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Modelling Emergent Medical Service in
the Netherlands with CommonCADS
Wenchao He
School of Information Systems and Technology
Faculty of Informatics, University of Wollongong, Australia
1 Introduction
Emergent Medical Service in the Netherlands has experienced difficulties in saving acute myocardial infarction patients’ lives by avoiding delay for treatment. A new knowledge system should be introduced to the organization to improve their business processes. Before a proper solution to the problem is developed, an insight into the organization is necessary. In this paper, CommonKADS methodology (Schreiber et al. 2000) is used to perform a scoping and feasibility study and an impact and improvement study by modeling the organization from different aspects.
2 Scoping and Feasibility Study
2.1 OM-1: Problems and Opportunities
EMS aims to quickly transfer patients in need to hospital to receive proper medical treatment. To deal with the problem of delay of GP, they have an opportunity to allow citizens to call them directly. However, a new problem has to be expected, which is the increasing number of direct calls from patients.
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Organisation Model
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Problems and Opportunities Worksheet OM-1
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Problems
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* Delay of patient, GP and treatment
* Increasing calls to EMS
* Difficult triage of really urgent cases
* Knowledge of assessing emergency by telephone is heuristic
* Dispatches that do not result in patient transport to the hospital
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Opportunities
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* Response to patients’ medical treatment request bypassing the GP
* Triage knowledge management
* Development of protocols for assessing emergency by telephone
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Organisational Context
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Mission
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Provide AMI patients with proper in-time treatment
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External Factors
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Patients’ preferences, GP’s practice, public traffic
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Strategy
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Proper decision and action should be made after assessing individual calls to EMS, in despite of increased number of calls from patients because of their bypassing the GP.
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Value Drivers
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Reducing morbidity and mortality from AMI and making the therapy available to the patients in time
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Solutions
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* Solution 1: allow citizens to make a call directly to the Emergency Medical Service
* Solution 2: develop priority service system for AMI patients and only let this kind of patients bypass the GP
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2.2 OM-2: Organisation Focus Area Description
The structure of the organisation is not complicated. Relationship between each subpart is clear and well defined. The business process is straight forward. The number of roles in the organisation is not large. The following table depicts the basic information about the organisation in more detail:
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Organisation Model
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Variant Aspects Worksheet OM-2
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Structure
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Process
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People
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Managers of Dispatch Centre and Ambulance Service, Nurse Dispatchers, System Manager, Paramedics, Drivers, etc.
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Resources
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* IBM RISC/600/320 machines under Unix
* An information support system that handles on-line emergency calls, and off-line reservations, reviews, finance, statistics, etc.
* Fully-equipped Ambulances
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Knowledge
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* Emergency call answering
* Triage
* Process of emergency handling
* Diagnosing and treating AMI
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Culture & Power
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* Dispatchers control ambulance personnel without being formally in charge of them
* Dispatchers and ambulance personnel do not socialise
* Paramedic is higher in the hierarchy than the driver
* Manager of the ambulance service holds power over the paramedic and the drivers
* Manager of the dispatch centre holds power over the system manager and over the dispatchers
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2.3 OM-3: Process Breakdown
EMS’s main business processes can be broken down into seven main tasks which are described in the following table:
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Organisation Model
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Process Breakdown Worksheet OM-3
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No.
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Task
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Performed By
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Where?
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Knowledge Asset
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Knowledge Intensive?
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Significance
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1
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Call Answering
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Dispatcher
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Dispatch Centre
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online call system operation, call answering techniques
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Medium
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Medium
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2
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Emergency Assessment
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Dispatcher
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Dispatch Centre
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Triage
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High
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High
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3
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Patient Information Sent to Ambulance Personnel
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Dispatcher
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Dispatch Centre
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Internal Communication
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Low
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Low
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4
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Ambulance Dispatched
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Driver and Paramedic
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Ambulance Service
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Ambulance Driving, Medical Care Preparation
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Low
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Medium
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5
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Patient Pick-up
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Paramedic
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Patient’s Location
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Assistance for patient’s getting on ambulance
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Medium
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Medium
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6
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Ambulance Back to Hospital
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Driver
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-
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Ambulance driving
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Low
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Medium
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7
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Medical Care on Ambulance
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Paramedic
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Ambulance
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Emergent medical care techniques
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Medium
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High
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2.4 OM-4: Knowledge Assets
The tasks mentioned in OM-3 are all based on specific knowledge assets. Without the knowledge, the staff member will not perform the task properly. These knowledge assets for EMS’s main tasks are described below:
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Organisation Model
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Knowledge Assets Worksheet OM-4
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Knowledge Asset
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Possessed By
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Used In
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Right Form?
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Right Place?
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Right Time?
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Right Quality?
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Online call system operation
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Dispatcher
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Task 1
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Yes
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Yes
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Yes
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Yes
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Call answering techniques
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Dispatcher
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Task 1
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Yes
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Yes
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Yes
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Yes
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Triage
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Dispatcher
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Task 2
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No, triage of AMI may no be processed via telephone properly
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No, triage of AMI may no be processed at Dispatch Centre
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Yes
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No
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Internal Communication
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Dispatcher and Paramedic
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Task 3
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Yes
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Yes
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Yes
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Yes
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Ambulance Driving
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Driver
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Task 4 & 6
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Yes
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Yes
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Yes
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Yes
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Medical Care Preparation
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Paramedic
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Task 4
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Yes
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Yes
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Yes
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Yes
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Assistance for patient’s getting on ambulance
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Paramedic
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Task 5
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Yes
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Yes
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Yes
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Yes
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Emergent medical care techniques
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Paramedic
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Task 7
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Yes
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Yes
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Yes
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No, proper treatment for AMI patient on ambulance may not be available
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3 Impact and Improvement Study
3.1 TM-1: Task Analysis
Task 2, Emergency Assessment, has been recognised as of high knowledge intensiveness and high significance. This task plays a critical role in the business processes of the organisation. The following table will describe this particular task’s different aspects:
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Task Model
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Task Analysis Worksheet TM-1
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Task
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Task 2: Emergency Assessment
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Organisation
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Dispatch Centre
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Goal and Value
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This task aims to determine the degree of emergency of the reported incident and prepare relevant medical treatment resources for the patient. This task is important as it can avoid delay of treatment for high-degree emergent illness.
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Dependency and Flow
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Input tasks: A call from GP comes in
Output tasks: dispatching ambulance and sending useful information to paramedic
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Objects handled
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Input Object: In-coming call
Output Object: Information package for Ambulance Service
Internal Object: Emergency confirmation
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Timing and Control
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Frequency: 400 per day
Duration: 3.6 minutes
Control: Ambulance Service will only take further action when they receive the information package from Dispatch Centre.
Constraint: the task has to be performed based on dispatcher’s heuristic triage knowledge; the decision has to be made within a short time.
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Agents
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Dispatcher
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Knowledge & Competence
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Online call system operation, call answering techniques, triage, internal Communication skills
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Resources
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Time, online call system, internal communication system
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Quality and Performance
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Proper response to the reported patients according to the correct judgement of their illness and degree of emergency
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3.2 TM-2: Knowledge Item Description
To perform Task 2 well, Dispatchers have to use some specific knowledge, and such knowledge can actually be broken down into different knowledge items. The author has identifies these items and display them in the following table. Furthermore, those recognised as bottlenecks have been labelled, which will be beneficial for solution development.
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Task Model
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Knowledge Item Worksheet TM-2
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Name
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Triage
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Process by
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Dispatcher
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Used in
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Task 2. Assessing Emergency
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Domain
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Nursing, Medical
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Nature of the Knowledge
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Bottleneck/To be improved?
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Formal, rigorous
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X
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Empirical, quantitative
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X
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X
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Heuristic, rules of thumb
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X
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Highly specialised, domain-specific
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Experience-based
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X
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Action-based
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Incomplete
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X
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Uncertain, may be incorrect
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Quickly changing
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Hard to verify
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Tacit, hard to transfer
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X
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X
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Form of the knowledge
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Bottleneck/to be improved?
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Mind
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X
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X
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Paper
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Electronic
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X
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Action skill
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X
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Other
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Availability of knowledge
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Bottleneck/to be improved?
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Limitations in time
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X
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Limitations in space
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Limitations in access
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X
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X
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Limitations in quality
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X
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X
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Limitations in form
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X
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3.3 AM-1: Agent Specification
Dispatcher is the only agent who performs Task 2. Here we are to describe this position.
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Agent Model
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Agent Worksheet AM-1
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Name
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Dispatcher
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Organisation
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Informally controlling Ambulance personnel, under the supervision of Manager of Dispatch Centre
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Involved in
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Task 1, 2 and 3
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Communicates with
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Paramedics
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Knowledge
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Online call system operation, call answering techniques, triage, internal communication skills
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Other Competences
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Perform nursing service to patient
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Responsibilities and Constraints
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Dispatchers is responsible for collecting accurate information about callers’ detail and patients’ situation, making correct decisions in terms of emergency confirmation, ambulance resources allocation, information package for emergent medical treatment preparation.
Dispatcher has limitation in triage of some illness (e.g., AMI).
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4 Conclusion
EMS’s organisation models show that its two subparts work closely to provide their service, where Ambulance Service’s action depends on the decision made by Dispatch Centre. And such decisions are based on the information about the patients that the Dispatcher collects via the emergent call system. Emergency Assessment seems to be critical in EMS’s business processes as it requires the dispatchers have sufficient triage knowledge so that they can perform the task properly and successfully. The role of Dispatcher has several responsibilities that directly relate the quality of the service. However, dispatchers’ limitations in triage knowledge access and quality have affected the organisation’s fulfilling their mission. As a result, the knowledge carried by dispatchers should be the focus for future study in terms of the solution to EMS’s problem.
5 References
Schreiber, G, Akkermans, H, Anjewierden, A, De Hoog, R, Shadbolt, N, Van de Velde, W and Wielinga, B 2000, 'The task and its organizational context', Knowledge Engineering and Management : the CommonKADS Methodology, MIT Press, Cambridge, pp25-67.
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