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. | 
