Debunking the Myths of System Status Management

This is the 11th installment in a yearlong series of articles developed by the Academy of International Mobile Healthcare Integration (AIMHI) to help educate EMS agencies on the hallmarks and attributes of high-performance/high-value EMS system design and operation. For more on AIMHI, visit www.aimhi.mobi.

The benefits of system status management (SSM) have been hotly debated, with some extolling the virtues of efficient resource utilization as a hallmark of high-performance/high-value EMS. For others it’s a bane that leads to crew fatigue and delayed response times. Mecklenburg EMS Agency (Medic) in Charlotte, N.C., has mastered the art and science of SSM, achieving a balance between system performance and crew satisfaction. Here’s what it takes to use SSM effectively.

Basics of SSM

At its core SSM is exactly what the term implies: a process used to manage a system. Management is an active process of transforming inputs (people, resources) into outputs (patient care, response times). Every EMS system is managed, but they can be managed differently.

One way to manage a system is to use a static deployment model, producing the same number of resources throughout a 24-hour period placed in fixed locations. An alternative way to manage a system is to be flexible in your deployment strategy, producing the number of resources likely needed to meet anticipated demand during a given period over a given geography.

Jack Stout, the economist credited with first describing the concept of system status management in EMS, believed using resources effectively creates value in EMS. The term SSM is used to describe the process of refining EMS resource management and utilization to improve patient outcomes and reduce the cost of EMS delivery.

When managing a system, it’s important to understand what your organization produces. EMS agencies produce unit hours; a unit hour is composed of four ingredients: staff, supplies, equipment and a ready-to-deploy ambulance (or fire response unit, etc.). When considering flexible deployment of unit hours, there are essentially two components to consider: temporal and geospatial.

The temporal component addresses the “how many and at what time?” question. The development of a unit-hour production schedule should be based on anticipated demand. In high-volume EMS systems, there are often patterns to call volume. Call volume is generally higher when more people are moving about—morning and afternoon rush hours, lunchtimes and what we in EMS affectionately refer to as “bar-thirty,” when drinking establishments close. These times typically also have traffic congestion (often discussed as impedance) that makes it difficult to get anywhere quickly. If you analyze your community’s demand over time, you can plan your production strategy to produce more unit hours when the predicted volume is high and fewer when the predicted volume is low.

The geospatial component of flexible deployment addresses where to place available unit hours. Placing the produced unit hour in or within reach of an area of anticipated call volume enables you to improve response times. Think of it this way: You can dramatically reduce response times by starting your response closer to the call. It’s not cheating to use data to inform deployment decisions and thus be ready to respond where our patients need us. Again, based on the demand, call locations can be generally predictable, which lets you actively manage your deployment plans. 

Why Use SSM?

Medic’s mission is “To save a life, hold a hand and be prepared to respond in our community when and where our patients need us.” We take that seriously. The largest expense to an EMS agency is the cost of readiness, and most of that cost is the people expense (wages, benefits, overtime, etc.). Being able to effectively manage this expense makes more money available for other things that make EMS systems great places to work and improve our care delivery: better pay for employees, the types of ambulances used, the equipment on those ambulances, employee-recognition programs. If you squander money doing a poor job at resource allocation (management), you have less available to do other important things. 

SSM is a way to use scarce (and expensive) resources effectively. If you want to be a high performer, you need to understand what you’re producing—the unit hour—then use that product effectively. This is why many high-performance/high-value EMS systems can operate efficiently and have great results at a lower cost, resulting in reduced taxpayer subsidies and a sustainable funding model.

The idea of SSM has, to some extent, been vilified by some in EMS. This may not be fair. It takes a very robust skill set to effectively and efficiently manage an EMS system. Without that skill set, you run the risk of creating imbalance in the system. SSM is implemented in three different ways: 

• Competence—People who do it right: the correct skill set, paired with the tools, data and technology to match supply to demand, working collaboratively with the people who will be responsible for implementing and operating within the system.
• Incompetence—People who think they’re doing it right but lack appreciation for the complexities and human impact of deployment planning and execution. They’re not bad people or systems, they simply don’t know what they don’t know.
• Malpractice—People who know how to do it correctly but intentionally choose to push the limits too far, drive crews to the point of fatigue and cause systems to fail. 

The two latter methods of implementation are most likely responsible for the vilification of SSM. The unintentional and intentional mismanagement of systems, to the detriment of employees and the community, results in poor system performance. Instead of understanding how to work within the system and improve, we blame the methodology, even when it hasn’t been implemented correctly.

SSM does not abuse people—failure to correctly develop, implement and manage a system plan causes the abuse. Balance is achieved when people know how to manage the system based on understanding the needs of the employees and patients. Jack Stout often asked, “How long does a unit hour last?” The answer is just about an hour—no more, no less. Unit-hour production is almost the perfect example of just-in-time production: You want to build just as many hours as you need given your demand—no more, no less. If you build your plan with an expectation that you’ll produce a certain number of unit hours and fail to produce that number, the system will be challenged regardless of the operational controls you put in place. 

Keys to Implementation

To implement SSM, you first have to commit to developing your leaders, have clarity on process and be willing to test changes in your practice. Once that underlying structure is present, we’ve learned there are three keys to effective system management:

• Predict—Forecast the demand in the system, both time and space; 
• Produce—Produce the resources needed based on the forecast and goals of your agency; 
• Observe—Measure performance and process reliability; not just response times but all the pieces that go into creating the outcome that is response time. 

We understand the gravity of the system management plan and its impact on our employees and customers, so we take the plan very seriously. Yes, we have all the tools, talent and resources to develop an effective plan, but we also realize we need balance in the plan to assure employee well-being and customer satisfaction.

We use a cross-representative team to refine our SSM plan to make sure it remains consistent with our mission. For example, we measure post-to-post moves and other daily activities and reduce unnecessary movement as much as possible.

These reviews have recently led us to an interesting discussion. EMS is still learning about call prioritization. Some would say we’ve created unrealistic community expectations for many of our low-acuity calls. If someone with a low-acuity medical need walks into an emergency department, how long would they wait to be seen? EDs queue patients based on acuity, and in some urban areas it may be hours before you see the inside of a treatment room.

Yet for some reason EMS agencies have set a community expectation that even low-acuity calls need a response in 15–20 minutes. Is that realistic when we know ambulance transport to a hospital emergency department will not speed up care for a low-acuity patient, and that ED may not even be the most efficient or effective resource to meet the patient’s need?

If we think of an EMS system as a healthcare system, how many “beds” (ambulances) do we have available, and where are they located? We’re starting to ask ourselves, “Is it OK to queue low-acuity calls to maintain resources for higher-acuity calls and decrease the stress and workload of our employees?”

From Static to Flexible

When implementing SSM, first, realize you’re already doing it. Any EMS agency that responds to calls has a deployment model; some are just not doing it intentionally. Their structure may be historically based on what’s easy for the agency or desired by the employees.

Think about your resource allocation and all the things you could do with the money saved by making more effective use of unit hours. Who wants to work for an agency that squanders money on ineffective resource deployment when it could be better used to improve the well-being of the employees and the community?

Then, start measuring calls by number and location. One of the most interesting questions to start asking yourself is, “How many calls did we run yesterday?” Many EMS agencies struggle with a definitive answer to that question. Requested responses, actual responses, those canceled en route or on scene, those with no patients or multiple patients—it’s a harder question to answer than you think. 

Build and follow the data. Learn how to develop and implement effective plans from systems and people who do it well. Start slowly and learn as you go. Some agencies have 90% of their EMS units on static deployment, with 10% as “peak demand” units. If you take a hard look at the data, you could slowly and intentionally begin shifting those static resources to dynamic resources, becoming more effective and creating clinical and economic efficiencies in the system. 

Final Words of Wisdom

EMS is healthcare. Healthcare is rapidly changing to a value-based economic model. Local taxpayers are beginning to focus on the same value-based models, and you’re seeing communities across the country begin to ask tough questions about the costs of service delivery and value.

Why should you become an expert in the production and placement of ambulance unit hours? Outside the benefits noted above, cost efficiency and the ability to pass those efficiencies on to our employees, unit-hour production is the core responsibility of EMS managers uniquely. No one is going to produce unit hours for us when and where we need them.

If we can apply management and improvement theory to how we produce unit hours and improve our response-time reliability, we can also apply those methods to improving patient care. It’s about matching resources to need, whether the need is system coverage to meet demand, a defibrillator to convert ventricular fibrillation or a conversation with a patient who may not be best served by ambulance transport.

Effective resource utilization is paramount in this new environment and a major disruptor in the provision of EMS, regardless of the type of agency providing the service. We encourage the EMS profession to continue identifying innovative methods to manage systems and match the resources we create with the needs of our patients. 

Joe Penner is executive director at Medic, the paramedic service for the Charlotte-Mecklenburg, N.C. area. He is a board member for the Commission on Accreditation of Ambulance Services, the American Ambulance Association and the Academy of International Mobile Healthcare Integration (AIMHI), as well as a fellow of the American College of Healthcare Executives. 

Jonathan Studnek, PhD, NRP, is a deputy director for the Mecklenburg EMS Agency. He is responsible for planning, developing, implementing and overseeing a comprehensive strategy for performance improvement, clinical education and human resources to include risk and safety. He also serves as the agency’s lead clinical researcher.