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Insights by Matt Zavadsky, MHA
focuses on the implications of recent news from around the world and it's impact on EMS nationally and in your home town.
Matt Zavadsky, MHA
About the columnist: Matt is the Director of
Tri-State Ambulance, a not-for-profit subsidiary of the Gundersen Lutheran Healthcare System located in La Crosse, Wisconsin. Tri-State serves as the sole 9-1-1 advanced life support provider for the 2,200 square mile greater Coulee Region local in Western Wisconsin and Eastern Minnesota. |
He holds a Masters Degree in Health Service Administration and has 25 years experience in EMS including volunteer, fire department, public and private sector EMS agencies. He is a former paramedic and has managed private sector ambulance services from 10,000 to more than 100,000 annual call volume in locations including Fairfield, Connecticut; Augusta, Georgia and Orlando, Florida. He has also served as a regulator in Lincoln, Nebraska and Volusia County (Daytona Beach), Florida.
Matt is a frequent speaker at national conferences and has done consulting in numerous EMS issues, specializing in high performance EMS system operations, public/media relations, public policy, employee recruitment and retention, data analysis, costing strategies and EMS research.
He has served as the American Ambulance Association as Chair of the Industry Image Committee and membership on the Professional Standards, Strategic Development and Management Training Institute Committees.
Matt is an Adjunct Faculty for the UCF's College of Health and Public Affairs teaching courses in Healthcare Economics and Policy, Ethics, Managed Care and US Healthcare Systems.
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Ask most people about the key components of EMS system design and they will typically bring up concepts such as public or private providers, advanced life support or basic life support, single or multi-tier systems, or even subsidized or non-subsidized providers.
While all these components to an EMS system are important, they pale in comparison to what I believe to be the single, most important aspect of EMS system design.
GOVERNANCE!
That's right - the age old question of 'who decides'? Who decides whether a system is local, regional, or a combination? Who decides if there is one provider for an entire medical trade area, or multiple providers engaging in retail competition? Who decides what the performance criteria will be and what the penalties for non-compliance are (or, if there will be performance criteria at all?).
Most EMS systems of today are not the product of policy decisions which deliberately selected certain features and rejecting others with the full understanding of each option's demonstrated advantages and pitfalls. Conversely, most EMS systems simply evolved over time through a process of short-term, issue-driven political decisions, usually after some untoward sentinel event, or significant 'lobbying' by one stakeholder group. Most EMS system leaders will tell you that if they had the opportunity to truly design an EMS system from scratch, it would look NOTHING like the one they are operating in today.
The framework of system governance usually has its initial foundation in state statute. The state legislature creates some general framework for EMS system governance. Some states designate county, city, or regional authority for regulating EMS (California, Florida and New York), but in some states there are no regulatory rights granted other than the state's own EMS regulatory authority (Wisconsin). Even still, 'regulation' is only loosely akin to governance.
One of the major pitfalls of most EMS systems is the fact that no one is really "in-charge". The recent Institute of Medicine report on EMS is highly critical of modern EMS systems because of the significant variation in levels of care and even operational efficiency when crossing geopolitical boundaries. This leads not only to disparities in patient care, but too often also creates significant duplication of services and a dilution of paramedic utilization resulting in an overall diminishment in skill proficiency. This occurs when counties, cities, towns and even villages each make local political decisions on their own EMS systems in a virtual vacuum, without collaboration with bordering areas to regionalize EMS delivery.
Some of the nation's most highly regarded EMS systems have created regional EMS authorities that are charged with the responsibility to make decisions not based on politics or local issue driven policy, but instead on what's best for the patients in the entire area serviced by the EMS system. It is for this reason that the Public Utility Model EMS system design consistently produces the highest system performance (clinically, operationally and financially) with little to no political influence.
All too often, a decision made by one local jurisdiction can have a ripple effect (or in some cases, a tsunami effect!) on neighboring jurisdictions. This is not only true in EMS, but also on economic development, transportation, and education. While most progressive communities have created regional authorities to coordinate transportation, economic development and education, EMS has not been as successful become ‘regionalized'.
Most healthcare leaders will tell you that healthcare is a regional delivery model and since EMS is healthcare, it fits well into this model. Especially when you consider that EMS systems typically have high start-up and infrastructure costs and they perform best when they cover a diverse geographic area. Similarly, the most effective EMS systems are one's that have few, well utilized paramedics (as cited by the May 2006 study presented at the EMS Scientific Assembly).
What we really need to promote is the creation of EMS authorities that can focus on mobile healthcare delivery and not political pressure. Imagine a scenario where decisions effecting patients throughout an entire healthcare delivery region is not made by locally elected officials subjected to intense pressure by 'lobbyists' and conflicting agendas, but by appointed experts in emergency medicine, healthcare delivery, accounting, law, human resources and even just ‘patients'.
Here's how it could work....,
The cities, townships and/or counties that comprise a logical healthcare delivery region are provided the opportunity to appoint members to the regional EMS authority based on full-time taxpaying households. Larger population bases can appoint more than one member, but no more than three. Appointments have to meet certain criteria. The criteria can be things like not being a provider of EMS services, not be an elected official, have expertise in emergency medicine, healthcare delivery systems, healthcare law, accounting, or represent the elderly or children, etc. Once appointments are made, this in essence 'de-politicizes' the process and allows informed citizens to make determinations about the who, what, when and how EMS services will be provided. The authority could be the contracting entity if a contract is used, and could also be the clinical, operational, and fiscal oversight as well.
Using this approach to EMS System governance would require local elected bodies to give up some autonomy and "home rule". However, based on recent discussions with numerous elected officials, many of them would feel relieved to have the burden of balancing conflicting alliances transferred to a knowledgeable team of informed decision makers whose sole focus is system improvement for enhanced services to the patients the EMS system serves.
So, consider asking your local leaders to establish this type of regional EMS authority. It certainly seems like a logical way to bring the correct focus to EMS system governance. It's the least we can do for all those who rely on our EMS systems.
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