to know exactly what we wanted from a provider. The RFP became very detailed. The providers had to meet a lot of requirements.

In November 1995 we did a presentation with the other three applicants who responded to the RFP and the commission voted to give us the contract.

NFC: What was the darkest moment during the whole process?
Locurto: I think the darkest moment was the time in between the presentation and the time of the award. It was very difficult. It was like the Miss America contest waiting for that moment to see who would win. There was heavy lobbying from the private providers and also by the county provider. It is quite a lucrative contract for anyone of them so they really pushed hard. Of course, being internal employees, we couldn’t do that type of lobbying so we were at a disadvantage in that respect.

NFC: If someone were going to do the same thing, what would be your key words of advice?
Locurto: My best recommendation would be to gather as many key people within the overall organization to put a proposal together.

NFC: Do you think because you used this cross-culture functional team it carried more weight with the city commissioners?
Locurto: It definitely did. There was a lot of verification from all different angles. I can write a budget, but by no means am I a budget analyst or a financial person. When you get the city comptroller saying, “This is a verifiable budget. These are true figures,” that carries more weight with the city commission.

NFC: What makes this unique? Why wouldn’t any municipality do it this way?
Locurto: Interesting that you mention that. I think there are a number of cities that are starting it. What made us unique is that we were going through a transition period. Not too many municipalities or counties have been through this type of situation where they totally changed the provider of EMS. They are unlikely to have an internal cross-functional team preparing it. They could have done an RFP, but their own fire department might not participate in it.

NFC: Or the fire department might, but they might not use a cross-functional team.
Locurto: Right, they might not use cross-functional teams or they may simply hire a consultant. They might not use quality tools.

NFC: What quality tools did you use?
Locurto: We used all the charting tools—Fishbone, Pareto. We used Pareto when we compared the demographics. Fishbone was used when we looked into Root Cause Analysis.

NFC: If your response time is low, aren’t the obvious answers that they were caught in traffic or that there isn’t enough equipment?
Locurto: Right, that would be the obvious. And that was one of the problems with the county service. We discovered the overall root cause was that the county was nonresponsive. The city had no input on how the county operated their service and that was really the main cause. In addition, we were a receiving plant for 911 calls so we would receive a call and the conversation would go something like this:
911: Is this an emergency?
Caller: Yes.
911: What type of emergency do you have?
Caller: We have a sick person—somebody is having a heart attack.
911: Can you hold on please while I switch you to Broward County.
They would press a button, but there were times when the phone would ring three, four and five times before the county would actually pickup. Then when the county would pick up the caller would have to go through all that again.

NFC: Once it was accepted, how did you reduce the response time to less than six minutes 95 percent of the time so quickly?
Locurto: A couple of ways. We increased the number of units—one of the four units was funded through a contract with the city of Parkland, which is north of Coral Springs. So we actually doubled the number of units and the units were dedicated to Coral Springs and Parkland, which covers 39 square miles and approximately 125,000 people.

We doubled the units and now we dispatch our own units so there is no transfer of calls. The units are dedicated to Coral Springs; they will only leave Coral Springs if they are transporting a patient to a hospital outside of the city or if we are requested to run a mutual aid call to another city. Also, we train and continue to train all the people we hire on to get around the city and how to read the maps.

NFC: How often would you look at your data in terms of response times? Daily, weekly and is it all automated?
Locurto: It is all automated off the CAD (Computer Aided Dispatch) system. There was a point when I was doing it every other day and then it went to weekly. I was keeping very close track of it in the beginning.

NFC: Did you use control charts?
Locurto: We used some control charts. The data from the CAD system comes up fairly raw. The ISP people put together a report for me so that I can actually see how many calls we get in minute intervals. And then I have to do some control charts myself and look at it that way—to put up some norms. We did have a performance measure and knew what we wanted to meet, so we looked at not only how many calls were not in the norm, but we looked at the ones we had difficulties with and looked at why we had the difficulties. So we got together a group within our EMS division and we talk about the problems we were having in the field and how we could improve those problems. We met every other week during the test phase and a lot of things came out where we had to move certain units to certain areas at certain times of the day. For example, during school hours when we had school zones to worry about. There’s a lot of little things that we fine tuned.

NFC: When a call comes into Coral Springs to 911, where is it immediately routed?
Locurto: It goes immediately from the call taker to our dispatcher. Our performance measure from the time we receive the call to the time that we dispatch the call is 90 seconds at least 95 percent of the time. And we’ve beat that. We are down to about a minute or less.

NFC: That’s five percent of the time where it’s 90 seconds or more. Why is that?
Locurto: There are times when the call is not received properly. In other words, a call may come in and the call taker cannot find out immediately what the problem is. Sometimes it is a language barrier, sometimes somebody might just be too weak to talk and what they’ll do sometimes is route it to the police dispatcher thinking it’s a police call and they will stay on the phone. Even though they are a 911 call taker and employed by the police department, by means of budgeting we pay for part of that service so we have a large input into dispatch.

NFC: Did you involve any of the 911 operators in any of this?
Locurto: In the initial team, no. But later on, absolutely. They were included from day one on the operational end of it. They took a big part and we brought in a new service which is Emergency Medical Dispatching through a company called Apco. All our dispatchers and call takers are trained to give first aid instructions over the phone while the units are enroute—I’m sure that you’ve seen that on television. And we never had that before we started this. That’s an added service for us. We work very closely with them.

We also do quality assurance. We’ll review cases on a monthly basis. We’ll see how we can improve, how they can improve, what we are doing right, what we are doing wrong and we’ll continue to monitor.

NFC: What happens if, with an operator, there are some deficiencies that are hurting the response time or getting you less than 100 percent customer satisfaction? Because they don’t really report to you, have you had to cross that boundary with the police department?
Locurto: Yes, we have crossed boundaries. However, we have been given the green light as far as our fire and rescue dispatchers are concerned. While we don’t have direct supervisory capabilities, we do monitor what goes on there constantly.

NFC: So they are an internal supplier to you?
Locurto: Right. So they are looking to satisfy us as a customer and we are always giving feedback. I know what the call taker and dispatcher have done by monitoring and looking at the CAD report. I know the call taker and dispatcher’s name from the report and I can call or email them for an explanation of what happened on a call.

NFC: Why do you think other municipalities don’t work in this kind of approach?
Locurto: I kind of think that quality management has not really been accepted in the governmental structure yet. I just think that one of the main reasons is that politics are a large part of what happens in a governmental organization, which can be a problem if you are looking at the operation and what can work best in the operation but then you have to make all these political people happy.

NFC: In Coral Springs, it was the citizens, or customers who demanded a better system.
Locurto: That’s correct and I think that more and more political and governmental agencies are looking at it from that respect. I think that also you had a lot of older generation management in a lot of these cities that are very hierarchical and they go back to management by objectives type styles. They are retiring now and the newer people are coming in with the new management styles and quality management. So I think it’s evolving.

NFC: Is your team looking forward to presenting at the national conference? Are they nervous yet, or excited?
Locurto: Oh yeah, I don’t want to show it, but I’m a nervous wreck. I mean it’s a major challenge.Getting this far is great.

NFC: What would be your reaction if you came back with the Gold Award in the AQP competition?
Locurto: I’d be ecstatic. I would think that in looking at last year’s competition, with Honda Motor Company who was actually the winner, they were really super. I would think that just to be able to compete with those types of organizations is a great thrill.

January '99 News for a Change | Email Editor
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