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back to About EMS Performance Measures page

History of EMS Performance Measures

Performance measures in healthcare date back at least a century.

In the mid-18th century, the Pennsylvania Hospital collected data on its patients, sorted by diagnosis and outcome (McIntyre). In the 1850s, Florence Nightingale developed a data collection and analysis system to track death rates in British military hospitals (Nerenz and Neil). By creating a system that measured each hospital in the same way, it was possible to look at trends over time and differences between hospitals.

Historians give credit to Ernest Codman, a Boston surgeon, for creating one of the first significant outcomes measurement systems; in 1910, Codman suggested that every hospital should follow each patient to track the efficacy of treatments. His efforts were incorporated into the American College of Surgeons hospital inspection program, and later, the Joint Commission on Accreditation of Hospitals (McIntyre) when it was founded in 1951.

A century after Codman’s proposal, the use of electronic medical records has created a wealth of information that allows managers, practitioners, regulators and researchers to track nearly every aspect of healthcare. With the explosion of available data has come a stronger push to also track key performance measures.

In recent years, performance measures in healthcare have become even more critical when the U.S. Centers for Medicare and Medicaid Services (CMS), the largest healthcare payer in the country, began displaying hospital performance online, and then using performance indicators in its payment schemes. Hospitals that do not achieve certain standards face financial penalties.

Performance Measures in EMS

Performance measures are not new to EMS. In the late 1970s, a study concluded that out-of-hospital cardiac arrest victims have a higher chance of survival if defibrillation occurs within 8 minutes.

Soon after, a response time standard of 8 minutes for ambulances took hold through much of the EMS community, and a performance measure was born (Al-Shaqsi 2010). Today, one of the few performance measures consistently calculated by EMS agencies and requested by municipal administrators is response time.

Other measures have been proposed since that time, often in line with what is measured by the rest of the healthcare system, particularly hospitals. Many of the more recent proposed have tried to find ways to measure clinical performance, and some researchers have pushed for “patient-centered EMS performance indicators,” such as survival from cardiac arrest or MI, patient satisfaction, and protocol compliance (Al-Shaqsi).

In 2002, NHTSA and HRSA sponsored a forum, co-hosted by NASEMSO and NAEMSP, which brought together EMS leaders to discuss performance measures. That meeting eventually led to the EMS Performance Measures Project, a multi-year effort that published 35 indicators and attributes for EMS systems in 2009. Since then, however, national EMS leaders have urged for a renewed effort, one that would create an even broader set of evidence-based measures as well as a system for maintaining and updating those measures in the future.

There have been several other attempts to create a standard set of EMS performance measures, and the current initiative will build upon each of these. In California, the state EMS Authority received a grant to develop EMS Core Quality Measures. In England, “ambulance quality indicators” for the eleven ambulance trusts are publicly available online and provide data on clinical and operational measures.


Al-Shaqsi, Sultan Zayed Khalifah. “Response time as a sole performance indicator in EMS: Pitfalls and solutions.” Open Access Emergency Medicine 2 (2010): 1-6.

El Sayed, Mazen J. “Measuring quality in emergency medical services: a review of clinical performance indicators.” Emergency medicine international 2012 (2011).

McIntyre, Dennis, Lisa Rogers, and Ellen Jo Heier. “Overview, history, and objectives of performance measurement.” Health Care Financing Review 22.3 (2001): 7-22.

Myers, J. Brent, et al. “Evidence-Based Performance Measures for Emergency Medical Services Systems: A Model for Expanded EMS Benchmarking: A Statement Developed by the 2007 Consortium US Metropolitan Municipalities’ EMS Medical Directors.” Prehospital Emergency Care 12.2 (2008): 141-151.

Nerenz, David, and Nancy Neil. “Performance Measures for Health Care Systems.” May 2001. Available online.