Fleet Management

CHAPTERCHAPTER

Management of EMS

Fleet Management

11

Bruce E. Evans • Jeff T. Dyar — Management of EMS Copyright © 2010 by Pearson Education, Inc. Upper Saddle River, NJ 07458

Learning Objectives

11.1 Discuss various considerations for calculating the cost of an EMS service.

11.2 Distinguish between functional and direct services for operating budgets.

11.3 Describe the inspection processes for equipment.


Learning Objectives (Cont.)

11.4 Compare and contrast the concepts of unit-hour utilization and in-service ratios when determining workload.

11.5 Calculate cost per capita and cost per response for EMS runs.

11.6 Apply cost-out strategies for a variety of EMS system components.



11.7 Track and apply costing mechanisms for soft supplies.

11.8 Understand the types of inventory systems and replacement plans.

11.9 Track fleet maintenance and vehicle cost including failure rates.



11.10 Determine the equipment needed in the system and the specifications of that equipment.

11.11 Understand and apply federal, state, and local specifications and procurement processes for ambulances, biomedical equipment, and durable equipment.


Fleet Management and Equipment

• The delivery of EMS services cannot be accomplished without technologically sophisticated medical equipment and state-of-the-art emergency vehicles


Fleet Management and Equipment (Cont.)

• A number of factors must be considered in order to establish the cost of operating an EMS system– Direct services are the services provided to

the public This includes patient-care activities, public-

education programs, preventive-maintenance programs, and special events



• A number of factors must be considered in order to establish the cost of operating an EMS system– Functional services are those provided to

the agency within and can include such services as yearly physicals, EAP, training, uniforms, office support, and utilities



• A number of factors must be considered in order to establish the cost of operating an EMS system– An EMS manager must identify all the

services provided by the organization as the first step in identifying and costing out each key aspect of the operation


Fleet Management

• Fleet administration requires EMS managers to supply vehicles and services to support fire and EMS activities

• These services cover a wide range of job tasks– Logistics chief officer or front-line

supervisor


Fleet Management (Cont.)

• An EMS manager must consider replacement policies, contracting and government bidding standards, whether to purchase or lease apparatus and equipment, and replacement criteria

• A contingency plan should be put in place to provide reserve equipment or equipment on loan during planned and preventive maintenance


Fleet Management (Cont.)

• In the event that there is equipment failure, a procedure should be put in place for using reserve equipment, such as borrowing an ambulance or cardiac monitor from a neighboring department or perhaps a local vendor who will loan you a demo unit if your reserve unit is unavailable or you need additional resources


Verifying and Maintaining Checkout

• Accountability for the inspection and inventory of equipment and vehicles should be imbedded as part of an organization’s culture

• It is important for EMS leadership to instill in the company officers, paramedics, and EMT’s that regular inspections need to be conducted every shift, cycle, and monthly by on-duty EMS personnel


Verifying and Maintaining Checkout (Cont.)

• Equipment check should be established as the first action at the start of the shift

• Ensuring the equipment is ready for service should be reinforced during employee orientation, taught during in-service training, and included in management objectives as the very first thing to be done at the start of a shift



• Routine inspections should be conducted every day, on every shift and equipment not used very often should be inspected monthly

• Vehicle checkouts should be completed during every shift on mechanics as well as fluids, belts, and tires



• Vehicles should be inspected on the outside for damage and leaks, and to ensure working lights and warning devices

• Mileage and engine hours should be recorded daily



• Critical medical equipment should be included on the vehicle-checkout list including oxygen, backboards, and soft supplies

• Any equipment that requires batteries, such as suction devices, laryngoscope handles, and cardiac monitors must be checked before any vehicle is made available for a call



• Responding to a call without working equipment has resulted in significant litigation and financial losses for EMS organizations

• Two of the first items usually requested by attorneys in medical malpractice cases are the prehospital care reports and the vehicle checkout report



• Regulatory inspections are inspections conducted by the government authority that licenses ambulances

• The regulatory agency inspects the vehicles for items mandated by law or regulation

• Frequently, expired drugs or equipment that is on a state inventory, yet rarely used within the agency, are found to be missing



• Regulatory inspections also verify insurance coverage, proper licensing, and personnel certification

• EMS employees should have their driver’s licenses inspected regularly to identify those whose licenses who have been reported revoked or suspended

• Any of the inspections can occur on a random basis



• As a management tool, EMS leadership should conduct random audits or inspections to ensure compliance with check out procedures

• Most accreditation agencies will conduct spot checks when conducting a site visit

• Management must establish the importance of checkout procedures to avoid any errors or interruptions in EMS service


Ambulance Specifications

• EMS managers and the organization should create specifications for EMS vehicles within the system

• An ambulance is defined as a vehicle for emergency medical care that provides a driver’s compartment; a patient compartment to accommodate an emergency medical technician or paramedic, and two litter patients so positioned that the primary patient can

(Cont.)


Ambulance Specifications (Cont.)

(Cont.)

be given intensive life support during transit; equipment and supplies for emergency care at the scene as well as during transport; two-way radio communication; and, when necessary, equipment for light rescue/extrication procedures



• Local health departments often have standards for EMS vehicles and mandated equipment, usually listed in the local board of health regulations or in an operating agreement

• State EMS authorities usually have specifications for EMS vehicles that are reflected in state law or state statue



• Federal Specification for the Star-of-Life Ambulance (KKK-A-1822E), prepared by the Government Services Administration in June 2002


FIGURE 11.4AMD and NTEA Activities.


Ambulance Types, Classes, Configurations

• The Federal standard uses three ambulance types, with further divisions into classes and floor configuration– Type I conventional truck, with cab chassis

and a modular ambulance body Type I ambulance can have an additional-duty

(AD) unit when modified for neonatal, critical-care transports, and rescue or fire suppression package


Ambulance Types, Classes, Configurations (Cont.)

• The Federal standard uses three ambulance types, with further divisions into classes and floor configuration– Type I conventional truck, with cab chassis

and a modular ambulance body This is often referred to as a “medium duty”

rescue in the fire service; The vehicle types are divided into class I or class II, representing two-wheeled and four-wheel drive, respectively



• The Federal standard uses three ambulance types, with further divisions into classes and floor configuration– The Type II is a standard van with an

integral cab-body ambulance A type III ambulance is a cutaway van, cab-

chassis with integrated modular ambulance body



• The Federal standard uses three ambulance types, with further divisions into classes and floor configuration– The type III ambulance can also have a

classification of additional duty (AD) It is recommended in the federal standard that

ALS ambulances be either type I or type II Type I and III ambulances also have two

standard configurations in the federal specification: “A” for ALS and “B” for BLS


Specification Processes

• The first step in purchasing or leasing equipment is to create a procurement process for your agency, whether for a new ambulance or a cardiac monitor

• Defining the specifications for the vehicle or equipment is really one small part of the process


Specification Processes (Cont.)

• More ownership and pride in the equipment when employees have input into the design and construction

• Vendors normally provide a set of specifications and place in those specifications conditions or statements designed to exclude other vendors



• Rarely is that set of specifications designed to a performance standard– In many cases, the vendors reserve the

right to substitute or change the specifications

• It is important to use the request for proposal (RFP) process and include key performance criteria and penalties if the equipment fails to meet those standards



• Similar to construction contracts, bid specifications can include monetary penalties for late delivery or for not meeting performance criteria



• When purchasing equipment, EMS managers ask for several different requests for proposals or contracts used by other agencies for purchases, and employ a committee to review the content and use the best of the content to create a custom request for proposal


Procurement Process

• A simple approach to procurement is to apply the incident management system under the title of a procurement or specification committee

• The committee will have an EMS leader that manages the process

• The operations person will supervise, research and evaluation of the products


Procurement Process (Cont.)

• A planning section will create the request for proposal (RFP) or bid request

• The logistics person will arrange for the testing and demonstration, and will make sure that coordination of facilities is achieved



• Lastly, a finance person will qualify bidders, account for cost, monitor budgeting, and ensure payment and transfer of money

• Each of these sections needs to be populated with field personnel and end users of the equipment



• Timeline should be established and a budget arranged with a 10% to 15% emergency allocation or reserve fund for unforeseen issues

• Notes and records need to be kept on the decision-making process


RFP Construction

• Vendors should be qualified by the committee or the EMS manager overseeing the process

• A stable operational history, solid customer support, FDA approval, and up-to-date technology are important in a profile of a vendor


RFP Construction (Cont.)

• Most companies should support your product for its life cycle– Seven years for vehicles and eight years

for medical equipment

• An EMS manager should contact the vendor’s most recent customers and at least three other customers who have used their product for several years


Scoring and Evaluating Bids

• An easily understood scoring process is beneficial

• A simple 100-point scoring system that weighs the specifications from most important to least important helps secure the best vendor


Scoring and Evaluating Bids (Cont.)

• A point system needs to reflect each area, including finance, operations, background with customer service, vendor presentation, and functional ability

• Field evaluations of equipment must be part of the process


Vehicle Inspections

• When accepting delivery of an ambulance, a series of procedures is recommended– A source inspection should be completed

by EMS management or leadership prior to shipment from the manufacturer and should include workmanship, quality conformance, and a first-production inspection

– First-production inspections ensure the manufacturer is conforming to the standards


Vehicle Inspections (Cont.)

– This should be done at the manufacturing plant, and the cost of getting EMS managers to the factory should be borne by the manufacturer

– A destination examination also should include a check of all ambulance controls, electrical systems and devices, door, windows, cabinets, and accessories, as well as a road test at highway speeds, a brake test, and a test for rattles and squeaks



– Road test of new vehicles involves driving a total of 150 miles, with 75 miles of that on highways at a speed of 70 mph; 30 miles on city streets at 30 mph, 15 miles on gravel or dirt roads at 35 mph, and 5 miles on cross-county operations that are muddy or open field areas

– A water spray test subjects the vehicle to a water spray at 25 psi for 15 minutes in order to look for any evidence of a leak



– Oxygen-system test must be tested and the system should be pressurized to 150 psi with dry air or nitrogen and be able to hold that pressure for four hours

– Have a checklist prepared in advance that details the tests and inspection points to be completed before acceptance of the vehicle



– If a vehicle fails any of these tests and the vendor cannot fix the vehicle after a reasonable number of attempts, the EMS leadership should have the option to terminate the contract


Training and In-service

• When a new vehicle arrives, EMS personnel should receive appropriate education and training

• This should also include how the vehicle is to be checked out and maintained according to manufacturer’s specifications

• EVOC and CEVO are two programs designed to help train EMS personnel to operate emergency vehicles


Training and In-service (Cont.)

• Crashes are a common cause of litigation and risk for an EMS agency

• Emergency-vehicle collisions are often serious, and some court cases have resulted in criminal charges being levied against EMS workers involved in them


Vehicle Cost

• Vehicle costing starts with the initial cost of the vehicle– The purchase price, taxes, warranty, and

delivery charges are the initial cost of the vehicle

• The cost of maintenance, repairs, and non-warranted parts is recorded and feed into the cost for EMS vehicles


Vehicle Cost (Cont.)

• It is important that a job card be filled out for any repair or maintenance on the vehicle and it should include the vehicle number, odometer reading, hours and cost of labor, and any miscellaneous expenses around the event, for example, towing

• Fuel cost for each vehicle needs to be tracked


Vehicle Cost (Cont.)

• Overhead cost such as support personnel, office, cell phone, and filing or computerized applications to operate the system should be included as a portion of the expenses


Cost-Tracking Software

• Fleet Accounting Computer Tracking Systems (FACTS) or another computer-based system that tracks all information about vehicles, should be in place


Cost Tracking Software (Cont.)

• The system links specific information on each vehicle with operational data, such as labor hours, costs of parts, and frequency of parts usage, so that the office can assess its performance against established targets

• Most fleet-management software enables automated parts ordering and allows users to determine which parts are in stock



• A fleet-management software system should use the information to calculate costs for vehicles by type and age, which helps planning for future purchases and maintenance

• Fleet software systems allow EMS managers and front-line supervisors to collect and analyze performance data and establish benchmarks to continue improving competitiveness



• EMS managers can use tracking programs to track the initial cost of the vehicle, set up a preventive-maintenance schedule, issue work orders, and do fuel and warranty tracking


Calculating Unit-Hour Cost

• A measure of the total cost of providing coverage during a given accounting period divided by the total number of unit hours of coverage provided during that same accounting period

• This measurement can be used to identify whether or not unit-hour costs can help identify excessive cost compared to the quality of care being delivered


FIGURE 11.11Cost Per Unit Hour.

Cost Per Unit-Hour


Cost Per Mile

• Cost per mile is calculated by taking the specific vehicle cost, including the fuel, insurance, maintenance, and indirect cost to support that vehicle in a budget cycle or calendar year, and dividing it by the annual mileage accumulated on that vehicle


FIGURE 11.12Figuring Cost Per Mile and Cost Per Capita.


Medical Equipment

• EMS managers will be responsible for the maintenance, specification, and purchase of biomedical equipment

• Biomedical equipment is any medical device, medical supply, or tool used to take care of a patient


Medical Equipment (Cont.)

• The cost-effectiveness of such equipment is rarely tracked or rationalized before budgeting

• EMS agency defibrillators, ancillary equipment, biomedical services for preventive maintenance on defibrillators, routine non-warranty work, training equipment, and trainer/provider certification become part of the expense of implementing new equipment


Vehicle Maintenance

• It is important to establish a schedule for preventive maintenance

• Preventive maintenance is a schedule of mechanical checks or changes designed to prevent critical failures in vital equipment

• Preventive-maintenance schedules should be based on manufacturer recommendations, or schedules should be determined within the organization


Vehicle and Equipment Failures

• The annual critical vehicular failure (CVF) rate, or the average frequency at which something fails, should be calculated

• This is done by identifying a specific mileage or operating-hour benchmarks for the entire fleet– A common benchmark is the number of

incidents for the fleet every 100,000 miles, 1,000 engine hours, or 100,000 engine hours


Vehicle and Equipment Failures (Cont.)

• Mileage and hour benchmarks work well, since wear and tear on equipment is based on use and not calendar days

• Common areas to plan for in preventive maintenance are replacement of items such as tires, batteries, belts, fluids, brakes, and any other parts determined to need replacement on a scheduled or regular basis



• A common rate of failure in public-safety or ambulance fleets suggest that out-of-service incidents occur at a rate of 0.87 vehicle failures per 100,000 fleet operating miles

• A vehicle failure above this rate in pubic safety may indicate a vehicle should be taken out of service with a problem identified in a vehicle checkout


FIGURE 11.14Calculating Vehicle Failure Rates.


Vehicle and Equipment Failures

• When performing a critical failure rate, the automotive industry tends to use three parameters for each failure – severity, occurrence, and detection – and gives each one a score between 1(not critical) and 10 (extremely critical)



• Safety-analysis guidelines propose a scoring scheme along the following lines:– Severity: The hazards associated with each

failure should be categorized into 10 different levels ranging from 1 (least severe) to 10 (most severe) based on safety and impact on the operation



– Occurrence: Is the number of events and the probability of random failures in a given mileage benchmark or a specific number of hours of engine use; the occurrence of random faults should ideally be scored objectively using a percentage per certain hours or mileage

– Detection: A meaningful interpretation of this number is a measure of the degree to which preventative systems and vehicle checkouts can be detected; it should be made up of the probability expressed in a percentage


FIGURE 11.15Documented Vehicle Failure of Process for Electrical System.


Preventive Maintenance

• Preventive maintenance (PM)– Prevent a malfunction or failure, not just

correct it after it occurs– Should also be a key component of

managing vehicle recalls; vehicle warranties also help to prevent unnecessary costs to the EMS agency

– Equipment and vehicle manufacturers normally provide routine maintenance and inspection recommendations for their products


Preventive Maintenance (Cont.)

• Preventive maintenance (PM)– These recommendations should be used as

the basis for developing the system’s routine maintenance requirements and PM schedule

– Individual team members should be accountable for performing and documenting routine inspections, cleaning, and maintenance, using standardized checklists as part of regular shift changes


Preventive Maintenance (Cont.)

• Preventive maintenance (PM)– Using a standardized checklist makes the

task easier and helps to avoid overlooking any requirements


Replacement Considerations

• Agencies should have a written replacement policy that is calculated using economic factors such as depreciation cost, increasing maintenance cost, service life, and warranty limits

• The goal is to reduce overall equipment costs


Replacement Considerations (Cont.)

• EMS vehicles and their equipment should be replaced if the annual maintenance cost plus trade-in/replacement value exceeds the cost of a new vehicle


FIGURE11.16Replacement Cost Factors.


Training and Certification

• Managers overseeing fleet operations ideally need an associate’s degree in management, automotive diesel technology, or a related field

• Most require several years of hands-on experience in automotive maintenance and repair


Training and Certification (Cont.)

• A well-documented training program for your fleet-service people is a must if a vehicle is involved in an accident – law enforcement, lawyers, or regulatory agencies may examine your mechanics training records



• Emergency Vehicle Technician Certification Commission– Certification is the minimum standard set in

many states and is one of the most common ways for fire mechanics and emergency-vehicle technicians to demonstrate their qualifications to work on emergency vehicles



• Other technicians and mechanics who service county and municipal fleets go on to achieve the highest EVT certification by taking both the EVTCC tests and seeking certification by the National Institute for Automotive Service Excellence (ASE)



• Certificates demonstrate the skills and experience needed to perform high-quality maintenance and repair services; further, they instill confidence in the fleet’s drivers and customers that the fleet operation is professionally run


Accident Reports

• Accident history and repair cost need to be recorded, and a number of analysis reports produced


Facilities

• EMS facilities are often co-located within fire facilities

• It is important to ensure that existing facilities are budgeted for maintenance and are on a replacement or rehab cycle much like EMS equipment


Facilities (Cont.)

• Any master plan that includes current EMS facilities should also be able to identify the city-, county-, or agency-owned land

• The age, condition, and serviceability, should be evaluated against changing response patterns, street, traffic conditions, and demand patterns


Summary

• The task of an EMS manager overseeing fleet operations is to serve field personnel by making available to them an ambulance of a type and design favored by those who use it


Summary (Cont.)

• For the sake of the patient and the family, that ambulance should rarely if ever malfunction in the field and should be provided at a competitive operating cost

• It is important for EMS managers to determine whether a particular system reliability measure meets the organizations requirements


Summary (Cont.)

• A poorly managed vehicle or fleet does not protect the public and the agency

• An agency’s fleet should reflect the organization: it should provide professional service and present an image to the pubic that reflects pride and competence

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