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FirstWatch customer Chuck Walker, Clinical Services Coordinatorfor Sunstar Paramedics, uses FirstPass to enhance their QI processMany of our FirstPass Customer Partners:Advanced Medical Transport, IL – Alachua County, FL – Allina Health EMS, MN – AMR CSA, CA – AMR EMSA, OK – AMR Portland, OR – AMR San Bernardino, CA – AMRSan Diego, CA – AMR Santa Barbara, CA – AMR Santa Clara, CA – AMR Ventura, CA – Anchorage Fire, AK – Austin-Travis County EMS, TX – Baltimore City Fire, MD –Brewster Ambulance Service, MA – Broken Arrow Fire, OK – Care Ambulance OC, CA – Charles County EMS, MD – Clark County Fire Department, NV – CommunityAmbulance, GA – Community Ambulance, NV – Contra Costa County, CA – CRESA-Vancouver AMR, WA – CRESA-Vancouver Fire, WA – Cy-Fair, TX – Durham CountyEMS, NC – Eastside Fire & Rescue, WA – Envision Healthcare, CA – Falck Northern, CA – Falck Northwest, CA – Falck Rocky Mountain, CA – Falcon Ambulance, CA –Greenfield Fire Department, WI – Guardian Elite, CA – Guilford County EMS, NC – Hackensack UMC EMS, NJ – Hawaii County, HI – Jersey City EMS, NJ – JFK EMS, NJ –Johnson County, KS – Lake County, FL – Las Vegas Fire Rescue, NV – Lassen County, CA – Lassen County EMS, CA – Life EMS, MI – LifeCare Ambulance, MI – LifeNetEMS, TX – Littleton Fire, CO – Louisville EMS, KY – Louisville Metro EMS, KY – MAAS, GA – Marion County, FL – McCormick Ambulance, CA – MedStar, TX – MercyMedical Transportation, CA – Montgomery County Fire & Rescue Service, MD – Mountain Valley - AMR, CA – Mountain Valley - Oak Valley, CA – Mountain Valley - PattersonDistrict, CA – Mountain Valley-Pro-Transport, CA – Mountain Valley-West Side, CA – New Hanover EMS, NC – Niagara EMS, Ontario, Canada – NorCal Ambulance, CA –North Shore Fire Rescue, WI – Northwell SkyHealth, NY – Pinellas, FL – Prince George's Fire, MD – REMSA, NV – Richmond Ambulance Authority (RAA), VA – RiggsAmbulance, CA – Robert Wood Johnson, NJ – San Marcos Hays County, TX – San Mateo County EMS, CA – SCCAD, MD – Sedgwick, KS – SNOPAC 911, WA – SolanoCounty, CA – Sonoma, CA – Spokane Fire, WA – Suffolk FRES, NY – Trinity EMS, MA – Tucson Fire Department, AZ – UC Health EMS, CO – WestMed Ambulance, CA –Williamson County Emergency Services, TXLET US SHOW YOU HOW FIRSTPASS CAN HELP.Know what’shappening in yoursystem to makeimprovements nowCollaborate amongstakeholders withinone viewReview qualityindicators mostimportant to youAnalyze systemand individualprotocol compliance

A word from ourImprovement GuideAlmost every EMS system has something with the wordquality in it: a quality plan, a peer review QI committeeor a quality improvement manager. Yet when you askEMS leaders what their quality program has madebetter, shoulders shrug and the subject changes.Somewhere along our path we seem to have forgottenthe improvement part of quality improvement. So howdo we put the missing ‘I’ back into QualityImprovement?Improvement success comes from making the Modelfor Improvement a regular part of the EMS organization,and it comes from effectively measuring your efforts. Inthese EMS organizations, the principles and practicesassociated with the science of improvement have beenintegrated into their DNA. They monitor theirperformance data in all vital areas of their operations,so they are able to spot problems before they get outof control.There is no one right process or theory for how todo this, but we must expose and train ouremployees to these ideas in order to makeimprovement thinking automatic. We cannotsimply say “we will now be a performanceimprovement oriented organization.”At FirstWatch it is our goal to help provide you with thetools to help your organization and employees becomesuccessful, improvement oriented systems, and to alsohelp you understand how our FirstWatch real-time,quality improvement tools can fit into yourorganization’s overall Quality Improvement program.The next time someone asks you those “What have youimproved lately” questions, you can answer withconfidence, and data!- Mike Taigman, FirstWatch Improvement Guide2Automateperformancemeasurement soyou can focus onwhat mattersmost - yourpatients.

The traditional approach to Quality Improvement in EMSis labor intensive, time consuming and often confusing,leaving little time to actually improve care. EMS agenciesneed the ability to monitor and analyze patient caredata, identifying deviations rapidly, consistently andautomatically.What isFirstPass?FirstPass is a Performance Improvement system thatmakes it easy for you to see your systems overallperformance for clinical care and billing. It helps youquickly identify big areas that need improvement andthen helps you figure out what improvement action willproduce the best result. It also makes call review,protocol compliance monitoring, and pre-billing reviewfast and easy. With FirstPass you can let the computerdo the initial review of all of your calls, saving your stafffor the things computers can’t do.FirstPass doesnot only tell youwhen a call isflagged becauseit did not meetprotocol, but italso tells youWHY the callflagged.How does it work?FirstPass provides continuous monitoring of ePCR andother data. It quickly reviews each call based on yourspecifications and flags calls for review when based on theePCR something is amiss, clinical issues, urgent patientsafety issues, or missing data elements.We offer a standard bundle of FirstPass protocolsincluding ACS/STEMI, Stroke, Trauma, AirwayManagement, Cardiac Arrest, and Universal. All ofthese or other protocols that you’d like to monitor willbe customized to meet your needs.Each of your FirstPass protocols feeds data into adashboard that displays all of your system performance onone constantly updating page. The display allows you tosee how you’ve performed over time for the things thatmatter most. With one click you can drill into each protocolto see the performance of all of the sub components thatmake up a protocol. This allows you to fine-tune yourperformance improvement efforts like never before.3

ENMTENFirstPass v3 InterfaceNCEMHAO D ULEThe FirstPass Dashboard has run charts or control charts that display your system’sperformance to your protocols over time. This makes it easy to see if the training, protocolchange, or other improvement you’ve implemented resulted in actual improvement. Thesecharts make it easy for your team to know where to focus your quality improvement efforts.Drill down into charts for a view of individual test performance.4

FirstPass makes it easy to see how an individual provider’s performance comparesto their previous performance and the system overall for each individual test.ENMTENFirstPass v3 InterfaceNCEMHAO D ULEThe FirstPass gives you the ability to send direct feedback to crew members regarding aspecific call.5

FirstPass Standard ReportsProvider Protocol ComplianceDisplay compliance of protocols and compare them against the system for the sametime frame selected. Individual tests can be selected to view the incidents used forcompliance reporting.Expand ProviderName to viewcompliance toindividual testwithin eachprotocol6

FirstPass Standard ReportsSummary of Tests by ProtocolThis displays the system protocol compliance. When the protocol is expanded, theindividual protocol test information and compliance is displayed. When expanded, thisdisplays the protocol and the associated tests with their system-wide compliance.7

FirstPass Standard ReportsProtocol Compliance GraphThis is a graphical representation of the tests for each protocol. The bar graph can beclicked to provide a detailed summary of all incidents that failed a particular test withina protocol. Drill through the graph to display incident information for each incident thatfailed within a protocol.Drill-down:8

FirstPass Standard ReportsProtocol Summary ReportProvides a count of incidents and displays the raw pass and count percentage as wellas the adjusted pass count and percentage of incidents in FirstPass. Adjusted refersto incidents that were reviewed and found to have passed due to predeterminedexception criteria.9

FirstPass Standard ReportsCall Review Status ReportThis report displays which incidents in FirstPass have been assigned to individualreviewers and displays how long they have been in the queues for review. It isdesigned to track the time an incident is assigned in FirstPass and includes each ofthe users which can review incidents.10

FirstPass FAQsHow is FirstPass different from FirstWatch?FirstPass is an add-on, enhancement module that sits on top of FirstWatch. FirstWatch is thefoundation for which the data is derived, where you define the things you want to look at and callsare pulled based on user-defined filters. FirstPass then takes that data through a very structuredprocess of algorithms and logic to evaluate specific quality oriented protocols, tests and outcomes.A queue based tool, FirstPass allows members of QI, risk management and the medical director’soffice to all access and work through one singular quality improvement tool.Can FirstPass be customized to fit my system’s protocols?Providing that the data source (CAD, ePCR, ProQA, Hospital Data etc.) FirstWatch is interfaced withcaptures relevant data that can be used to evaluate against your systems protocols, FirstPass canhave a high degree of customization. Once a customer defines what they want to measure, we canbuild custom protocols that look for quality metrics driven by customer focused initiatives as well asregional or state level mandates. While FirstPass is highly customizable, we recommend starting withour “Bundle of Care” approach. This initial set of evidence-based protocols is designed toencompass recognized standards of care, the affordable care act and overall best practices. TheBundle of Care is made up of the following protocols: ACS/STEMI, Stroke, Trauma, AirwayManagement, Cardiac Arrest, and Universal OR Billing. Additional metrics to consider mightbe: Pain Management, Patient Care Aspect, High Risk/Low Frequency Event or NonTransports/Refusals.How will my QI department benefit from using FirstPass?The overarching goal of FirstPass is to provide automated data analysis for clinical indicators andquality measures – all in real-time, at your fingertips. With FirstPass, QI teams can now spend moretime working to improve patient outcomes rather than filtering through every patient record to locatepotential outliers that could indicate opportunities for improvement in patient care. FirstPassautomates a process that is traditionally time, resources and labor intensive; you will now know rightaway when a call is outside the expected parameters occurs. Real-time feedback and knowledge ofwhat is happening within your system at all times allows for collaboration amongst crew members,managers, QI analysts, the Medical Director and any other stakeholders involved. Ultimately, this willresult in rewarding success to crew members for a job well done and improving patient outcomes byfocusing on areas of improvement and continuing education in a timely and continuous manner.Additionally, FirstPass comes with real-time reporting tools; examples include Provider ProtocolCompliance, System Protocol Compliance and Summary of Test by Protocol.How is FirstPass connected to Healthcare Reform and the new focus on QualityOutcomes?Healthcare is moving to quality measurement, bringing with it improved patient care – and financialimplications. Simply stated, the components of the Affordable Care Act are directly related tocontrolling cost through a focus on quality of care. The same quality measures that are drivingchange in healthcare will soon be coming to EMS. Progressive EMS agencies are monitoring,measuring and managing quality to improve patient care and ensure success when financialincentives become realities. FirstPass helps agencies to define, automate and streamline theirmeasures and monitor in a timely, consistent and reliable manner. This will allow systems to makecorrections and demonstrate timely and effective care through the tracking of patient satisfactionand outcomes in real-time.11

Customer Highlight: PinellasPinellas County employee Provider Protocol Compliance report compares employeecompliance to overall system compliance, including their raw and adjusted protocolcompliance percentages.Using FirstPass, Pinellas County has dramatically improved their performance over time.12

Customer Highlight: Metro Atlanta Ambulance ServiceMetro Atlanta uses FirstWatch and the FirstPass Quality Improvement (QI) module tomonitor our ZOLL Dispatch and ePCR data, which automatically scans those recordsand compares them to goal times and clinical, operational and billing rules. Thegraphic below shows the FirstPass module’s main screen, with queues (on the left)showing calls that have passed or flagged a series of detailed, automated tests, basedon their medical director’s specific protocols.QI reviewer works througha queue of calls that needhuman review, withinminutes of the call.The graphic below shows the specific tests that are automatically performed byFirstPass for their Chest Pain protocol. Their QI staff reviews the calls that wereflagged and is able to provide feedback to crews quickly, often during the same shift,while the call is still fresh in their mind.13

Customer Highlight: Metro Atlanta Ambulance ServiceCalls where the treatment was appropriate, but not documented as expected, can beidentified and marked as appropriate, and the adjusted pass/fail information isreflected in our Employee Scorecard Report, along with simpler Operationsmeasures, including: Chute Time, Response Time, Scene Time, Hospital Offload Time,and Task Times.Employee ScorecardThe Employee Scorecard is a custom report that combines operational performance(chute times, time on task, etc.) as well as clinical performance (FirstPass protocolcompliance) and displays it by medic. The summary page is the first page of the reportand shows the overall system compliance for all elements. It is designed to be pagedby provider for feedback purposes, and uses both CAD and ePCR data.14

Customer Highlight: Metro Atlanta Ambulance ServiceBilling in FirstPassWhat’s the quality of your billing?Do you know your organization’scompliance in obtaining yourneeded billing information?Can you get your billing complianceat the fieldemployee level?If you create a billing protocolin FirstPass, you will!15

You have thedata. Now whatyou need is a wayto understandwhat it meansquickly andconfidently.KEY BENEFITS Real-time Automated Performance Improvement - useone tool to monitor protocol compliance,documentation, and improvement success Measure Protocol Compliance - prioritize and monitorthe protocols that are most important to your system Enhance Documentation Quality - real-time review ofcompletion of required ePCR fields Provide Meaningful Feedback - ask questions andprovide medics with feedback before they end their shift Save Time & Resources - Let the computer do thework, and save the human for what is most important Monitor Medic Performance - Track individualperformance to overall system objectives31.7Million 158 Live SitesRecordsProcessed1,483 Protocols7,052 TestsFirstPass by the Numbers 31/2 years in research and development6/2010Started developingFirstPass withSt. Charles CountyAmbulance District(SCCAD)167/201111/2011Initial SCCAD FirstPassrecordsTrademarkprocessed 1/2014FirstPassVersion 1released atNAEMSP6/2015FirstPassVersion 2released7/2015FirstPassprocessed1 millionth rec.

“By using FirstPass, our team has saved a minimum of 20 hoursa week by reviewing only those charts flagged as needing to bereviewed. FirstPass has created significant efficiencies for uswith a long term annual savings of a half FTE.” FirstPass User, Tony Sorensen, Life EMSHEMSI MedicsLife EMS Quality Team Member Reviewing FlaggedCalls in real-time for follow-up with crews“We use our FirstPass billing protocol everyday. We love itbecause it saves us both time and money. Without FirstPass, wewould definitely need to hire an additional full time employeejust to keep up with reviewing more than 50,000 ePCR recordsper year. I don't know what we would do without FirstPass!” FirstPass User, Jon Howell, HEMSILive Sites1Billion Tests Run26 ePCR SystemInterfaces3/2016Mike Taigmanjoins FirstWatchas ImprovementGuide5/20181/2017FirstPassprocessed5 millionth rec.3/2018FirstPassVersion 3releasedFirstPassprocessed10 millionth 891 LiveSites2019Mid-2020Mid-202117

PHOTO COURTESY ROB LAWRENCE/RICHMOND AMBULANCE AUTHORITYRichmond Ambulance Authority usestechnology to enhance its QA/QI processBy Michael Gerber, MPH, NRP and Rob Lawrence, MCMIRichmond, Va., Ambulance Authority (RAA) is well known for being ahigh-performance EMS system andfor its community education efforts and implementation of a culture of safety.But the agency has also recently taken a hugeleap forward in the areas of quality assurance(QA) and quality improvement (QI). RAA,which serves as the sole provider of emergencyambulance service for the Virginia capital, hasimplemented the “Total Quality Management”(TQM) system.The system links quality man agement efforts in the clinical, operations andbilling arenas in order to comprehensivelyimprove RAA’s service and efficiency.Each month, RAA’s TQM committee meets to discuss any potential areas forimprovement.The director of reimbursement5818JEMS JULY 2015might mention a specific documentation issuethat’s causing delays in billing or collections.The chief clinical officer may discuss intu bation rates and educational programs beingimplemented to improve them.The idea behind TQM is that everythingis interconnected. Dispatch and operationsimpact clinical care, clinical documentation impacts reimbursement, reimbursementimpacts operations, and so on. Like manyagencies, RAA has a clinical services committee that focuses solely on clinical issues,where the medical director is joined by theclinical officer, the QA/QI coordinator, thetraining staff and other paramedics. But theTQM meeting adds another layer.Attendees at the TQM meetings includethe chief operating officer, the director ofoperations, the chief clinical officer, the qualitymanager, the director of reimbursement, thecompliance officer and the operations andcommunications supervisors.Believing that each aspect of agency performance is connected and part of the cycleof providing high-quality services, RAA usesits TQM approach to measure and analyzeoutcomes and processes and make adjustments to training and policies to achieve itsdesired outcomes.USING TECHNOLOGYTO FILL THE GAPSPreviously, RAA’s clinical and documentation QI process focused on reviewing specifictypes of patient care reports (PCRs), suchas all cardiac arrests; specific high-risk, lowfrequency procedures (e.g., cricothyrotomy);and a certain percentage of other calls. Theagency also would choose to review specifictopics or themes during certain months—perhaps looking at reports written by new hiresone month and field training officers the next.WWW.JEMS.COM

The billing team would then review the report to identify documen tation issues related to reimbursement.Like most departments, RAA performed these focused PCR reviewsbecause trying to review every PCR provides a limited return on a significant investment of manpower and resources. Either several reviewers read the reports with little consistency or guidance on what to lookfor, or one person attempts to review every PCR but eventually gets sofar behind they scramble to catch up and can’t provide effective feedback to providers or correct documentation errors in time to impactbilling. Practitioners often didn’t receive the feedback until severalweeks after the call, when they might not even remember the patient.In Richmond, agency leaders felt the process wasn’t as effective asit could be. They began searching for other solutions, and found oneright in their own headquarters.In the dispatch center, supervisors had already seen how technologycould provide real-time feedback and lead to improvements. At any timeduring the day, dispatchers can look at a monitor that shows whetherthey’re meeting certain performance standards. RAA uses FirstWatch, aCalifornia-based data and technology firm, to monitor computer-aideddispatch (CAD) data and provide almost instant analysis.In the dispatch center, that has helped drive improvements in areaslike call processing times, where no dispatcher wants to be the one notmeeting the goal that day.On the clinical side, RAA recently began using FirstPass, a tooldeveloped by FirstWatch to automatically evaluate PCRs for adherenceto protocols. FirstPass works by running each PCR through a series oftests based on certain criteria as soon as the data is available.The testsare based on treatment bundles and tailored to the agency’s protocols.The software also compares each PCR to a universal protocol thatchecks reports for certain demographic and basic clinical data, suchas baseline vital signs, signatures and other information RAA wantsto collect for every patient.Certain types of reports are screened further. For example, if thepatient complaint is for chest pain or another cardiac-related problem,FirstPass will look for documentation of a 12-lead ECG. If none isdocumented, the incident is flagged. For chest pain patients, FirstPasswill also look for appropriate documentation of specific treatments,such as aspirin or nitroglycerine administration. FirstPass’s clinicalcare bundles are evidence-based but also tailored to RAA’s protocolsand training. RAA is also working with the FirstPass team to developeven more sophisticated analysis and reporting tools.24Y E A R STHE TQM PROCESSWhen paramedic and RAA’s QA/QI Director of Operations Tom Ludinarrives each morning, he checks to see which reports were flagged bythe FirstPass system. He can immediately review the PCR to determine if it was a documentation error, an omission in patient care or ifthere was a reasonable deviation from protocol. If the answer isn’t clear,he can talk to the crew who treated the patient first to help make hisdecision while the crew still recalls the details of the call.“It gives a lot of opportunity to look through and see where improvements are needed,” says Ludin. “We can’t fix it if we don’t know it’sa problem.”FirstPass not only allows for every PCR to be reviewed for at leastminimal criteria, it also creates a system for measuring overall performance of the agency and individual providers. In many systems, simpleWWW.JEMS.COMFor more information, visit JEMS.com/rs and enter xx.JULY 2015 JEMS5919

TOTAL QUALITY MANAGEMENTdatabase searches and spreadsheet computations can determine how often 12-lead ECGsare documented as having been performed onchest pain patients. But FirstPass creates aneasy way to then track why that happened. Ona continuous basis, supervisors can determinewhether providers require re-education in clinical areas, documentation, or both.“Ninety-nine percent of the calls pass the criteria. I never look at most of those,”says Ludin.After Ludin reviews a PCR that failed aFirstPass test, he decides whether there wasa deviation from protocol or a documentationerror and emails the provider who wrote thereport within one business day.That providerthen has a chance to review the call and explainwhat happened, or correct the PCR, and Ludinand his colleagues determine whether anyfurther action—such as remedial training—is required.But while FirstPass allows RAA to checkeach PCR for certain criteria, it doesn’t replacehaving a real person dedicated to QA/QI.“FirstPass is a tool,” Ludin says, explainingthat he still uses his own database queries andother methods for other aspects of the qualitymanagement process.For example, Ludin reads a random selection of PCRs each month so he can look forany issues the computer might not catch. Asan accredited dispatch center, RAA alreadyreviews the 9-1-1 calls for critical cases and arandom selection of other calls each month—Ludin uses the same list to determine whichPCRs he will review.Having a TQM system means that whenissues are discovered by one department, theentire agency helps find a solution. This willbecome even more critical for EMS agencies when the next revision of the International Statistical Classification of Diseasesand Related Health Problems (ICD-10) isadopted by payers later this year.With ICD-10, the number of billing codeswill greatly expand, and the importance ofgood documentation will increase. Having aTQM program is helping RAA prepare forthese changes by bringing billing and clinicalservices to the table together. When the billersfind an issue with documentation, they can askthe clinical supervisors about it and determineif it’s a documentation error or a misunderstanding by the billers over what service wasactually provided. If systemic problems arediscovered, the clinical supervisors can conduct training or change the minimum requiredinformation to complete a PCR.CLOSING THE QI LOOPRAA keeps its quality management as nonpunitive as possible, focusing instead on findingways to motivate its staff to make correctionsand solve problems. Just publicly displayingsome performance measures, either at the individual level or system-wide level, has led toimprovements. Clinical lapses aren’t necessarilytied to performance evaluations, unless supervisors feel there are no efforts made to improve.“You’re not evaluated on your QA/QIresults,” Ludin says. “Instead it’s your responsiveness to training.”When it was recently discovered that intubation rates were slipping after an influx ofnewly qualified paramedics, RAA’s trainingThe TQM system links quality management efforts in the clinical, operations and billing arenas in order tocomprehensively improve RAA’s service and efficiency. Photo courtesy The RedFlash Group/RAA6020JEMS JULY 2015coordinators instituted a system-wide effortto improve—even though they knew not everysingle paramedic had unsuccessful intubations.In the Login Room, they set up intubationmanikins and equipment, as well as some literature and videos on airway management.At the beginning of each shift, every ALSprovider took 10 minutes to practice intubation before heading out on the ambulanceto run calls.After the recent intubation refresher stations, RAA’s training staff received positivefeedback from the providers, including oneparamedic who credited the training with helping make his first live intubation successful.RAA was also an early EMS adopter ofself-reporting. Several years ago, operationalmedical director Joseph Ornato, MD, signedoff on a self-reporting protocol that encourages providers to come forward when theymake an error or omission.But this isn’t to say that RAA doesn’t letproviders know they value high performance.Each year when employees submit preferences for which shifts they want to work, RAAranks them using a combination of seniorityand compliance to certain standards. WithFirstPass now in effect, that might includecompliance to clinical protocols and PCRdocumentation in the future.THE FUTURE OF QA/QITechnology adds one more tool to the TQMprocess, allowing personnel to spend moretime doing what they do best—analyzing theproblems and finding solutions—instead ofspending hours determining whether the rightboxes were checked. Software can’t replace having dedicated providers and educators, but itcan make the system more efficient and morerobust, allowing agencies to focus on areaswhere improvement is necessary and ultimatelyprovide better care for their patients. JEMSMichael Gerber, MPH, NRP, is a paramedic, instructor, authorand consultant in Washington, D.C. He has more than a decadeof experience in EMS and the fire service. He can be reachedat mgerber@redflashgroup.com.Rob Lawrence, MCMI, is chief operating officer at RAA andwas named an EMS 10 Innovator for his work on the Rider Alertprogram in 2011. Rob is a graduate of the U.K.’s Royal MilitaryAcademy, Sandurst, and spent his first career as an active-dutyArmy officer in the British Royal Army Medical Corps, afterwhich he held various senior leadership roles in U.K. ambulance services before moving to Richmond, Va., to join RAA.WWW.JEMS.COM

7/27/2017EMS TopicsImprove EMS performance like a championParamedic ChiefArticlesBetter EMS Performancewith Mike TaigmanImprove EMS performance like achampionLearn how one EMS agency improved EMS provider performance withan Olympic-themed competitionJan 6, 2017By Mike Taigman and Tony SorensenMy most vivid Olympic memory is the 1996 women’s gymnastics all-around competition. TheRussians had dominated the sport and going into the final rotation it looked like it would bepossible for the U.S. to win for the first time in Olympic history. The last U.S. event was the vault.U.S. team member Dominique Moceanu had fallen twice when Kerri Strug, the last U.S.competitor, lined up to vault. Strug under-rotated the landing of her first attempt and injured herankle.With the point difference smaller than a blood cell, she asked the coach, "Do we need this?"He said, "Kerri, we need you to go one more time. We need you one more time for the Gold. Youcan do it; you better do it."She limped to the end of the runway and then landed the vault on both feet long enough toregister a 9.712 before collapsing in pain, cementing the Olympic gold medal for the U.S.OLYMPIC INSPIRATION FOR EMS IMPROVEMENTInspired by champions like Strug, the team from Life EMS Ambulance, established in GrandRapids, Mich. in 1980 and proudly serving over 3,700 square miles of west Michigan 1/621

7/27/2017Improve EMS performance like a championparamedic response, decided to have some fun and see if the

District, CA - Mountain Valley-Pro-Transport, CA - Mountain Valley-West Side, CA - New Hanover EMS, NC - Niagara EMS, Ontario, Canada - NorCal Ambulance, CA - . regional or state level mandates. While FirstPass is highly customizable, we recommend starting with . Metro Atlanta uses FirstWatch and the FirstPass Quality .

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the wisdom of the phrase just let it go. I found comfort and peace in knowing that God knows, He is just, and in a fallen world even good people do some things to you that make you scratch your head. So, let me encourage you, “Let the little stuff go.” Let God handle it. Pass the ball of injustice to Him

Exercise 4 Let pad: N ! # be de ned as pad(s;‘) s#j, where j max(0;‘j sj). For A and f : N !N, let pad(A;f) fpad(s;f(jsj)) js 2Ag. Solution 1. We show that, if A 2DTime(n6), then pad(A;n2) 2DTime(n3). 1.Let Mbe a DTM deciding A in O(n6) time. 2.Let M0be the TM that, on input w, performs the following computation: 2