Exercise description:

 Exercise on Organization Modelling (Ch. 3)

This exercise assumes that you have read Ch. 3, The Task and its Organizational Context, of the KE&M book, especially the first part on knowledge-oriented organization analysis. Answer the following questions.

1. Construct a description of worksheet OM-1 (problems & opportunities, organization context & mission, possible solutions) based on the problem statement below.
2. Given the description of the Emergency Medical Service, construct a model of the EMS organization according to worksheet OM-2.
3. Assume that a knowledge system is built for supporting the dispatchers in the handling of calls related to heart problems. Analyze the impacts such a system will have, both for the external context surrounding the organization (OM-1) and for the internal organization itself (OM-2).

Case: the Emergency Medical Service

Initial problem statement

The case concerns the introduction of a knowledge system at the Emergency Medical Service (EMS) for the largest area in the Netherlands. The service area of 1015.34 km2 stretches out over 17 municipalities and approximately 1.250.000 citizens. About 400 calls are handled daily, 250 to 300 of which require transport to a hospital. Approximately 40% of these calls are directly related to heart problems. Many calls come from General Practitioners who have diagnosed a patient with a disease requiring emergency treatment.

The domain is acute myocardial infarction (AMI), one of the major causes of early death (15.0% for men, 11.7% for women; CBS statistical office figures, 1992). Reducing mortality from AMI will increase life expectancy significantly.

The most effective treatment that is currently available to AMI is coronary reperfusion. This therapy can decrease both morbidity (the number of people that are ill) and mortality (the number of people who die) by 20 to 40%. The effect of this intervention, however, strongly depends on the time elapsed since the onset of the symptoms. When treatment starts as early as possible the best results are obtained. The effect of the therapy vanishes after about nine hours. Therefore, speed in detecting symptoms and starting therapy is crucial. Major gains in reducing the mortality from AMI must come from improvements during emergency management. However, several types of delays play a role:

• Patient delay: the patient waits one hour on average before calling the GP. Reduction of this delay could be achieved by encouraging patients to ask for medical assistance earlier. Recognizing a cardiac problem is essential. The Netherlands Heart Foundation distributes educational material to citizens. Unfortunately, psychological factors strongly reduce the effect of trying to improve self-assessment. Additionally, most people are hesitant to contact a GP, especially outside "office hours", when they are not sure that something serious has occurred.
• GP arrival delay: it takes about one and a half hour before the GP is with the patient and has made a judgement about the disease.
• Treatment delay: if treatment is delayed until arrival at the hospital another 25 minutes is lost. However, the treatment is only warranted if the patient is diagnosed to have AMI.

The Emergency-Management Service

 For the current case it was decided to reduce the "GP delay" by allowing citizens to make a call directly to the Emergency Medical Service, thus bypassing the GP. At the same time solutions had to be found within the constraint of budget neutrality (that is, no new solution may cost more than what is spent in the current situation). This simultaneously posed a problem and an opportunity for the EMS. When the GP is indeed bypassed, an increase of calls to the EMS is to be expected, consisting of a substantial proportion of non-urgent problems. Therefore, triage of really urgent cases will become more difficult. Cardiac expertise is necessary for diagnosing and treating acute myocardial infarction, but is only available at the hospital. It seems safe to assume that the triage knowledge currently available at the EMS is insufficient for proper triage of acute myocardial infarction by telephone.

The organization has more problems with respect to knowledge that is involved in assessing emergencies by telephone. Most knowledge is heuristic. Dispatchers say they can "feel" when something is wrong. This vague notion of an emergency prevents the knowledge from being similar across the dispatchers. It also complicates the evaluation of the process of emergency handling. There is a strong need for protocols, both for dispatchers and for management.

The EMS is a part of the section General and Social Sanitary Care, which is a main section of the Municipal Medical and Sanitary Service (GG&GD). Two units are part of the EMS: the dispatch center and the ambulance service. The dispatch center and the ambulance service are physically separated. The Municipal Medical and Sanitary Service has its own information services department.  Two types of functions are distinguished at the EMS: emergency-management functions and support functions. There are three emergency-management functions: (i) communication & coordination, (ii) emergency medical care, and (iii) the ambulance function. Support functions are archiving, evaluation, policy making, and supervision.

The dispatch center is equipped with nurse dispatchers who carry out the communication & coordination function. At the ambulance service, each ambulance unit consists of a paramedic, who carries out emergency medical care, and a driver, who is responsible for the ambulance function (transport and delivery). A system manager is responsible for the archiving function. The managers of both the dispatch center and the ambulance service carry out evaluation, policy making and supervision functions.
The manager of the dispatch center holds power over the system manager and over the dispatchers; the manager of the ambulance service holds power over the paramedic and the drivers. The paramedic is higher in the hierarchy than the driver. The manager of the General and Social Sanitary Service is head of both departments. At the dispatch center, one dispatcher is in charge of handling medical emergencies and in this role controls those who perform the ambulance function, without being formally in charge of them. The ambulance personnel and dispatchers do not socialize.

The EMS uses IBM RISC/600/320 machines under Unix, to run an information support system that handles on-line emergency calls, and off-line reservations, reviews, finance, statistics, etc.. This system is developed by the information services department of the Municipal Medical and Sanitary Service. Graphical terminals are not used. Three knowledge items are very important for the EMS. Within the EMS, the costs of new solutions can only be paid for by increased efficiency, for example by savings in not sending an ambulance without a "proven" necessity.  The manager has recently been confronted with the policy of the inspector to reduce the number of dispatches that do not result in patient transport to the hospital.