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“We had to go to the root of who we are to change our culture and come out the other end being different. That’s not something that a single person can do by themselves.”
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Creating an Emergency Medical Services Improvement Culture

By Ernesto Rodriguez | Wednesday, April 17, 2019

Emergency Medical Services (EMS) professionals don’t typically take part in health care quality improvement trainings, but Ernesto Rodriguez, the Chief of Emergency Medical Services in Austin, Texas, USA, believes that needs to change. A graduate of the Improvement Advisor (IA) program, Chief Rodriguez describes how creating an improvement culture in his organization has helped his team work more efficiently, communicate more effectively (including with elected officials), and saved their community money.

On his interest in learning more about quality improvement

I’ve been very interested in quality improvement for a long time. One of the improvement advisors (IAs) I met on my journey was [IHI Senior Lead, Improvement Science & Methods] Dave Williams. He did a training in our agency and I believe it was Dave who first introduced me to The Improvement Guide. I started reading it and ended up thoroughly confused! I decided I needed someone to help me understand improvement, so I enrolled in Wave 34 of IHI’s Improvement Advisor (IA) program and my world has never been the same.

On why more EMS agencies should learn about health care quality improvement

EMS does a lot of critical things in a very short amount of time with very little room for error. When you operate in an environment where everything you do matters, and you don’t have redo options, you’ve got to get it right. It’s important to find ways to simplify and standardize some of what we do and to provide the tools and the information so that people can make good and wise choices as they perform critical interventions.

There is a lot to be learned [from health care quality improvement] and the exposure to many different facets of health care is eye-opening. It’s good to learn with professionals from a variety of disciplines about how we can do what we do better.

On why he started investing in building the improvement capability of his staff

After I went through the IA program, one of the first things I learned was that I couldn’t do what I wanted to do by myself because we didn’t just need to improve the organization — we had to transform it. We had to go to the root of who we are to change our culture and come out the other end being different. That’s not something that a single person can do by themselves.

I decided to identify individuals with some skills and interest and sign them up for improvement training. When I looked into IHI’s Improvement Coach program, I found that it provides all of the essentials we need, so I sent three individuals to participate. The key result was that we sent them as individuals, and they came back as a team. That propelled us going forward.

An example of how improvement thinking reduced waste and saved thousands of dollars

We buy ambulances and they cost around $200,000 each. We buy them year after year, replacing old ones with new ones, and we continuously got complaints about the work space in the ambulances from our medics. The cabinets aren’t designed properly. Our equipment doesn’t fit. The flow is wrong.

So, we had been spending all this money trying to buy better ambulances, but we failed at it over and over. After coming back from an IA training, I had the idea to use PDSA cycles and see what we can learn using an ambulance prototype. I talked about it with several of our employees who are responsible for buying and designing, and I said, “Hey, let’s figure out how to mock up an ambulance.” My idea was to have a bunch of our medics walk through the mockup and give us some feedback.

The team built a wooden ambulance out of plywood using the exact dimensions of our ambulance. It included seats, a stretcher, and all the cabinets. We had a hundred medics walk through the mockup with a schematic diagram for our next design. Based on the input we received, we redesigned our ambulances. We don’t get complaints anymore. We get compliments. The medics tell us they finally have ambulances that help them get their jobs done.

I would estimate that we’ve probably saved easily $100,000 a year because we don’t have to make repeated modifications. Now when we get an ambulance, it’s ready to work. Turning an ambulance over to a medic crew and they’re smiling and can’t wait to get in it because they’ve heard how cool it is — that’s success.

On his mission to promote EMS measurement and transparency

We introduced the concept of making our data accessible to everyone. We used an open data platform provided by the city’s internet gurus. Now, we put our data online. Not only can someone log into our system and look at our performance, they can also download the data behind it and do their own analyses. It’s forced me to be smarter, faster, quicker, and to find better ways to involve the workforce. For me, it feels like we grew up. We make more intelligent choices because they’re backed up by data.

As an industry, EMS doesn’t typically monitor our performance as well as we should. We certainly don’t share the results of what we do know publicly. I personally have set out to change that.

One of the things I’ve done is worked with my team to put together a performance dashboard. We’ve identified the areas where we expect key results, including emergency response times and providing recommended evidence-based care. We’ve defined what our measures ought to be and what the results should look like. We’ve made it public.

It required some courage to be so transparent because sometimes you don’t do as well as you want to be doing. But that’s part of what we learned through IHI. It’s okay to not be as good as you want to be. It’s not okay to ignore it. You have to find a way to make it better.

On using improvement skills when working with elected officials

Our improvement skills help us communicate what our work means to our community. One example is how we’ve responded to our elected officials concerns about the opioid crisis. We took a dive into our data and produced a dashboard that covers the last fiscal year focusing on opioids. We used some techniques that we learned through the IA and the Improvement Coach programs. We were able to produce an infographic utilizing our open data system. It showed the impact on the community and on our organization. It helped us identify a population we could work with. And it was all on one page. I don’t think we ever had the capability before to present our data and say, “This is what this means to us. This is what it means to the community. This is how we can help address the problem.”

On his proudest moment as an Improvement Advisor

My proudest moment is when I see the results of what we do communicated in an effective way. The world is exposed to data every day. We see it every day, and a lot of times you’re left confused. But our data speaks clearly because one of the things that we’ve learned — and it was almost a sidebar thing that we didn’t anticipate learning — was how to communicate better with information. We’ve learned how to communicate intelligently using data. We display our data better. We think through our charts better. We look and quantify things more deeply than we did before. We learn to aggregate things in intelligent ways that make sense.

Whenever we launch a project, we gather together and start by asking, “What’s the aim? What’s the purpose? What are we trying to do? How are we going to measure that? What’s that going to look like when we’re done?” We ask all these simple questions that seem like common sense that we never asked before. I look at that and I say, “Wow. We’ve really made a difference.”

Editor’s note: This interview has been edited for length and clarity.

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