In quality management (QM), a general distinction is drawn between organizational and operational structures of companies. The organizational structure of a company (i.e. a functional-organization) is depicted in the organization chart and determined by different hierarchical levels, and staff and line functions. The guiding idea of organizational structured companies is to attain highest quality by specialization and differentiation within each single discipline. In such organizations, topics regarding overall operational procedures quite often take a back seat.
As a classic example, dispatchers; medical emergency technicians; paramedics or prehospital emergency physicians, and the staff of the emergency department may each be highly specialized and work in harmony together; but often do not consider whether and how emergency patients experience the entire prehospital emergency process—from the emergency call and treatment to the admission to the hospital—as satisfying and efficient. Besides that, highly specialized disciplines are usually costintensive and prone to cause interface management troubles due to competitive exclusion (Schmidt, 1995; Mangler, 2006; Nicolai, 2009) (Figure 1).
In contrast, the operational structure of a company, i.e. process-orientated organization, is depicted in a process flow chart, which notes all operating processes such as the management-process, single working processes or different sub-processes. Operational structured companies aim to an interdisciplinary approach and are geared toward flexibility and integration. A steering committee defines annual objectives, disciplinary boundaries are exceeded by integrated supervizion teams, and resources are considered in the focus of the overall process. The development of ‘patient pathways’, for example, might be a guiding idea in a process-oriented organization.
In consequence, interface-management plays an important role, equal to control and continuous quality improvement activities. Patient satisfaction ought to be considered as a key quality and outcome criteria beside medical outcome oriented criteria such as mortality, the number of days of hospital stay or life quality (Kühn et al, 1997; Moecke and Ahnefeld, 1997; Fleisch, 2000; Ahnefeld, 2003; Redelsteiner et al, 2005; Grenzwürker et al, 2007; Nuckols et al, 2009) (Figure 2).
In public health services, organizational structured companies traditionally have priority. A reappraisal has occurred and process-orientated management ideas have gained increasing importance. This article discusses an investigation of the prehospital emergency medical service of Innsbruck/Austria (EMS-Innsbruck), which is based on a functional-orientated, organizational management structure.
Our hypothesis is: organizational structured companies cause problems, which are not found in the same degree in process-oriented, operational structured organizations.
The main objective of the article is to highlight how implemented management structures influence the effectiveness and efficiency of a particular prehospital EMS. Both the necessity of continuous quality improvement and the patient's point of view is thereby put in focus.
Method
We used a two-step approach to explore our research question. First, expert interviews were taken to identify current problems of the EMS-Innsbruck (Bogner et al, 2005; Buber et al, 2009). Second, and based on the results, the subsequent chapter ‘discussion’ is used to demonstrate how the organizational structures of the EMS-Innsbruck promote these problems.
To obtain a comprehensive view of the current situation, experts from all parts of the prehospital emergency process were contacted—from the emergency call, the treatment, to transport and admission in the hospital; as well as responsible stakeholders, such as dispatcher, emergency medical physicians and paramedics, staff of different emergency departments and officials from the appropriate authority (Table 1).
| Interviewees | Hierarchical level | Code | |
|---|---|---|---|
| Dispatch centre - DC | 1 | Management | DC 1 |
| EMS paramedics | 2 | Management | EMS 1 |
| Paramedic | EMS 2 | ||
| EMS physicians | 4 | Management | EMS-P 1 |
| EMS physician | EMS-P 2 | ||
| EMS physician | EMS-P 3 | ||
| EMS physician | EMS-P 4 | ||
| HEMS | 1 | HEMS physician | HEMS-P |
| Emergency department—ED | 2 | Management | ED 1 |
| ED physician | ED 2 | ||
| Authority officials—AO | 2 | Management | AO 1 |
| Management | AO 2 | ||
| Total | 12 |
EMS associated with the Medical University of Innsbruck
The prehospital EMS associated with the Medical University of Innsbruck is a ground-based and physician staffed EMS including a special emergency physician's car. This car is based at the university hospital for 24 hours a day with an anaesthetist from the university's Department for Anaesthesia and Intensive Care, and a specially trained paramedic who is also the driver of the car. Approximately 30 emergency physicians of the University Department for Anaesthesia and 15 fully employed and 25 voluntary paramedics from the local Austrian Red Cross are involved in this part of the Innsbruck EMS.
Both groups additionally have duties on other days such as performing anaesthesia at the hospital or transport service at the Red Cross, respectively. Austria, as in some other European countries, does not offer a clinical speciality training in prehospital EMS medicine. In general, emergency physicians complete at least 60 hours emergency physician training after having finished their postgraduate 3-year training to become a general practitioner, or their 6-year training to become a medical consultant. The emergency physician training has to be renewed every second year by a two day training course.
The Austrian EMS training model differentiates between EMT as ‘Rettungssanitäter’ and paramedic as ‘Notfallsanitäter’. After their general training as an emergency medical technician, which includes 100 hours theoretical education and 160 hours work experience at an EMS, Austrian paramedics graduate in special training courses including 160 hours theoretical, 40 hours practical training in a hospital and 280 hours work experience at an EMS (Austrian paramedic level a). As an option, these paramedics can additionally receive a license to administer certain non-intravenous drugs after a 40 hours theoretical education (competence for drugs–level b); a license for intravenous access after a 10 hours theoretical and a 40 hours in-hospital training (competence for iv access–level c) and, very rare, following 500 hours experience on the emergency physician's car, a license to intubate and to ventilate patients in cardiac arrest after a 40 hours theoretical education in airway management and a 80 hours in-hospital training in a department of anaesthesia (special competence for airway management–level d). In general, the last is comparable to the application of the term paramedic in the Anglo-American world.
Besides the physician staffed ground-based EMS, a helicopter emergency medical service (HEMS) is also positioned near the university hospital, including 20 emergency physicians and 15 paramedics.
The call taker and dispatcher at the Tyrol Dispatch Centre execute the emergency call by using the ‘advanced medical priority dispatch system–AMPDS’ (National Academy of Emergency Medical Dispatch, USA). This IT based system was introduced in the dispatch centre in 2001 as the first in German-speaking Europe. Worldwide, the AMPDS is used in approximately 3000 dispatch centres. It helps to categorize the emergency call within 33 graduated main emergency codes of medical emergencies and 5 emergency levels by using a structured pre-determined questionnaire. The questionnaire results in a letter and number code, e.g. 12D2, where 12 stands for seizure, D for a potentially life-threatening level and 2 for continuous or repeating seizures. Together with the alarm, this code is transferred to the EMS. This procedure is regularly evaluated by internal quality assurance (Vergeiner, 1999; Surhone et al, 2010).
A corresponding local deployment plan additionally directs the dispatcher's decision concerning the necessary life-saving appliances. For example, ambulance, ambulance and emergency physician's car, physician staffed helicopter, fire brigade and police force. The prehospital emergency team combines both the ambulance staff with EMS medical technicians or paramedics and the emergency physician's car with the emergency medical physician and paramedic. This two-tiered system is also called ‘Rendezvous-system’ as both teams start from different points and meet at the patient. This is common in Austria, Germany, some regions of Switzerland, and also in Italy, France, Spain, and many Eastern European countries.
Following the primary emergency treatment at the scene, patients are brought to three different emergency departments, which are under the general management of the Innsbruck University Hospital (ED of the Departments of Internal and Neurological Medicine, Trauma Surgery and Paediatric Medicine).
In summary, five single organizations are involved in the prehospital emergency process to guarantee the best possible emergency treatment: the dispatch centre, the physician-staffed EMS, the helicopter emergency medical service (HEMS), the local rescue service and the emergency departments of the hospital. Each of them is an autonomously organized structure. The subsequent analysis of the expert interviews follows three steps of qualitative data analysis (Neuman, 2007; Bryman, 2008; Carol et al, 2009): a) transcription of the interviews, b) qualitative content analysis of the expert's statement and generation of key categories by combining the most valuable arguments, c) the evaluation of the hypothesis and the research question based on the findings.
In the following section, a summary of the most important problems mentioned by the experts is given to each section of the emergency process. In order to highlight the mentioned problems, one key argument of an expert will also be cited. The quotations give additional information on the research question hypothesis. Repeatedly mentioned topics are presented only once and the content-quality of the statements is important rather than their frequency. To ensure the anonymity of the experts, only the particular unit is named and the experts are referenced by a code. One expert refused to be cited.
Results
Collaboration with the dispatchers at the dispatch centre
AMPDS and local deployment plan
Problems mentioned by the experts: results of EMS data analysis show that the implementation of the AMPDS entailed an increased rate of completely unnecessary missions of the emergency physician's car up to 15% and additionally up to 30% of NACA 1 and NACA 2 missions. It had not been determined whether this is due to the AMPDS questionnaire system itself, the patient or relative's answers or the EMS deployment plan.
This unwanted effect was strengthened by the missing evaluation and adaption of the local deployment plan which should have been carried out twice a year under medical guidance and responsibility. In consequence, emergency physicians and paramedics became discouraged and stakeholders claimed a sudden increase of missions and costs. As the AMPDS query dispatchers are unauthorized to withdraw or downgrade an already made report—they are only authorized to upgrade them—the problem is increasing.
EMS-P 1: ‘The rate of unnecessary emergency missions has increased up to approximately 30% during the last years. I think this problem has different reasons. With the new AMPDS and the correlating local deployment plan, dispatchers are bound to pre-determined mission codes and are not allowed to chance the code due to their own experience. Hence, they must follow the possibly higher estimated mission code and order an emergency physician, although it probably wouldn't be necessary. Legal security has displaced the former flexibility of the dispatchers.
A second problem is the AMPDS itself It was originally developed for American paramedic systems and is therefore not one-to-one adaptable to our two-tiered rendezvous-system. But when the questionnaire was initially translated into German, they didn't consider that point. Thus, important questions are missing such as ‘For how long have you already had your disorders?’ Sometimes we are called to emergency patients who have suffered pain for 14 days and we drive there with siren and flashing blue light! Another problem is the local deployment plan. This plan is defined by the operating EMS company and should be evaluated and accordingly improved from emergency physicians twice a year, However, the most recent amendment happened in 2004, nobody really feels responsible for doing that!' (Table 2).
| Section 1 | Mentioned problems | Experts code |
|---|---|---|
| Dispatch Centre | Increased rate of unnecessary emergency missions | EMS 1, 2; EMS-P 1, 2, 3, 4; HEMS-P; ED 2 |
| Missing evaluation and adaption of the local deployment plan | DC 1; EMS-P 1 | |
| Discouragement of EMS physicians, paramedics and emergency department physicians | EMS 1, 2; EMS-P 1 2, 3, 4; HEMS-P; ED 2 | |
| Impossibility to withdraw or downgrade an already made report by the dispatcher | DC 1; EMS-P 1 | |
| Increase of costs | AO 1, 2; | |
| Important questions are missing in the AMPDS questionnaire | EMS-P 1 |
Primary emergency treatment at the emergency scene
Emergency skills, documentation, failure management and the ‘do not attempt resuscitation—DNAR’ decision
Problems mentioned by the experts: the great advantage of the two-tiered EMS rendezvous-system is the rapid professional medical response at the emergency scene. Professional emergency physicians and paramedics guarantee best emergency treatment. However, this high specialization is often not well used; first, when paramedics do not sufficiently apply their special trained skills (level b, c, d), because emergency physicians are present or it is because frowned upon by their superiors; and second, when emergency physicians are sent to emergencies which could have easily be managed by the technicians or paramedics alone. In consequence, the frustration of all system partners and the discussion about undue missions and increased costs increases. Due to the increasing rate of unnecessary missions during day and night more and more very experienced and thus older physicians resign from EMS shift.
The emergency department physician mentioned a corresponding problem, which also aggravates their demotivation:
ED 2: ‘Due to the demographic trend, the percentage of elderly people increases. Hence, emergency physicians are more often confronted with the end-of-life and DNAR decision-making. Less experienced, young emergency physicians and the fact that they do not have patient's records at the emergency scene, often forces them to perform resuscitation attempts even in futile cases. In consequence, the admission rates at the emergency department are rising steadily. Meanwhile we treat patients at the intensive care unit who were successfully resuscitated at the scene although it's often entirely hopeless and there is no reasonable chance for them to survive. We urgently need a more open culture of failure management in the emergency physicians training and practice and a common discussion about the ethical aspect of that topic. Everybody in the entire emergency process suffers from this problem, including the moribund patients themselves. A sophisticated documentation and ethical proved prehospital and clinical guidelines should be installed.’ (Table 3)
| Section 2 | Mentioned problems | Experts code |
|---|---|---|
| Emergency treatment at the emergency scene | Paramedics (level b, c, d) do not sufficiently apply their skills | EMS 1, 2; EMS-P 1, 2; HEMS-P; AO 2 |
| Unnecessary attendance of the emergency physician | EMS-P 1; HEMS-P | |
| Increase of costs | AO 1, 2 | |
| Experienced and older physicians resign from EMS shifts due to frustration | EMS-P 1 | |
| Questionable DNAR decisions due to less experience of young emergency physicians and missing patient's records at the scene | ED 1, 2; HEMS-P; EMS-P 3, 4 | |
| Lack of documentation and ED 1 ethical proved prehospital guidelines for DNAR-decisions. |
Transport and admission to hospital
Emergency protocols and controlled feedback regulations, quantity of HEMS
Problems mentioned by the experts: In the federal state of Tyrol, up to 16 official and private helicopters operate at the HEMS at a highly advanced level but maintaining them is expensive. Given aspects such as the global economic crises, the national desire to make savings in the public health sector, and the fact that patients often receive invoices directly from the HEMS company, this triggered a discussion about the necessity of the high quantity of the HEMS.
Additionally, other admission problems were mentioned: paramedics, emergency physicians and the staff of the emergency department's claim that the standardized EMS protocol sometimes is unreadable filled out or not duly completed. Necessary information gets lost, in particular, when a physician-to-physician handover at the emergency department is impossible due to another urgent emergency mission. As there does not exist a standardized protocol or a telemetric data transfer for paramedics, the situation becomes even worse.
HEMS-P: ‘Caused by tourism and other factors HEMS missions increase every year. Due to a lack of local emergency physicians, operating companies hire emergency physicians from other regions such as the adjacent Bavaria. These doctors often don't know much about local health services and give the order to fly to the University Hospital of Innsbruck, although another hospital might be nearer. Hence, conflicts are very likely. Emergency physicians claim the impolite behaviour of the emergency department staff and the high amount of unnecessary emergency admissions they get. It's a vicious circle. As there is no general challenge of triage-criteria, the problem intensifies steadily.’ (Table 4)
| Section 3 | Mentioned problems | Experts code |
|---|---|---|
| Transport and admission to hospital | High quantity of HEMS expensive maintaining | AO 1, 2 |
| High amount of unnecessary emergency admissions | ED 1, 2 | |
| No general challenge of triage criteria, no controlled feedback regulations | EMS 1, 2; HEMS-P; EMS-P-1 2, 3, 4; ED 1, 2 | |
| Impolite behaviour of ED-physicians due to high workload | EMS 2; EMS-P 4; HEMS-P ED 2 | |
| Unreadable or not duly completed EMS protocol - loss of information | EMS-P 1, 2; HEMS-P; EMS-P 2, 4; ED 2 | |
| Sometimes no physician-to-physician handover—loss of information | EMS 2; EMS-P 1; ED 2 | |
| No standardized protocol for paramedics | EMS 1, 2; EMS-P 1; ED 2 | |
| No telemetric data transfer | EMS-P 1 |
Discussion
The highlighted quotations of the expert interviews show how structures of organizations may cause conflicts and continuously reproduce and strongly increase the likelihood of further divisive issues. All experts reflect the so-called silo-mentality which is typical for organizational structured companies, i.e. the accentuation of the own strength and skills in opposition to the others (Quality Austria, 2009).
Due to the fact that there is no institutionalized leading process manager who feels responsible for the entire prehospital emergency process (from the emergency call to the admission to hospital) the necessary improvement is insufficient, despite the experts mentioned problems and suggested solutions.
The sudden rise of unnecessary emergency missions, for example, generates tensions on all sides—dispatchers; emergency physicians and paramedics, stakeholders, as well as the staff of different emergency departments, are unsatisfied (Heward et al, 2004; Deakin et al, 2006; Trimmel et al, 2006; Gray and Walker, 2008). The lack of information regarding the AMPDS enforced additional misunderstandings and communication changed for the worse. As each company within the entire emergency process is autonomously organized, there is noone who is tasked with the responsibility to look beyond the own discipline. For instance, the periodical evaluation of the local deployment plan—which was suggested as one approach of the problem—has not taken place since 2004 although everybody realized that this evaluation would decrease the rate of unnecessary emergency missions.
In contrast, within a process-orientated operational structured company it would be the duty of the entire process manager to install a well-organized interface management to note evolving problems, such as the evaluation of the local deployment plan and to chance them for the better (Quality Austria, 2009).
Hierarchical management structures allow for an excellent vertical job specialization but are in the majority followed by high costs of the entire organization (O'Regan, 2008). In our investigation this fact was confirmed by the high quality but rather expensive technical standard of the dispatch centre, the high number of HEMS and the insufficient deployment of the well-trained paramedics (level b, c, d). Unlike a process-orientated management structure, in which lean management is a key issue, this economical perspective is entirely missing in the described EMS (Holden, 2010).
Interface management implemented in hierarchical structured companies is all too often just a supplementary duty for employees, which is therefore more or less ineffective due to a lack of time or personnel. In contrast, in operational structured companies, interface management is a ‘conditio sine qua non’ of the leading management. The basic principle applied points out that excellent interface management raises the effectiveness and efficiency of the process flow (Nicolai, 2009).
This statement is again confirmed by the experts—for example, information, communication and documentation problems are mentioned concerning the interfaces of the emergency process, the dispatch centre and the emergency department (lack of sufficient information concerning the disorders of patients; absence of standardized protocols for emergency technicians and paramedics; no standardized feedback regulations; sometimes impolite behaviour of the emergency department staff; no general challenge of triage-criteria, etc).
Our hypothesis that within organizational structured companies problems are caused which are not in the same degree given within operational process-oriented structured organizations, is additionally substantiated by the fact of the frustration of all the involved professionals of the emergency process (experienced physicians resign from EMS shifts, etc).
Not least the lack of focus on patient's satisfaction, i.e. the patients-orientation, does in our investigation not come to the fore, a typical aspect of hierarchical organised system structures (Mangler, 2006). Due to the continuously high workload in the emergency departments, staff may experience the treatment of patients as ‘stress- and load-factor’ than as fair cooperation in partnership. Steadily increasing admission rates and DNAR decisions which sometimes are not considered, give a greater impression that this is the case. In contrast, the ongoing evaluation of patient satisfaction is a pre-condition for continuous quality improvement measures within operational structured companies (Quality Austria, 2009).
Our method, to use expert interviews to prove our hypothesis as well as to highlight the advantages and disadvantages of the two initially introduced management structures has proved valid: on the one hand, it could be shown that problems in the first place evolve due to structural, disciplinary and professional boundaries concerning all system partners within the emergency process. On the other hand, we highlighted that the complexity of the illustrated problems requires a common solution for all system partners and should not be the responsibility of only one. Expert interviews are time-intensive. This fact and the limited applicability of the findings depict the limitations of the used method. The results serve to a lesser extent for solving urgent problems but are rather useful for long-term and sustainable optimizations.
Finally, the problems evidenced by the experts might as well emerge in every prehospital EMS. Our main objective was primarily to raise awareness of the necessity of continuous quality improvement in every prehospital EMS and secondarily, to take a critical look at organizational structures and to open one's mind for necessary seminal changes.
Conclusion
If efficiency and quality are focused in quality management, and seen from a long-term and sustainable perspective, a restructuring and linkage of all parts of the prehospital EMS towards a process-oriented operational structure is highly recommended. This is confirmed by the results of the expert interviews.