REACH Air Ambulance: Built on innovation, committed to excellence☆

Article Outline

• Built on innovation
• Dedicated to excellence
• Growth and stability
• One step back, two steps forward
• Copyright

In 1983, I was “assigned” program director responsibilities for the University of Iowa Hospitals and Clinics' Air Care flight program. I did not want this assignment and did my best not to accept it. I was completely content and more than busy doing my thing with EMT-D and other emergency care training in my home state. But I was made an offer I couldn't refuse—it was a direct order, as I recall—and in the intervening 19 years, I have enjoyed the pleasures, frustrations, unparalleled rewards, occasional humbling defeats, and limitless challenges and opportunities of managing 4 different air ambulance programs in Iowa, Texas, and northern California. Ten months ago, I transferred CEO responsibilities for REACH Air Ambulance to my successor, Jim Adams, and now enjoy the “business” from an entirely new perspective.

I have had the privilege of serving with 4 wonderful, progressive, successful air ambulance programs. Among them, REACH Air Ambulance is unique in so many ways it will be hard to fit them all into the scope of this article. Is it because the program's in California, a land of innovation where anything is possible? Perhaps in part.

In larger part it is because of a confectioner's son from Boston who, after 30 years of immersion in his adopted West Coast community, had not even begun to lose his native accent, a man of almost extreme integrity, drive, and dedication who reveled in sticking out like a sore thumb. Whatever the reasons, from its birth to last year's 15th anniversary celebration, this program most assuredly has followed the path less traveled. This is my opportunity to share some things these good people would never say about themselves.

It began as any other helicopter program—a service provided by a hospital at the instigation of an ED doctor passionate about his calling. But a mere 18 months later, when its financially troubled parent threatened to close the program down, Redwood Empire Air Care Helicopter (REACH Air Ambulance) took the first of many steps into uncharted territory. The passionate ED doc who had cajoled hospital administration into funding the program the year before was not about to let it die such an early death.

We are talking, after all, about a man who, as a general practitioner, created the first ED in this growing city of 40,000 people, first put paramedic skills on its streets, and was forced to defend in court his license to practice medicine for ordering a lifesaving shock only weeks before the state granted these newly trained rescuers “man's authority” to save lives. John McDonald had little regard for “man's authority” when it conflicted with his innate sense of a higher moral authority.

From McDonald's commitment to doing what is right whatever the cost grew a most unusual company; perhaps the only one of its kind in the country and almost certainly the first—a family owned and operated, for-profit, freestanding helicopter ambulance program. The audacity of it! A community service owned by an individual for profit? If a hospital couldn't find a way to operate the program without losing substantial sums of money, who was he to think he could?

The plan was to do it in partnership with McDonald's aviation vendor, Helicopter Air Transport (HAT) of Portland, Ore. HAT would continue to provide the aircraft, pilots, and maintenance, and McDonald would form other relationships to minimize the clinical and administrative infrastructure and keep costs as low as possible. HAT stayed with it only the first 2 years, asking McDonald to buy them out in 1990 and forcing REACH to obtain its own air taxi certificate and hire its pilots and mechanics directly. By 1996, when I entered into a consulting relationship with REACH, the company still employed only its pilots and mechanics, plus a handful of support staff. The nurses and medics were “leased” from American Medical Response, communications services were farmed out to the local 911 call center, patient billing was contracted out, and the company had yet to see a budget.

But REACH was alive and well. And while McDonald had taken no money out of the company in these 8 years, he also had avoided putting much of his own money into it. The company was operating with its nose just above the water. But in doing so, it had developed a culture and had honed crucial skills that would serve it well as it entered a dramatic growth phase in the late 1990s.

In learning to survive on very limited resources, REACH developed a culture of frugality that remains evident today. To do this consistently in a program whose slogan is “Do what is right for the patient” requires resourceful, creative managers and staff, which REACH has attracted (and retained) in ample numbers. Seven of the 11 senior managers have been with the program 8 years or more; the top clinical, flight, and maintenance managers have been around for 10 years or more. These people know this company well, and they know first-hand how it got to where it is today. They quietly form one of the strongest management teams in the country.

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Built on innovation 

If you want to fly helicopters but don't have a lot of money, you're clearly faced with a challenge. But if you have Jim Larsen on your team, you learn that a good challenge is nothing more than a reason to get up in the morning. Jim literally grew up in aircraft. According to his father, he was flying IFR at age 6—before he could see over the instrument panel—in a Larsen Helicopters aircraft. Both a multirated rotor- and fixed-wing pilot and a talented A&P, Larsen became REACH's director of operations in 1993 at the tender age of 29. One of his first tasks was to find a way to squeeze more serviceability out of the economical but performance-challenged Agusta 109A. The goal: substantially increase the power-to-weight ratio in a commercially manufactured aircraft with a well-earned reputation for being underpowered and therefore marginally useful in hot or high conditions. The result: the A109 Lite, literally the creation of Larsen and a small team of REACH mechanics.

Beginning with the A109 Lite, Larsen and these mechanics never looked back. They have designed and implemented countless modifications on REACH aircraft, rotor and fixed, over the years to enhance serviceability both as aircraft and, more specifically, as air ambulances. As the fleet has grown to a dozen aircraft, each ship has undergone its conversion in the REACH hangar in accordance with REACH design standards. Many of the custom features and modifications are unique in the industry.

For example, REACH was the first U.S. program to install all-terrain satellite communications systems on commercial helicopters. Why? Because the alternatives were either losing communications for at least some part of most flights in its mountainous service area or bearing the high cost of supporting multiple mountaintop repeaters. Taking an innovative approach not only cost significantly less money, it also produced a better result. The REACH communications center in Santa Rosa recently maintained direct radio contact with 1 of its aircraft supporting the Olympic Games in Salt Lake City.

Other important innovations in the aviation arena include being the first program west of the Mississippi to win approval for off-airport GPS helicopter approaches to key hospitals and the first in the nation to obtain approval for direct GPS routing to these approaches.

Larsen has now moved up in the organization to make room for others to spread their wings. Without question, the most enviable and prized accomplishment of this committed group of managers—Vicky Spediacci, director of operations; Art Gotisar, chief pilot; and Hank Hilsmann, director of maintenance—is 15 years and more than 18,000 patient transports without accident or incident.

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Dedicated to excellence 

On the clinical side of the house, REACH enjoyed the benefit of an energetic, highly committed full-time medical director until McDonald's tragic and unexpected death in October 2000. His core instruction to the flight crews: do what is right for the patient. As long as their decisions were guided by this principle, his reciprocal commitment to them was to support them, regardless of financial or political cost. As REACH flight crews followed this simple instruction through the years, McDonald made good on his commitment to them. His successor, Dr. Gary McCalla, and the entire clinical management team continue this legacy.

On several occasions, 2 helicopters have been dedicated to a single patient when necessary to secure the best outcome: 1 aircraft to get a REACH crew to the patient as soon as possible and another to retrieve a neonatal specialist for rendezvous at the sending hospital; or another aircraft to retrieve antivenin or some other special pharmacologic agent, while the primary crew responds directly to the patient.

How is doing what is right, no matter the cost, consistent with trying to keep a small company with limited resources afloat in a fiscally challenging environment? REACH is a case study for the argument that “the customer is always right” (translated as “the customer's needs are always most important”) is a philosophy that also happens to be right for business. The company's top clinical manager, Jennifer Hardcastle, RN, is also principal marketer. Her sales message is simple—“Try us once. I'm confident you'll be so pleased with the experience that you'll call us again.”

REACH's commitment to its customers is that they need to make only 1 phone call to take care of their patient transport needs, no matter what the circumstances. If they can't find a receiving hospital, the helicopter will respond and initiate patient care while the communications center works to identify options for the sending physician. If the patient doesn't need a helicopter but can be more appropriately moved by ground ambulance, the communications center will make all the arrangements, including obtaining patient acceptance and bed assignment at the receiving facility and getting an ambulance going—even though REACH doesn't operate a ground ambulance. If REACH is not available, or if the customer requests a closer helicopter, the communications center willingly checks availability and transfers the caller to the appropriate competitor. A high priority is placed on ensuring full compliance with patient transfer laws and keeping the sending and receiving facilities updated on the status of the transport until it is completed.

This level of customer service, along with top-notch clinical care and commitment to the patient, has proven to be an attractive combination. Though it is a freestanding service, REACH has become the preferred provider for an impressive list of hospitals and specialty referral centers throughout San Francisco and much of northern and central California. An example is Children's Hospital Oakland. According to Hope Friedman, RN, pediatric transport and outreach coordinator, REACH is Children's preferred provider because it “consistently performs beyond our expectations in areas of clinical expertise, responsiveness to input, and most of all in their commitment to the care of pediatric patients.”

REACH is among a handful of U.S. helicopter ambulance services whose nonspecialized flight nurses and medics have been entrusted by Level II and Level III neonatal centers with moving the very small and very ill. To earn this trust, REACH, in cooperation with several of these NICUs, implemented a comprehensive neonatal training program for its crews. As the training progressed and experience levels rose, so did patient acuity in inverse proportion to patient size. Last year REACH performed more than 50 isolette transports using its own team.

Dan McDonald has built a career and an international airplane program almost entirely on customer service. In the past 5 years, fixed-wing transport volume has grown 38% and includes a high proportion of transcontinental and international flights. Until recently, the only aircraft in his fleet were Cessna 421s!

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Growth and stability 

REACH shares its primary service area with 6 other helicopter ambulance services supporting 15 separate bases of operations. Despite this highly competitive market, it has managed to grow substantially. Total transport volume has more than doubled during the past 5 years, growing 13% in the most recent year alone to nearly 3000 flights. The fleet of aircraft has grown from 1 in 1987 to a dozen today.

Growth has a healthy appetite for cash, and REACH's cash must come entirely from its own patient billings. Fortunately, a change in billing contractors 2 years ago has paid huge dividends, increasing monthly cash collections by more than 50% and providing the capital to support an expanding infrastructure.

REACH continues its fiscally conservative tradition and is financially stable as a result. Though it is a for-profit company and pays taxes on its earnings, all profit earned in its 15-year history has been invested back in the company. At his peak, McDonald paid himself an $18,000 annual salary for full-time medical director responsibilities. While the company has been more realistic with its managers and staff, McDonald's financial relationship to the company was certainly an answer to the few skeptics who questioned whether a community air ambulance service should be owned by an individual.

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One step back, two steps forward 

On October 4, 2000, John McDonald, an avid private pilot, was killed in a plane crash on his way to a REACH base meeting in Concord, Calif. Though he'd been cautioned by his director of operations about flying IFR without a professional pilot in the right seat, he was fully certified and simply wouldn't have been himself if he'd agreed to this limitation. He lost control climbing through fog just feet shy of breaking into clear skies and died as he lived—doing it his way, without fear, without regard for the obstacles in his path, with absolute confidence he would prevail. At any given time, there is only a handful of John L. McDonalds. But these few passionate individualists, these haters of bureaucracy and rules, almost paradoxically create institutions around which the rest of us build our careers and our lives.

McDonald is not replaceable, but in an important sense, he doesn't need to be. Like a parent who has instilled strong values and high standards in a child, he needn't have worried what will become of this “child.” It will be what it was raised to be.