By Randall Reid, ICMA Staff

Not long ago I was sitting in my local hospital waiting room for clearance to see my wife, who had just had surgery. The room overlooked the emergency entrance, where ambulance and rescue squads deliver patients. This was familiar territory, as the crews were from the county and the surrounding municipalities I formerly managed. I know these dedicated public emergency workers and the details of their department’s staffing, numbers and types of rescue equipment, and the response challenges of our unique regional medical hub, which serves a half dozen rural counties and heavily traveled interstate systems.

Looking down on the scene, I reflected on the planning public managers do to provide high-quality medical services that require substantial expenditure of tax dollars. It is vitally important to have complete data and carefully thought-out metrics to monitor the performance of delivery systems like emergency medical services. I could not help thinking of the nexus between performance management and the scene in the emergency entrance outside my window.

Metrics for emergency medical response are numerous and varied.

Most county rescue squad commanders are metrics-oriented and would be concerned with the number and skill level of the personnel on duty and available during each shift for each squad or rescue unit, the medical inventory controls per call, and downtime for vehicle maintenance.

Many jurisdictions would focus on the transparent reporting of cost per call, staffing coverage ratios, and insurance claim cost recovery rate. Others might highlight service delivery equalization within demographically formulated response districts or zones.

Most jurisdictions would capture dispatching metrics as well, such as unit response from time of call, ALS/BLS counts, and prevalence and survival rates for cardiac events. On top of that, interjurisdictional comparisons would need to take into account population density, median age, poverty rates, and information on the organization of the EMS functions (e.g., integrated with fire, third-service, consolidated public safety department, franchise, volunteers, etc.).

What I am describing is a complex series of measurements in a complicated delivery system involving multiple agencies and a major hospital. Every governmental service delivery system has critical points and needs to develop performance metrics to monitor key indicators on each segment.

From my perch on the third floor, I could see that at least on this weekday much of the county’s rescue vehicle fleet on call were out of service because they were waiting for patients from other units to be processed by the busy hospital emergency room staff. In this case a series of metrics would undoubtedly show that this transition point of handoff between two systems deserved its own focused metrics and analysis. And my management curiosity would make me ask the question “what must these metrics look like on a busy Friday night?”

Citizens at budget hearings question rising taxes and the rising costs of expanding paramedic staff. They ask why such a large number of expensive rescue units are required to serve our county. Many would question why we roll fire trucks first on medical calls when there is no fire. Some would speculate that uninsured populations seeking primary treatment in the emergency room could divert resources from true emergency calls. A few might consider how the growth and policies of the county affect health care delivery. As a public administrator I would be concerned with both the efficiency and the effectiveness of our emergency services.

The drama of an emergency room illustrates why efforts to establish metrics and collect data for this service must be well thought out and reflect the reality of the scene below me. On this day the critical metric of choice would be “minutes to return to service.” Based on what I observed, any productive management effort to improve this system would require sharing performance data with the hospital administrator and the medical staff. Collaboration like that is needed for improvement in any field of municipal service delivery.

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