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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Effective EMS Oversight - The "R" Theorem

In the previous "Insights" column, I outlined the reasons why EMS needs effective oversight - but many of you are surely waiting in major anticipation to read my opinion on what "effective" really means.

Effective oversight can be broken down using the "'R Theorem'":

Relevant

The oversight agency needs to focus its energies on projects that are relevant to today's EMS world. Many oversight entities still focus way too much energy on making sure we have enough 4 x 4s on the units and far too little energy on preparing EMS providers for the future of our profession. Too much focus on what we are DOING as opposed to where we are GOING. Oversight must be relevant to the core mission of "mobile healthcare". That's what we do - provide healthcare in a mobile environment. Oversight agencies need to spend less time assuring NIMS compliance and more time developing strategies to manage EMS system abusers; less time creating mandates for data collection and more time creating interpretive models to learn what the data tells us about the needs of our patients and communities. One EMS oversight agency recently sent a mass mailing carefully articulating to all ambulance providers why they cannot officially endorse the use of a King LT airway, when their real focus should be on establishing programs to help assure effective airway management.

Respected

We all need to be able to look up to our leaders. Respect is not given, it is earned. There are numerous ways leaders of the oversight agency can accomplish this feat, but none is more important than having actual experience. All too often, appointed leaders of oversight entities come from other departments or divisions of state government unrelated to EMS. Without the "been there, done that" factor, there is no way to establish credibility and respect, either from the agency's employees or the regulated providers. A State EMS bureau chief that has never performed CPR, worked a Trauma Alert, or been in an ambulance wreck, not only lacks insight into the real challenges of the profession, but they are often dangerous. They get lost in the bureaucratic quagmire of trying to mandate control using fear tactics as opposed to nurturing innovative ideas through teamwork and collaboration, not only with their employees, but also with the providers they regulate.

Responsive

EMS is a constantly changing field. The oversight agency needs to be able to anticipate the changes looming on the horizon and respond quickly in order to meet the challenges head-on. State and regional oversight agencies that are writing guidelines today for RSI have missed the boat. Many progressive regulatory bodies are already looking past this practice as either too risky based on current research, or that it simply does not make a significant enough difference in patient outcomes. The new horizon in the literature and overheard in the hallways during the "EMS Today" conference was "Pharmacologically Assisted King Airway". If regulatory agencies are to be responsive, they need to be prepared to help providers respond to the future trends in EMS.

The notion of responsiveness also applies in the literal sense as well. If it takes longer than 24 hours for the oversight agency to respond to a call or e-mail, they send the impression that either a) you don't matter, or b) they don't care. Either is unacceptable. When I worked in Florida, it was not unusual for the State EMS Office to respond to an e-mail or phone call in less than 3 hours. In another state, I have placed three calls and three e-mails to the EMS Bureau Chief and have not received a response to any of them. Which agency do you think is more responsive and as such, earned my respect?

Resourceful

Let's face it - governments are being forced to do more with less (as we all are by the way) and oversight agencies can be stretched very thin. The "parent" of the oversight agency should provide the resources necessary to allow the regulatory agency to provide effective service to the providers and patients. If the "parent" does not provide enough resources then the agency and its regulated providers need to lobby the legislature for the resources. Recently, a group of EMS providers and stakeholders in one state became fed-up the state's EMS office being decimated with numerous positions unfilled, ineffective statutes and ordinances, and an annual turnover of the EMS Bureau Chief position. They all got together and lobbied the State Legislature to support the concept of a "Legislative Council" comprised of elected and appointed officials to review and make recommendations for an overhaul of the State EMS Office. The initiative did not pass, in part because the EMS Division's parent department did not support or understand the importance of the initiative.

Faced with increasing demands and decreasing resources, effective EMS oversight agencies engage in a "triage" process, continually evaluating which services they provide are most important for the overall EMS system, thereby focusing their limited resources on those areas. Most of these agencies also make effective use of innovative resources such as the internet, distance learning, telecommuting, and even part time or contract staff that can be flexibly deployed as necessary.

Regional

EMS oversight at a State level is the basic foundation of regulation. The state typically regulates certification, basic scope of practice, service licensure and medical director standards. However, HOW EMS is provided is a more localized concern. It's often said, "Once you've seen one EMS system, you've seen ONE EMS system". The authors of the recent Institute of Medicine report "Emergency Medical Services at the Crossroads" invested a lot of ink opining that EMS systems need to be regionalized to help gain clinical proficiency, operational efficiency and economic stability, as well as to eliminate significant differences in care standards across arbitrarily drawn geopolitical boundaries. Therefore, effective EMS oversight must have a basic foundation of state-wide requirements, but the local community should have regional oversight as well. The regional entity should set community standards for level of care, number of providers, numbers of personnel, medical protocols and system financing. Without effective regional oversight, communities run the risk of uninformed and parochially focused politicians making decisions for their local community that would negatively impact neighboring communities.

Florida has one of the best processes for combining state oversight with localized regional control. The State sets the basic standards for the processes listed above, but by statute, the 67 counties in the state have the local level control to decide what's best for their residents. The state can only grant an EMS license to agencies that have first obtained a "Certificate of Public Convenience and Necessity" from a local county. This way, if Orange County wants to allow ANY ambulance provider to enter the market, the COUNTY elected officials make that determination. Conversely, if Volusia County wants to gain the clinical, operational and fiscal advantages of a SINGLE ambulance provider, that's the choice of the county elected officials on behalf of their residents. Implementing this same process on a city or town level is problematic for the same reasons you do not have a hospital in every city.

Representative

The final "R" has to do with the makeup of an effective oversight agency. The governing board of the system oversight agency (state or regional) needs to represent the major stakeholders in the system and NOT the providers. Providers are not appropriate members of the agency that regulates them. EMS is healthcare; therefore at least half of the members of an oversight board need to have healthcare experience such as doctors, nurses, and healthcare system administrators. EMS also has a "public safety" role in the community and often receives ad valorem revenue (tax subsidies). Therefore, elected officials should also have a heavy presence on EMS oversight boards. Using this approach, the elected officials represent the "will of the people", while the healthcare providers inject the "reason" into the oversight. The elected officials may want a paramedic on every street corner, while the emergency physicians recognize that high number of paramedics in the system will lead to patient care experience dilution and a bunch of clinically incapable paramedics.

Conversely, the docs may want an AED every 500 feet in public buildings, but the elected officials know that would cause a revolt from the building industry and add $5 per capita to the tax role. They balance each other out and together will make appropriate public policy decisions.

Now, at this point many of you are sitting back with your eyebrows raised saying "what about representation from the ambulance services, fire departments, first responders, EMT and paramedic educational institutions and such". Those agencies can be on an "advisory board", but it is inappropriate for them to be part of an oversight agency.

There are many great EMS oversight agencies and systems across our great country. But, there are also some that are not so great. As you all have read this, I hope you have kept a report card of grading your oversight agency to some of these R's. If there are more A's than D's, cool! However, if the GPA is less 2.5, it's time for the one of the final "R's" for the EMS oversight agency: Revise or Remove! EMS is too vital to be left to mediocre oversight. Each of us has the responsibility to act in order to assure effective system oversight because sooner or later, we will be the one"s needing EMS. When we do, we should be able to do so with the satisfaction that WE took action to be sure the system is the best it can be!