A prior post considered the benefits of municipal officials holding pre-hospital emergency medical services (EMS) providers accountable for the community health impact they have – regardless if those providers are government-operated, private enterprise, or volunteer-based. It suggested ways to establish those accountabilities through public reporting of their performance on the processes of care that have been shown by research to influence patient outcomes. This post will consider the use of performance-based contracts and service level agreements to reinforce the implementation of those accountabilities.
Performance-based contracts for private ambulance services are relatively common. A municipality will often grant market rights to provide emergency and/or non-emergency ambulance services to their community in return for specified levels of service. For emergency ambulance services, it is common to require advanced life support equipment and personnel (i.e., paramedics). It is also common to require a certain minimum number of ambulances and certain minimum average response times (typically in the 8-10 minute range for urban and suburban areas).
The consequences for failure to meet those standards can be loss of the contract that grants markets rights in the event of gross and sustained violations. Fines may be levied for lesser violations. While these types of contracts are a step in the right direction by setting performance standards and accountability, they usually fall short by not being more specific about the performance expectations for the quality of medical care delivered once the ambulance arrives.
Performance-based contracts for government-operated ambulance services, which are often within the fire department, are virtually unheard of. Local government is not going to be inclined to ‘fire’ their own government-operated ambulance service. Fining them for performance shortfalls is simply moving money from one government pocket to another.
This is where a service-level agreement can be utilized. It has much of the same language as a performance contract, but rather than losing market rights or being fined, a service-level agreement puts ambulance managers and fire rescue chiefs on notice for the performance levels that are expected. It also creates an opportunity for the department and its managers to gain or lose political capital via public reporting for exceeding or falling short on performance. Senior ambulance service managers would also recognize the potential for being replaced if performance expectations are chronically missed.
Like the private sector private ambulance service contracts, a service level agreement for a government-operated ambulance service should also be specific about the performance expectations on the quality of medical care delivered once the ambulance arrives.
Ambulance service is not the only element of a prehospital EMS system. The 9-1-1 communications center plays an important role. Beyond the prompt dispatch of appropriate emergency crews, they can also provide telephone-based instructions to callers on how to initiate care before emergency crews arrive on scene. This would include coaching callers on how to perform CPR, stop bleeding, deliver a baby and other first-aid. Their performance in providing these services can be measured, reported and accountabilities can be established through service level agreements. The same holds true for non-transport medical first response services commonly provided by fire department crews that respond to 9-1-1 medical calls on fire rescue utility trucks, fire engines, and other non-ambulance vehicles.
Performance-based ambulance service contracts with private ambulance companies should have a pre-determined duration. The end of the contract period provides an opportunity to update performance expectations based on the latest medical standards and guidelines. It can also provide an opportunity to put the contract back out to a competitive bidding process to find a better provider.
The most opportune time to implement service level agreements with a government operator is in conjunction with the budget request and review process. The ambulance service director, fire chief, and 9-1-1 communication center director will each present and defend their budget requests. This presentation is usually made to the city manager, county administrator, or elected officials. At that time, the negotiated budget can be approved contingent on the department head accepting a service level agreement that clearly articulates the specific performance measures, the desired performance levels on each of the metrics, and the processes and deadlines for submitting their data for public reporting process.
Mic Gunderson is a GovLoop Featured Contributor. He has been involved in emergency healthcare for over 40 years in various leadership, educational, and clinical roles. Currently, he is the President of the Center for Systems Improvement where he provides consulting and training services related to emergency systems of care and EMS systems. Read his posts here.