Transparency.    It's been a buzz word around Wall Street ever since the Worldcomm and Enron debacles.   Thankfully, it is now a requirement for accounting in most publicly traded corporations.   But what about in EMS?   Is your organization providing transparency to your stakeholders?   What are the risks and benefits of making things "perfectly clear"?

In the past, some private providers felt it was necessary to keep some things about their EMS operation secret. Response times, clinical performance, attrition rates, and the deepest, darkest secret - revenues and expenses. In today's environment, public trust and disclosure is more important than ever. It does not matter whether you are a public or a private provider, transparency can be one of your greatest public relations and market retention tools.

There are two primary barriers to being completely transparent:

1. Fear and insecurity. For some, it's the fear of showing that your response times are not what they should be, or that your intubation success rate is below the accepted standard. For others, perhaps it's showing that you are making gobs of money (by the way, if you are, you're probably tracking your profit and loss statements properly!). Or worse yet, perhaps you are fiscally failing and clinically a wreck. If so, it's most always best to come clean - but be sure to have a plan of correction! As for insecurity, there are providers out there who believe in the ostrich theory of operations and partnership. Sort of the ''don’t ask, don’t tell'' approach to performance reporting. You may be unsure about your ability to stand-up to the benchmarking process and risk losing the market. If no one knows how well, or bad, you are performing, no one will try to replace you, or get you replaced.

2. Lack of Knowledge. It may be that you are unsure how to account fully for revenues and expenses. Honestly, this is true for almost every public provider agency in the business. It's not that the people are unaware of how to track and report key performance indicators, but rather, it's HARD to identify and quantify certain things in the public sector. It could also be that the agency has never tracked certain KPIs and are not sure where to begin...

Let's tackle these barriers in reverse order.

What to track and report.

There are numerous articles and published tools on EMS KPIs and benchmarking. You can find one of the best tools at the Fitch and Associates web site (http://www.fitchassoc.com/resources.html). If you've never done it, start small and simple. Stick to the KPIs that will really matter to your stakeholders. Things like incremental and fractile response times, gross revenue, net revenue, revenue per unit hour, revenue per transport, total expenses, expenses per unit hour and expenses per transport. From a clinical perspective, you should report IV and intubation success rates (on both a procedural and outcome basis), cardiac arrest survival using the Utstein template, and percent of patients whose condition "improved" during the EMS encounter.

Financial KPI traps. There is a huge difference between "gross revenue" and "cash in the door". Many EMS agencies - especially public providers - fall into this trap, either by accident or by design. During recent site visits to several public agencies, when asked "what was your net revenue last fiscal year?" many of them reported how much they BILLED for the year. Billed is not collected. Most EMS agencies have collection rates between 55 and 65%. If you are reporting billed charges as your revenue, you're overstating your income by almost 50%. Similarly, you need to account for all expenses. Public agencies will have a significant challenge with this. You need to account for capital, purchases, shared services (the city or county accounting staff, HR staff, legal folks, etc,). Once you have accurate revenue and expense figures, the rest of the math is simple.

Clinical KPI traps. The biggest issue here is that many agencies mistake "outcome" measures with "procedural" measures. If your patient needs to be intubated and you make two attempts at the intubation with the second being successful, your outcome is 100%, but procedural success rate is 50%. You should track and report both. By the way, there has been a lot of discussion about what constitutes an "attempt" at an intubation. Most EMS physicians and anesthesiologists define an attempt as the cessation of manual ventilations with the goal of placing an endotracheal tube. Once you stop one treatment to do another, that is an attempt. It's NOT JUST inserting the tube, realizing it's in the wrong passage, and removing the tube. While that IS a failed attempt, a failed attempt is also stopping ventilations, attempting the visualize the vocal chords only to find the bulb on your #7 Mac blade is burned out.

Fear and Insecurity.

If you are providing poor service, or not bringing value to your community, you DO have much to fear. If that is the case, DO something about it. Set in place mechanisms to improve performance so that you will want to trumpet your KPIs from the top of the mountain. If it means going to flexible deployment and system status management to improve response times, do it. If it means initiating a comprehensive clinical quality improvement program, your patients (and your medics) deserve it! Similarly, if you have out-of-kilter finances, fix that too! Making too much money? Make enhancements and invest in your employees, facilities, etc. If you're making too little, or losing money, address that seriously before it's too late. Don't be ashamed to report your finances. If you are a for-profit company, people half expect you to make money. It's not unreasonable to make a 7 - 10% return on your investment. It is unreasonable to make 20 - 30% though! But thankfully, CMS and MCO reimbursement rates have helped prevent this type of arbitrage profit. Conversely, if you're losing money, report that too. It may help gently prepare the community for a change, either in system structure, finance, subsidy or all of the above.

Get the word out.

Now that you know how to use KPIs and have refined your agency to a level you're proud to report, "just do it". Mail a KPI report monthly, put your stakeholders on an e-mail distribution list and send out monthly reports. Use the web – it's a great tool! At Tri-State we actually have a KPIs page on our web site with all the year to date charts, graphs, reports, etc. and we do mail the reports monthly to our elected and appointed officials. Some of the statistics used in KPI reporting can be a little difficult for officials to understand, so when you are ready to distribute your first reports, it's a good idea to set up at time to sit with the key stakeholders to explain the reports. In doing so, be sure to relate what the reports mean to THEM, or to their constituents. We found this to be true especially for the whole 'fractile' reporting concept. We used two hand-drawn diagrams to help. One with the standard bell curve representing a normal distribution for determining "average" response times and one curve skewed to the right to depict the fractile measure. A picture is truly worth 1,000 words.

Benefits of Transparency

Today's EMS market is very volatile thanks to the continued ramping down of reimbursement rates from most large payer groups and increasing expectations of the public. We should not have any 'secrets' from our customers and stakeholders. Demonstrating a commitment to transparency, you can build a trusting relationship with those responsible for helping assure your success.

It is often said that if you've seen one EMS system, you've seen ONE EMS system. There are currently not well defined 'national standards' for EMS system performance. But, you can establish you community's standard for the EMS system's performance. If your agency is truly bringing value (defined as the intersection of the sloping lines of cost and quality), let others try to beat your performance!

It's one thing for YOU to say "our agency meets a XX% fractile response time under XX minutes, with an all ALS system, and an average patient charge of $XXX with no public subsidy. AND we have a workforce with an average tenure of XX years; each paramedic treats XX ALS patients per shift with an IV proficiency of XX% and intubation proficiency of XX%."

It's something entirely different when the chief elected official in your service area can quote those stats!!

Any elected or appointed official will tell you that the thing they detest the most, is surprise! If they are forewarned, they can be for-armed if necessary to battle FOR you….

If you need any assistance setting up a KPI monitoring system, please contact me and I'd be happy to help.

To view our published KPIs, feel free to visit www.tristateambulance.org/performance/key_performance.htm