A few months back I mentioned how I HATE the term "customer" in fire and EMS because it brings to mind the wrong impression on the delivery side.
Sure we can pound into the heads of our line personnel that they need to be more "customer service oriented" but what does that mean to them? To me it means ignoring people and putting out a tip jar, getting their order wrong, then refusing to notice.
Let's all agree that reminding our crews that in many cases the person who they anger in the field can vote your salaries down, or to block your company's contract renewal. Besides, they have been told they are customers to you and what is the one thing we know about customers?
"The customer is always right."
Well that's just a poor way to run an emergency service, catering to the needs of people who have no idea what service you offer or how it should be administered.
So let's slowly back away from the customer service model for a moment and take a deep breath. Let's assume what we already know, that the general public has no idea what so ever the difference between an emergency and an inconvenience. So why let these folks determine how the millions of dollars of equipment, staff and vehicles are utilized?
Because we are so afraid of a lawsuit we'll take anyone in for anything so long as they get the result they wanted.
But what about their neighbor five minutes later?
Imagine I take Erma Fishbiscuit in because her dial a nurse told her to call 911 to arrange her colonoscopy. Erma demands transport and I am bound by law to oblige her, regardless of her lack of need of an ALS ambulance. We take her because of a perceived liability, that if we don't take her and she sues us we will not like it one bit.
5 minutes after getting Erma loaded up a code 3 CPR in progress comes in next door to Erma and a 6 month old child dies before ALS can arrive on scene. Are we liable for not having more ambulances? Which liability is greater? Which liability makes national headlines?
Liability, like patient, has two completely different yet totally accurate definitions.
Liability: ...being liable. A responsibility or obligation...
Liability: Something that holds one back. A disability, disadvantage or hindrance.
Well no wonder we use that word.
When we speak of liability in the pre-hospital arena our minds automatically shift to defending our actions in court, right? We don't want to be held liable in court do we?
Here's a shocker: I do want to be held responsible as I have an obligation to both the people who do call me and those who are about to call.
But I am surely in the minority.
It is this fear of court, retribution, lawsuits and bad press that clouds our minds and won't let us see the real liability, the next call.
Our current liability, taking Erma in for no medical reason, acts as a hindrance, a disadvantage to the EMS system by taking highly trained resources to do the job of a taxi driver. So why do we not have that resource in most places?
Liability.
There it is again! That word gets thrown around so easily it's starting to give me a headache.
I argue that by taking Erma in we increase the threat of actual violation of responsibility should someone who actually needs EMS intervention is required to wait for it. How long is an appropriate wait time you ask? How long was Erma willing to wait?
We, as providers, are indeed locked into rigid 35 year old concepts of when to take people and why.
"Does he want to go?' the supervisor asked me as I was discussing the finer points of prescription refills with a client on a street corner at 3 AM.
"Yes, but I think we can get him to the pharmacy two blocks over if he just walks." I answer as the ambulance pulls up.
"We don't want that liability, take him in." She answers and the protocols once again trade the actual responsibility liability for the hindrance liability.
So who is liable when the 6 month old dies because the ALS resource was transporting Erma for no medical reason? What if the child's parents find out you took her in non emergency for no medical reason? Can they sue the City, Company, Town, Agency? You bet they can, and publicly. All because we are afraid of that word that no one bothered to explain in depth to us. Even in my semester long Pre-Hospital Medical Legal class liability boiled down to just transport and let the next license up deal with it.
I say we need to rethink liability, both definitions, if we're going to enact change in this Profession.
Get Erma the ride she needs from someone who can actually help her and be there for the 6 month old neighbor. That is your obligation. That is your responsibility. That is the liability. And that is exactly why your system will never do it.
Keep in mind that even though I make grand assumptions, I still follow all local protocols and standards, no matter how outdated, wrong or misguided. So should you.
Sure we can pound into the heads of our line personnel that they need to be more "customer service oriented" but what does that mean to them? To me it means ignoring people and putting out a tip jar, getting their order wrong, then refusing to notice.
Let's all agree that reminding our crews that in many cases the person who they anger in the field can vote your salaries down, or to block your company's contract renewal. Besides, they have been told they are customers to you and what is the one thing we know about customers?
"The customer is always right."
Well that's just a poor way to run an emergency service, catering to the needs of people who have no idea what service you offer or how it should be administered.
So let's slowly back away from the customer service model for a moment and take a deep breath. Let's assume what we already know, that the general public has no idea what so ever the difference between an emergency and an inconvenience. So why let these folks determine how the millions of dollars of equipment, staff and vehicles are utilized?
Because we are so afraid of a lawsuit we'll take anyone in for anything so long as they get the result they wanted.
But what about their neighbor five minutes later?
Imagine I take Erma Fishbiscuit in because her dial a nurse told her to call 911 to arrange her colonoscopy. Erma demands transport and I am bound by law to oblige her, regardless of her lack of need of an ALS ambulance. We take her because of a perceived liability, that if we don't take her and she sues us we will not like it one bit.
5 minutes after getting Erma loaded up a code 3 CPR in progress comes in next door to Erma and a 6 month old child dies before ALS can arrive on scene. Are we liable for not having more ambulances? Which liability is greater? Which liability makes national headlines?
Liability, like patient, has two completely different yet totally accurate definitions.
Liability: ...being liable. A responsibility or obligation...
Liability: Something that holds one back. A disability, disadvantage or hindrance.
Well no wonder we use that word.
When we speak of liability in the pre-hospital arena our minds automatically shift to defending our actions in court, right? We don't want to be held liable in court do we?
Here's a shocker: I do want to be held responsible as I have an obligation to both the people who do call me and those who are about to call.
But I am surely in the minority.
It is this fear of court, retribution, lawsuits and bad press that clouds our minds and won't let us see the real liability, the next call.
Our current liability, taking Erma in for no medical reason, acts as a hindrance, a disadvantage to the EMS system by taking highly trained resources to do the job of a taxi driver. So why do we not have that resource in most places?
Liability.
There it is again! That word gets thrown around so easily it's starting to give me a headache.
I argue that by taking Erma in we increase the threat of actual violation of responsibility should someone who actually needs EMS intervention is required to wait for it. How long is an appropriate wait time you ask? How long was Erma willing to wait?
We, as providers, are indeed locked into rigid 35 year old concepts of when to take people and why.
"Does he want to go?' the supervisor asked me as I was discussing the finer points of prescription refills with a client on a street corner at 3 AM.
"Yes, but I think we can get him to the pharmacy two blocks over if he just walks." I answer as the ambulance pulls up.
"We don't want that liability, take him in." She answers and the protocols once again trade the actual responsibility liability for the hindrance liability.
So who is liable when the 6 month old dies because the ALS resource was transporting Erma for no medical reason? What if the child's parents find out you took her in non emergency for no medical reason? Can they sue the City, Company, Town, Agency? You bet they can, and publicly. All because we are afraid of that word that no one bothered to explain in depth to us. Even in my semester long Pre-Hospital Medical Legal class liability boiled down to just transport and let the next license up deal with it.
I say we need to rethink liability, both definitions, if we're going to enact change in this Profession.
Get Erma the ride she needs from someone who can actually help her and be there for the 6 month old neighbor. That is your obligation. That is your responsibility. That is the liability. And that is exactly why your system will never do it.
Keep in mind that even though I make grand assumptions, I still follow all local protocols and standards, no matter how outdated, wrong or misguided. So should you.
Comments
There are agencies in the United States that have ALS units ready 24/7 solely for responding to and transporting Erma and her 6 month old neighbor. The Houston Fire Department for example sends paramedics only to certain calls usually by SUV not ambulance. It prevents non-serious patients from being transported to trauma centers, see Houston Ambulance Traffic Control Program. It also re-directs some non-emergency 9-1-1 calls to a nurse line and pays for the first visit including transportation to a clinic.
There are agencies in the United States that have ALS units ready 24/7 solely for responding to and transporting Erma's 6 month old neighbor while also getting Erma the help she needs. The Houston Fire Department for example sends paramedics only to certain calls usually by SUV not ambulance. It prevents non-serious patients from being transported to trauma centers, see Houston Ambulance Traffic Control Program. It also re-directs some non-emergency 9-1-1 calls to a nurse line and pays for the first visit including transportation to a clinic.
"Do you want to go to the ER? Because that's the only place I can take you."
"No, I just need to go to the pharmacy in [the same city]."
"Gotcha. Sorry, I can only take you to an ER. Since you don't want to do that, sign here."
If Erma wants to go to the hospital to see the roto-rooter that badly, she's getting handed over to a private- who may just laugh in our faces. Either way, I tell the chief that I took myself our of service for an hour for something like that, he'd put a boot in my ass so hard I'd be having breakfast with Mark tomorrow. And that's if NOTHING happened. If we lost a baby because of something like that, they'd never find my body.
Additionally, Houston is huge, massive really, and what that article fails to mention is you still have all of the surrounding areas of Harris and Montgomery counties that do not have HFD being bound by the duty to transport laws and they are not able to consult. HFD is only fixing part of the problem, not the whole problem.
I am very lucky now that I work in an area where ALS is almost never short and that if it is, I have two hospitals pretty close by. What does scare me is we once had a four alarm fire that nearly drew half our system up on one call. We were watching the dispatches and what was left available and it was frighteningly little. We had well over half, if not more, of our tower/truck/ladder apparatus out at one call. A fair portion of our district is high rise apartments in need of those tower/truck/ladder apparatus in addition to engines if anything else was to catch on fire. We were incredibly lucky that nothing else major happened during that fire, as we may have then been presented with the situation of not having the resources we needed available. What then? What would have been said if we could not respond and someone was injured, or worse died? Can we be held liable for doing our job in once place but that risking the care in another? Pardon the rambling, it is getting very late for me.
"Do you want to go to the ER? Because that's the only place I can take you."
"No, I just need to go to the pharmacy in [the same city]."
"Gotcha. Sorry, I can only take you to an ER. Since you don't want to do that, sign here."
If Erma wants to go to the hospital to see the roto-rooter that badly, she's getting handed over to a private- who may just laugh in our faces. Either way, I tell the chief that I took myself our of service for an hour for something like that, he'd put a boot in my ass so hard I'd be having breakfast with Mark tomorrow. And that's if NOTHING happened. If we lost a baby because of something like that, they'd never find my body.
Additionally, Houston is huge, massive really, and what that article fails to mention is you still have all of the surrounding areas of Harris and Montgomery counties that do not have HFD being bound by the duty to transport laws and they are not able to consult. HFD is only fixing part of the problem, not the whole problem.
I am very lucky now that I work in an area where ALS is almost never short and that if it is, I have two hospitals pretty close by. What does scare me is we once had a four alarm fire that nearly drew half our system up on one call. We were watching the dispatches and what was left available and it was frighteningly little. We had well over half, if not more, of our tower/truck/ladder apparatus out at one call. A fair portion of our district is high rise apartments in need of those tower/truck/ladder apparatus in addition to engines if anything else was to catch on fire. We were incredibly lucky that nothing else major happened during that fire, as we may have then been presented with the situation of not having the resources we needed available. What then? What would have been said if we could not respond and someone was injured, or worse died? Can we be held liable for doing our job in once place but that risking the care in another? Pardon the rambling, it is getting very late for me.
Keeping a "customer service", type of a mind set does not hurt. It is the kindness and compassion that you show that the public and the patient will remember. BUT I don't think the happy customer and worry over liability should create a problem. Especially in a case like Erma. I have a hard time believing that any court would rule against you if, you made Erma wait at home, to respond to pulseless child call.
I agree with fire_man85's comment that we should look at new ways to continue to serve the needs of the community. Do you need to create a designated non emergency transfer service, with in your organization? Do you need more rigs on during certain "peak hours"? If we looked hard enough, there is probably some way that we could meet the needs of those who call. Will we be able to meet everyone's needs, NO. You can't please everyone. But there is nothing wrong with trying to improve the existing system.
more systems should have the ability and freedom to 'cancel' Erma....or refer her to the local convalescent service.
We do just that in the very system i work, and not only does it free up resources, it helps to maintain my sanity!
Keeping a "customer service", type of a mind set does not hurt. It is the kindness and compassion that you show that the public and the patient will remember. BUT I don't think the happy customer and worry over liability should create a problem. Especially in a case like Erma. I have a hard time believing that any court would rule against you if, you made Erma wait at home, to respond to pulseless child call.
I agree with fire_man85's comment that we should look at new ways to continue to serve the needs of the community. Do you need to create a designated non emergency transfer service, with in your organization? Do you need more rigs on during certain "peak hours"? If we looked hard enough, there is probably some way that we could meet the needs of those who call. Will we be able to meet everyone's needs, NO. You can't please everyone. But there is nothing wrong with trying to improve the existing system.
more systems should have the ability and freedom to 'cancel' Erma....or refer her to the local convalescent service.
We do just that in the very system i work, and not only does it free up resources, it helps to maintain my sanity!
The fire service grabbed onto Customer Service and the Phoenix model in an effort to forgo closures. And it worked, until a generation of citizens has been raised knowing the ambulance can not refuse to take them.
"Saying that we should not be customer service oriented because the public does not understand EMS is flawed logic" I respectfully disagree and am pushing to educate the public on what is and is not a 911 emergency, but it will take time. If we are to dive completely into the customer service model and meet the expectations of our customers in EMS, get ready to see the entire system grind to a halt with BLS rides to a doctor.
The triage you speak of is the also flawed Criteria based dispatch system and time targets for arrival of transport unit. More on that in Part 2.
We can all do better to educate our citizens, clients, customers patients, leaders and elected officials about what EMS really SHOULD be and what it COULD be, provided we stop relying on the person who knows the least about what is going on: the customer.
I thank you for reading and even more for commenting.
The fire service grabbed onto Customer Service and the Phoenix model in an effort to forgo closures. And it worked, until a generation of citizens has been raised knowing the ambulance can not refuse to take them.
"Saying that we should not be customer service oriented because the public does not understand EMS is flawed logic" I respectfully disagree and am pushing to educate the public on what is and is not a 911 emergency, but it will take time. If we are to dive completely into the customer service model and meet the expectations of our customers in EMS, get ready to see the entire system grind to a halt with BLS rides to a doctor.
The triage you speak of is the also flawed Criteria based dispatch system and time targets for arrival of transport unit. More on that in Part 2.
We can all do better to educate our citizens, clients, customers patients, leaders and elected officials about what EMS really SHOULD be and what it COULD be, provided we stop relying on the person who knows the least about what is going on: the customer.
I thank you for reading and even more for commenting.
our two biggest problems - lack of public awareness among a very uneducated (schooling, common sense, critical thinking, and every other sense of the word) public.
our two biggest problems - lack of public awareness among a very uneducated (schooling, common sense, critical thinking, and every other sense of the word) public.
But when the folks who are just stopping by on their way to the FD or medical school hear that they are a service to a customer, I believe they default to the tip jar on the counter mentality. No one is teaching them what that means. I'm sure not.
It is our fault our patients and citizens have no idea what we offer and we as a service have gone to great lengths not to tell them.
But lumping EMS into the same model as Crate & Barrel and the coffee at Starbucks misses the part where we are the only game in town. Certainly there are multiple companies in many places, but if I don't like the service from AMR, I can't cancel them and call BayShore, I get who I get based on the municipal contract.
"Customer Service" simply because we're a "service" still misses the part where the people who call us have no idea what we do.
If someone wanders into the Starbucks and demands a hamburger because they are the customer and the customer is always right, Starbucks will not give them one just to make their experience a better one. They will smile and suggest the McDonalds next door.
I want to be able to smile and suggest my clients go "next door" to get what they need from who can give it to them. So I can make coffee for those who need it.
I would welcome your thoughts on this topic on an upcoming Happy Hour podcast.
Now I need a coffee. Now.
But when the folks who are just stopping by on their way to the FD or medical school hear that they are a service to a customer, I believe they default to the tip jar on the counter mentality. No one is teaching them what that means. I'm sure not.
It is our fault our patients and citizens have no idea what we offer and we as a service have gone to great lengths not to tell them.
But lumping EMS into the same model as Crate & Barrel and the coffee at Starbucks misses the part where we are the only game in town. Certainly there are multiple companies in many places, but if I don't like the service from AMR, I can't cancel them and call BayShore, I get who I get based on the municipal contract.
"Customer Service" simply because we're a "service" still misses the part where the people who call us have no idea what we do.
If someone wanders into the Starbucks and demands a hamburger because they are the customer and the customer is always right, Starbucks will not give them one just to make their experience a better one. They will smile and suggest the McDonalds next door.
I want to be able to smile and suggest my clients go "next door" to get what they need from who can give it to them. So I can make coffee for those who need it.
I would welcome your thoughts on this topic on an upcoming Happy Hour podcast.
Now I need a coffee. Now.
http://burnedoutmedic.com/?p=129
for example, take the common "i need meds" call:
what they want: go to the ED or psych hospital to get their meds
what they need: walgreens (and some money)
having a system in place to help them get what they need instead of taking them all to the ED is a place to start. with that comes educating them on the basic life skills and how they get what they truly need.
http://burnedoutmedic.com/?p=129
for example, take the common "i need meds" call:
what they want: go to the ED or psych hospital to get their meds
what they need: walgreens (and some money)
having a system in place to help them get what they need instead of taking them all to the ED is a place to start. with that comes educating them on the basic life skills and how they get what they truly need.
system needs to be changed - i.e. no emerg calls which easily make up 70-80% of ems should be involve some patient responsibility ....even if it is a small fee but that should of course vary depending on circumstances (i.e. seniors, disable, etc..)
in any case it won't happen legal changes also have to happen and that is another matter all together
system needs to be changed - i.e. no emerg calls which easily make up 70-80% of ems should be involve some patient responsibility ....even if it is a small fee but that should of course vary depending on circumstances (i.e. seniors, disable, etc..)
in any case it won't happen legal changes also have to happen and that is another matter all together
system needs to be changed - i.e. no emerg calls which easily make up 70-80% of ems should be involve some patient responsibility ....even if it is a small fee but that should of course vary depending on circumstances (i.e. seniors, disable, etc..)
in any case it won't happen legal changes also have to happen and that is another matter all together
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