How the right consultant fixed ACT's ambulance service

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The ACT government had a good news story last week: Australia’s best ambulance response times. How it achieved it is a story that started in 2009 and owes much to a Tasmanian.

A new consultant’s report confirmed “major improvements in the structure, governance and performance of the ACT Ambulance Service” had flowed from a funding boost of $35 million since the 2011 budget, Emergency Services Minister Simon Corbell announced. Among the achievements, according to the Productivity Commission’s Report on Government Services in January:

• The best priority one response times at the 90th percentile of any capital city in Australia;
• A reduction in ambulance attrition level from 10% per annum — the worst of all Australian ambulance services — to 2.6%, far below the national average rate, and;
• Overall patient satisfaction increased from 96% to 98% and paramedic attitude has increased from 97% to 99%.

Back in 2009, the territory’s auditor-general found “significant scope” for improvement, particularly in response times, clinical governance and non-emergency transport. In addition, “ambulance data was not appropriately collected and analysed”, making it difficult for ACTAS to know how to improve or explain its needs to government.

Grant Lennox retired after 15 years as CEO of the Tasmanian Ambulance Service two months before the frank ACT audit. The government brought him on as a consultant, he began a thorough review and delivered sweeping recommendations by April. His report assured the service was “a long way” from crisis, but identified a number of challenges.

“The main factor was that the ambulance service, like every other, had been going through growth of demand, year-on-year-on-year, and it had eroded their response capacity,” he told The Mandarin.

“Management were being overwhelmed by demand … so they had less time to devote to the back end of the business. They hadn’t been able to introduce the critical governance systems which had become commonplace in Australia’s health services, and which had been endorsed by all health ministers through the national strategic framework for safety and quality in healthcare.”

It was lucky for the ACT that Lennox, Australia’s longest-serving ambulance service CEO, retired when he did — it would be hard to find someone with a keener grasp of the issues. In the late ’70s, he wrote the policy to create the statewide ambulance service he eventually led, after seven successful years as CEO of Royal Derwent Hospital. He was a long-serving Council of Ambulance Authorities board member and served for eight years on the Productivity Commission’s emergency services working group.

Lennox’s 2010 advice resulted in the appointment of three new general managers to oversee more focused organisational units, including a new quality assurance, safety and risk management unit. Four years later he’s impressed with the results, writing in his follow-up report:

“The difference in management team capacity between my 2010 Review and the current situation is quite profound. The additional government investment in this area has resulted in a completely re-energised organisation which now has the capacity to effectively and efficiently manage the organisation, focus on continual improvement, patient safety and performance.

“[…] The Service has not only benefitted from the investment in new positions — it has grown in stature and wider perspective through an infusion of talented people from other backgrounds (including police and nursing/health) who have added wider perspectives based on their experiences in other large organisations combined with their academic studies in various fields.”

Shift supervisor positions were also introduced and a highly trained paramedic was put in the communications centre at all times. Previously, staff were rotated between non-emergency transport and the call centre.

“I said to stop doing that, to build up their training instead and put a clinician in the call centre to help them,” Lennox explained. “That’s the best-practice model; even the non-paramedics have to be trained because a lot of the time their advice on the phone can save a life before a crew gets there.”

The first Lennox report noted ACTAS trained crews to the highest possible level, which meant it had “achieved what many other ambulance services aspire to” in reducing the number of low-acuity patients taken to the emergency department.

On this measure it led the nation, but Lennox strongly suspected the training system was also driving high staff attrition by attracting interstate paramedics to the ACT for brief stints in order to progress more rapidly. He was right; attrition is now a quarter of what it was.

The second Lennox report is glowing in its praise for the improvements at ACTAS with only minor further recommendations. Two main challenges remain: maintaining rapid response times in the face of an ever-increasing caseload, and ensuring every staff member has a positive approach to their professional responsibilities, including the need for oversight and continuous improvement.

In this, Lennox is uncompromising. “Ambulance staff need to accept that reviews of their performance are part and parcel of being a professional at the cutting edge of life and death,” he said. “A paramedic is delivering things that might save your life; you want them to be absolutely spot on, so I recommended they bring in the systems to check that systematically.

“A few people at the margins are not comfortable with that level of accountability, because they’re not used to it, but others embrace it because they realise they’re being treated as health professionals.”

Lennox considers professionalism vitally important and devotes considerable space to it in his recent report, including a list of quotes to illustrate the point:

“It is wrong and immoral to seek to escape the consequences of one’s acts.” — Mahatma Gandhi

“A step backward after taking a wrong turn is a step in the right direction.” — Kurt Vonnegut

“A body of men holding themselves accountable to nobody ought not be trusted by anybody.” — Thomas Paine

“If you think a professional is expensive, wait till you try an amateur.” — Paul “Red” Adair

“Your life begins to change the day you take responsibility for it.” [and] “The right thing and the hard thing to do are usually the same.” — Steve Maraboli

“Being a professional is doing the things you love to do, on the days you don’t feel like doing them.” — Julius Irving

“Professionals never guess; they make it their business to know their business.” — Michelle Moore