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Nominating Committee Letter 06/08/1983 H. R. EHRHARDT, M. D. 144 CHANNEL DRIVE VANDERBILT BEACH NAPLES, FLORIDA 33940 PHONE (813) 597-4719 June 8, 1983 Mr. Egon Hill Chr,}irman Emergency Medical Services Advisory Council : Naples , Florida 33940 Dear Egon, 'As chairman of the nominating committee (Hanna R. Ehrhardt , Marvin Cecil, C .U. Whidden) established on May 25, 1983, I am pleased to report to you: The committee met at the library of Naples Commu- nity Hospital in the afternoon on Tuesday, June 7. • The above mentioned committee members agreed unan- imously to nominate the following EMSAC members, their names given in alphabetical order: For Chairman: Richard Davidson Egon Hill For Vice-Chairman: Jim Billman Norris Ijams For Secretary: Jonathan Smelko It was felt that putting more than one name on the ticket for the two top offices was more parliamen- tary ,. than endorsing a straight ticket. The nominating committee , of course , realizes that the election of the EMSAC officers will be open to nominations from the floor. After carefully studying the Bylaws, the committee found no obstacle to nominating an ex officio mem- ber for office. Furthermore the committee decided to request that the elction of officers be taken by secret ballot . over H. R. EHRHARDT, M. D. June 8, 1983 144 CHANNEL DRIVE page 2 VANDERBILT BEACH NAPLES, FLORIDA 33940 PHONE (813) 597-4719 Finally the committee would like to bring to your attention that according to the Bylaws of Collier County ::.MAC , Article V, Section 1. , page 4 "The medibers of the Council shall elect from the members the following officers at each meeting held in June of each year A. Chairman «•ti:«,. • B. Vice-Chairman C. Secretary " Thus the committee presumes that the election will berheld during the regular meeting on June 8, 1983, provided there will be a quorum. • Sir. ere/l/ Harms R. Ehrhardt , M.D. C .C . :I-iarvin Cecil C .U. Whidden l f Financial Stra • 1 1 For Surviving • the 80s s- field paramedic has a right to expect, "There isn't enough money." Sound familiar? Financial planner Alan Jameson calls it and the man or woman who signs on "the excuse that wears a thousand faces,all ugly and unconvincing."This month and for as manager must,as they say, "make the next three, Jameson will explain why in a four-part series of articles on financial the necessary arrangements." management techniques and philosophies as they relate to emergency medical services. Probably no field paramedic has ever screwed up without having a Covered will be the topics of billings,collections and accounts receivable management; management practices for financing of system expansion and improvement; and long- great reason for doing so. of d tin- , term cost containment, financial stability and building financial reserve capacity. guish themselves e eld from the not byti the i After completing his undergraduate work at the University of Arkansas, Jameson qua quality y of t ic cuss ,be but a by thy earned a Masters in Public Health from the University of Michigan. In 1972 he became the fact th that eealmost but r need by I EMS coordinator for an experimental health delivery system based in upstate New York. exc se. that same almost true of need an In 1974, he became codirector of a national EMS demonstration project in the state of managers.The Every holds g r of every y Arkansas.Since 1976,he has been a principal in The Fourth Party,Inc.,an EMS consult- managero Every manager of every ing firm which has been responsible for many important innovations in EMS organization sloppy, low-performance ambulance and finance. Mr. Jameson, who is a Certified Financial Planner, is now based in Ann prove co conclusively public and private, the Arbor, Michigan. prove conclusively that: first, the situation is not really all that bad;and second, if there are flaws, the causes are totally beyond the control of this or any other manager. Maybe God fter reading much in the recent receive the,same sort of performance couldn't correct these problems, so the story goes. A literature about the pheno- from management. menon of paramedic burnout,I A There is apparently an inverse rela- couldn't help observing that I have ppreciated or not,the EMS mans- tionship between a paramedic's field ger has accepted the responsibility of performance and the same para- seen a lot more burned out EMS seeing to it that field personnel have medic's creative ability to make up administrators than burned out para- the tools they need to do their jobs. excuses.Really good field paramedics medics. The conscientious EMS What tools? Top quality equipment, are terrible at playing cover-up, prob- manager may often experience stress well-maintained, and on a replace- ably because they get so little practice. of a type and duration that could wipe ment schedule that retires equipment The same holds true for EMS mana- out the sanity of the most seasoned before it fails—not after. These gers. But the excuses employed by paramedic. (Observe the fact that "tools" include quality dispatching poorly performing managers are many paramedics are convinced that and vehicle placement capable of get- fairly common: the community their management staff has already ting the paramedic to the patient in doesn't understand, won't even suffered such a loss.) time to use his or her skills and field The field paramedic must perform equipment. They include the use of support CPR; ep city t won't play complex acts of analysis and must exe- staffing and coverage plans that can no ,e union fire contract r won't won It allow ay cute complex procedures under highly handle peak load demands. Decent key p r onion d ' gi won t m it; e stressful conditions, in an unpredict g key personnel dopy give a damn; the able and uncontrolled environment, Hiring Decent working conditions. owners denied my request; I need g practices that produce a truly more office help;there isn't time;and and under extreme pressure of time. professional labor force throughout so forth. The field paramedic who is capable the organization. Reputation and But the best excuse of all for a of such performance on a routine public image,both local and industry manager who is in over his head. . .the basis and who does so consistently wide.These are the"tools"that each excuse that wears a thousand faces,all with courtesy, compassion, and pro- fessional conduct under the worst ugly and unconvincing. . .the excuse conditions expects and has a right to by Alan Jameson that enjoys the widest circulation and is easiest to support with "fact".. . 30 MARCH 1983 jems is I - 1 I that excuse is, "THERE ISN'T ENOUGH entire industry spent most of its politi- —the large publicly operated systems ow., , MONEY." cal energy during the'70s trying to pry —never did catch on. The reason this excuse is so popular "grants" out of the federal govern- To sum it up for the 1970s, finance is that it is almost always somewhat ment,while over a billion dollars was and revenue in EMS meant grants- true.There aren't any EMS organiza- lost in unrealized revenues fromMedi- manship, out-promoting sister tions that couldn't use some more caid and Medicare.A handful of pri- departments of local government for money, with the possible exceptions vate providers knew the score, but local tax subsidies and revenue- of Austin, Texas, Pinellas County, even the American Ambulance Asso- sharing money,and that was about it. Florida,and the now long-gone seven- ciation was slow to pick up the ball Practically the entire industry was county Southeast Ohio national (they have now), and the sleeping managed by people who couldn't tell a M demonstration project.It's not neces- giants of political clout in the industry municipal lease from a revenue bond 1 sarily an EMS manager's job to solve 1,, all the financial problems of the system—just those that truly impair a Oe system's performance.When a mana- ger says that he is unable,for whatever , reason, to supply the "tools" neces- "The best excuse of all, sary for effective street performance, t it is the same as saying that he is tI the excuse that wears a unable,for whatever reason,to do his ! thousand faces, all ugly job. i ' l During the 1970s, EMS managers _ f A v//�'+,� and unconvincing: There needed several kinds of skills to suc- ^, ✓�V isn't enough money. cessfully oversee the development of / .� �,,�, almost any kind of ALS service— �ow , AEI_j ' public or private, high-performance �jw� �,IIir►� `1 or otherwise.Most of us who have had '� this experience harbor a certain secret e j respect for anyone who played mid ,k - C lil f ' ,, ,!I� �T1 I wife to the birth of an EMS system, �� `j ii{I' id 111.// !' even though we may thoroughly dis ✓/4 ' t� ��iaf `� „, agree with the philosophy of that //: �i system. J1r Successful EMS management in the o, l,1 /r/ 1980s promises to be considerably P ! more challenging.Many of the factors ?/ — \i)1 that made our lives difficult in t e 0s l ; still exist,but the need for much more ►, t� ' i sophisticated approaches to financial l�fi '�'r ! �,I 1 l ii I / 1n1 1 management promises to grow from a ., i`4�'i ' ? *■' i� need to an essential. _ - ,nil_ 'I, X112 It is true that almost everything a � 1 I kI k j manager does has some impact upon ��`. a gt organizational finance. However, to t� r `� '''� 1t' begin the discussion of financial �I�1 �� `-� `�I �-� ' management strategies it seems logical II," .rl. aj � If to start with the issue of bringing ' • :0..,e- money ,� '' fti .;„:- into the organization. I „� "Finance and Revenue—It's a ! /�� F 4�`�.�o�Dirty Job, But Someone's Got To ' 4!!Do It." �' F' ur If you're the manager,that"some- �� j one is you.In the 1970s,if there was ' ��'' any emphasis upon financial manage- 1 =f 9./iglis << ' ment skills at all in EMS (and there IR 'Ir wasn't much), that emphasis was ' ' i V mostly on cost containment. A 1 number of well-known publicly operated EMS systems failed to bill r for services at all,and man ,perha s t Y P a majority of those public systems, -�! ' ��billed at token prices far below actual �� , � , e,,r,;.; costs, and the billing effort was ama- _ �-� �� , "''' teurish and ineffective. ■ �.'::'$, As we have pointed out so often,the 1111 f 1 tittliittV ''''"1/,'"::'%. _. ...i,::".::':„1.1 1ar f; or a prevailing rate screen from a Pac- Man screen. America today and almost never be If the industry's billing and accounts �. may; outside the catchment area of a receivable management practices were substantial hospital institution. silly during the 1970s,the financing of `' , d= The management of complex capital equipment,especially in many � �, . health-care organizations is just not govern- public EMS operations, was even .•.� `' ° � _ the kind of thing that local govern- more poorly thought out. It might ment is very good at The effective have been funny if it weren't for the ' - - management of sophisticated and fact that bad equipment can and does wl� 9 efficient pre-hospital care is not less n. '` 'x' » complex than hos actually translate to increased patient , F f ,g f . P hospital more complex- morbidity and mortality. ° -1:. ;. - The r anything, it is more complex. The general theme went something The problem in the '70s was that to like this You wrote some grants(e.g., r`" � e� promote ALS, one was forced to 1203, 1204, RWJ, DOT, etc.) to get .,.. appeal to the compassion and some equipment,and you talked local humanity of elected officials and the government out of operating funds. political leadership of the medical Later on, the equipment wore out, Financial Strategies community. apparently to everyone's complete For Surviving the '$Os Sure,some of us made half-hearted surprise, and if you couldn't get attempt to argue that' ALS saves another grant, you begged local Y This special four-part series by Alan money, too. Reduced mortality. Sur- , government for some more money. Jameson will continue through the vivors pay more taxes than dead As you went alon June 1983 issue of jems.The scheduled people. Less complicated recovery g, you spent oper- parts are: ating capital on capital equipment, means a shorter hospital stay.Prevent March Part 1: Overview and History one young person from becoming and then ran short on operating capital. Bugs Bunny's household April Part 2: Billings, Collections quadraplegic,and you have saved the budget was more sophisticated. and Accounts Receivable taxpayers almost the entire annual One more thing about the 1970s. Management operating budget of a medium-size Twenty years from now, it will be May Part 3: Management Prac- ALS system. All true, but almost impossible to understand this little tices for Creating Financial impossible to prove. So, we were history unless one also understands Stability: Money Comes In, stuck with arguing mainly that ALS the kind unless esssonality it tunder t nds Money Goes Out — What reduces suffering and saves some it all happen. The general public Happens In-Between? people's lives. In some communities, thought advanced airway mainte- June Part 4: Long-term Cost Con- this is hardly a powerful argument. twice had something to do with the tainment — Breaking Even Our position was considerably FAA or at least the FCC. Politicians weaker than that of police depart- couldn't tell if ALS was apple pie or operated publicly or privately,EMS is ments and fire departments. Police- mud pie.Entire local medical societies just another local issue. One of the well asanv es eParamed cstonl p rot at ect were as likely to squash the movement problems with that orientation is that lives. Commerce cannot function as help it. The courts hadn't decided if it is true,then the local jurisdictions without policemen and firemen. You for sure whether EMS was truly a that need ALS the most—that is, can't insure anything without police- matter of"public health and safety" those with the oldest and (at least as far as anti-trust was con- poorest men and firemen. But commerce can (at least and far as oversold BLS con- populations—are automatically those function easily without paramedics, abadly that we had a helluva time ffo dl itions that are least able to and life insurance doesn't cost any convincing anyone that ALS could be more where the ambulance service is much better. Let's face it. . .an inti- hospitals were pretty muchafinanced terrible. The embarrassing truth is mate familiarity with sophisticated and operated as local facilities, the value is that it helps people.ng social financial management practices was nation was covered with little 15- to the not what it took to operate success- 20-bed city hospitals,county hospitals, now nunderstand tans tof 20 this, itawill be from fully in that kind of environment.But and the ubiquitous little private hos- easier for them to see why the same it is now. pitals owned by kindly old Dr. Angels of Mercy Don't Charge Whoever. You could drive across he'70s m is ight have been reluctant to America in your car, passing alter- send those same people a bill for$200 One last apology for the financial natively through the catchment areas foolishness of the past: everyone was of the charming, but deadly mom- when of was done. In fact, the whole confused about what, financially Y idea of financing an ALS system by Y and-pop facilities and then through billing the victims just seemed wrong. speaking, ALS is. Is it just another the catchment area of a real power- So here was the dilemma: viewing chunk of local government's responsi- house health-care institution. Today, ALS as strictly a local government bility? Or is it, as we have argued, more properly viewed as an imprtant hospital finances ome from local tax America bwould never have much component of America's health care resources; most hospitals are where it did exist, it would be con- industry? The differences are managed by boards and professional stantly at risk of losing out to more enormous. administrators who have little or no Y With BLS, it was easier to cling to connection to elected local govern- "necessary"as ar i local needs. Butt viewing f e the simple belief that, whether ment; and g ALS as an integral component of the you can drive across American health-care industry meant 32 MARCH 1983 jemS . I. 1 that we sure could improve the col- -. times easier to intimidate the truly lection rate, but we wouldn't ',fir I_._ poor out of their money than it is to recommend it, since the system was t „ii'1 I 1 stick with the collection effort on an already collecting every dollar that 'i we', Y g Y + i*�,; 1/-' , -; account owed by a well-to-do finan- could be collected without causing 1q r;�V��, cial escape artist. unreasonable hardship. Collecting µ!Il ;�f(-�� ,?,41/-'47,S. +y'�l, R. Miscellaneous any more would mean that we would to d�! 1,ir„ i� ,rtii be squeezing money out of people X °-°- it ii�i!�, fir,i ii• On a more detailed level of admi di- q g Y P P „►,J �, ,' tration, there are a variety of addi- who shouldn't be asked to pay in the y! �� P Y • tional standards we like to see in any first place. This particular elected \ E 4' 00 ALS billing system. For example: official is the type of fellow who feels ,1 o trip tickets should be processed if you can't pay for something that within 24 hours after the run was you desperately need, it's your own made; trip tickets and dispatch fault and to hell with you. "If your system is collecting more than Y 70 cents of every dollar billed, chances records should be routinely corn- When our answer didn't satisfy are you are taking money from the truly pared to locate missing records; the him, we invited him to go over our needy ... On the other hand, if your provider should be penalized finan- current board-approved collection system is not collecting at least 60 per- cially for failure to submit records practices in detail. We explained that cent, chances are your program needs to suitable for billing purposes; office eventually such a question comes be overhauled.” procedures must be designed to pro- down to something like making the vide tight accounting controls and third late notice more nasty or more are allowed to employ a detailed audit checks; bills should be out scary, or changing our policy of range of approved collection prac- within 72 to 98 hours after service accepting assignment on the accounts tices specifically designed to ensure was rendered; and so forth. of deceased patients. (There is just that the losses from uncollectibles, Unless local government just gets a something about hassling a widow when they occur, are allocated kick out of paying for ambulance about her dead husband's ambulance among the patients and families who services, there is no good reason for bill that most of our patient-accounts have the greatest need. In fact, you an ALS system, even a very high per- managers find distasteful.) We pre- can tell a lot about a billing system by formance system, to derive more fer—no, insist upon—remaining in a finding out who, when the dust has than one-third of its revenues from position where our own employees settled, got out of paying. It is some- local tax sources. Furthermore, RICO EMERGENCY . , ' ti The reliability you expect. The quality we insist on! j© = MEDICAL At ADSCO we are dedicated to one goal. To provide SUCTION ~ ASPIRATORS you with the best quality product possible, at a reasonable cost, and service second to none. 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I t I totally unsubsidized ALS systems of data processing procedures. We are capable of collecting between 60 and very high performance capability do not aware of any case where an 70 percent of all receivables gen- exist, and by their very existence, agency of local government has erated (before adjustments), present a challenge to the rest of the managed to operate an effective ALS although it must be kept in mind that industry. billing system for a system of any the However,as the rate structure of a financial size, say over $1 million in from newly initiated f billings cash rcl climbs high quality ALS provider with gross billings annually. Similarly, slowly and does not level off until the superb response time reliability most attempts to employ the corn- seventh or eighth month of the new approaches full actual costs of puter facilities and staff of a nearby practice. In fact, income will climb service delivery, then it becomes hospital, service bureau, or sister slowly even a year or more after increasingly important for the service department of local government initiating a new billing system. to perform with even greater pre- (e.g., water department, etc.) have Although it depends upon the cision and professionalism, and for proven to be ineffective, usually local economy, systems which collect the efficiency of that system to because the complexity of ambulance more than 70 percent of receivables approach the state of the art. Some- related accounts receivable manage- generated are probably overly agres- times it is necessary to arrange for ment is thoroughly underestimated sive, while systems which collect less financing of massive system up- by everyone involved. than ercent grading and perhaps a major over- The rate structure or the system's tuning 6 p.In additi na to the percent- haul of everything from union con- own internal financial structure age of uncollectibles, there still tracts to vehicle maintenance in order should be designed to neutralize fee- remains the question of, "Who isn't to fully justify a more aggressive rate for-service incentives to overserve or paying?" The goal is to allocate structure and collection policy. underserve any individual patient or those uncollectibles among the Effective and humane ALS billing neighborhood, and dispatch person- people who truly deserve a break— and collection practices always nel as well as field personnel should not just among those who present the require specialized and professional not be involved in any way in billing day-to-day administration,the use of or collection activities, or in an greatest Some collection should highly refined and tested office prac- screening of patients regarding for offerrin provision fixed be made tices, forms, and procedures, and ability to pay. g price annual the usually, extensive automation of The billing system should be elderly gand to younger persons with AirilleAl TS la COLLiflS Expanded Type II — Crusader 2.5 Ambulance INDUSTRIES,INC. n '. 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If our experience with monitoring the financial position of the �,, �� , i l ALS systems over the last three years system, and considerations for financing ' t c�-� �,�, '- capital equipment and other start-up or l � has shown us anything, it is that the expansion/improvement costs. The U ,w,:ii,.� I ,, financial management of ALS sys- financial management practices necessary terns in general is maturing very �� 1�1iriJl.,j; �.�/i �rf `""" A"q to satisfy lenders that the system is t ALS rapidly in a number of increasingly financially stable will also be discussed as I l I'ti H05PITRlS. publicized systems, turning by con- prerequisites to commercial financing of t!SPfChusis'SERVICES n i u nNCE bast some of the premier EMS sys- ALS capita! requirements along with ;� ? ., l�:j terns of the 1970s into financial building reserve capacity for weathering 1 dinosaurs left over from the wild and financial storms in the future. Finally, in - wooll da s of an industr 's birth. ❑ Part 4, the series will conclude with a dis- i. Ai Y Y Y cussion of strategies for long-term cost r6 7, , ; �� jll► f g f g !. • containment, and improving production Next month: The third article in this efficiency while maintaining high "For the purposes of applying fee for- series will deal with techniques for performance. service philosophies of billing and collec- I tions, we need to view advanced life support ambulance services as a part of �, �, the health care industry—not as part of the vast framework of loosely connected '� � s � r local services." chronic health problems requiring frequent use of ambulance service; .' "-. / ,. when such a program is offered, . '' controls must be instituted to guard ' , " , against abusive over-utilization. '� �. e , ` ' Finally, we must realize that •;- ��'4 , America's entire health care financial '- ' 'r s''1 structure is in turmoil and is moving f 8 - away from fee-for-service finance ' �* and toward various forms of prepaid coverage. It makes no more sense to ` : ` finance top-quality ambulance {.A'' : ' w service from the pockets of the "" victims than it does to finance /_ America's health care system from _ r .s-• k, the financial resources of the sick _-,, �_= till, " . '--....: 4' ' and injured. Eventually, third-party payers (whoever they may be) and prepaid provider organizations will -- probably move toward prepaid SELECT—A—TRAY ambulance service for their various client populations. Of course, this Making Your Job Easier During Those Intense Situations cannot happen unless a provider exists in the area capable of pro- - - _ .... M.A.B. Enterprises Inc. proudly presents its new line of SELECT-A-TRAY viding full-service ambulance paramedic kits. We offer three different styles, all constructed of durable = coverage to the population in ques- yet lightweight plywood, featuring removeable covered trays with adjust Y. tip ~ . able dividers.No longer is there a need for passing and handing drugs and tion. To those who may feel that - such talk of prepaid EMS coverage is equipment from a single box to each of the rescuers.Just select-a- tray that contains only the supplies you need.By utilizing the move � , ' a pipe dream, I would point out that able dividers or the styrofoam inserts you can categorize the trays :- when we did some preliminary work into medications, IV supplies, wound care supplies, etc. Now the y with the New York Health and paramedic needs only to select-a-tray of airway supplies and place it - -_ m Hospital Corporation (HHC)several next to the patient's head. He has all his intubation supplies in one years ago, we found the New York compact,organized tray within his reach.A second paramedic could --.••+.. Medicaid Program purchasing pre- select-a-tray of medications placing it at the IV site.The possibilities are endless. paid ambulance service from HHC TRAUMA KITS to the tune of about nine million Two other style kits,the FIRST RESPONDER and the MINI-FIRST vilacji_ dollars per year—no billings, no col- RESPONDER are offered for EMT's and First Responders.Both of lections, and a savings of thousands these kits are also constructed of plywood with molded ABS PATENT PENDING of dollars in administrative costs. interiors in all compartments for a smooth finished look and supe- We do not advocate conversion to nor strength.They feature adjustable dividers in every compart- ment as well as clear plastic covers making the entire contents fee-for-service visible by simply opening the case. Now the EMT and First we like fee-for-service financing Of Responder can have a strong,compact,and manageable kit. ALS systems. Rather, we recom- Call or write for complete information.Dealer inquiries invited. mend such conversion at this time ENTERPRISES, INC. because it works better than the alter- natives presently available to EMS P.O.BOX 126•WALES,WISCONSIN 53183•TELEPHONE(414)968-4103 Circle#36 on Reader Service Card jemS APRIL 1983 57 I ' FINANCIAL STRATEGIES LI -=.-- --..-:‘ ''.., , $1.49.-,-- 4 , : ii014.*`---1–.--=4,- - ,f,,,, FOR SURVIVING THE '80s, Part 3 Creating Stability How much is your business worth?If you don't know,your accounting system is not as in several different ways, and that, efficient as it could be,and your business is probably not fulfilling its growth potential.In alt the most part, each of these the following article, Part 3 of a four-part series on financial management techniques as good orives will have its own unique they relate to emergency medical services, Alan Jameson discusses net worth —how good or bad effect upon the -r organi- they get it and what it means. Cash flow projections, income statements, and equipment zation's short-term or long-range budgets are examined, as well as interest rates and taxes. fi Unless your being. Mr. Jameson earned a Masters in Public Health from the University of Michigan. In Unless your system has a "sugar 1972 he became EMS coordinator for an experimental health delivery system based in daddy" willing to guarantee your upstate New York. In 1974,he became codirector of a national EMS demonstration pro- for you it will probably any impossible ject in the state of Arkansas. Since 1976, he has been a principal in The Fourth Party, system you tp finance any sut being Inc.,an EMS consulting firm which has been responsible for many important innovations able to demonstr without of the in EMS organization and finance. Mr. Jameson, who is a Certified Financial Planner, is able ci det o tools many of the now based in Ann Arbor, Michigan. financial tools and techniques discussed in this article. That is because the hand-to-mouth finan- cial perspective of most ALS systems makes it impossible to n Part I of this series, I dis- the boys and girls is a complex array demonstrate medium or long-range I cussed in general terms the of financial tools and techniques for stability. financial management deficien- taking control of that intersection But even if your system could not cies of our EMS industry during the where income meets expense. Every benefit from some form of commer- last decade, and suggested the need dollar of income can be directed to cial financing arrangement, its for much greater financial sophisti- flow through the system's financial management should still be able to cation in the 1980s. In Part II, I channels in a wide variety of ways, demonstrate a full-range of financial talked about the "income side" of and that same dollar can exit the controls. Management should be • the ALS system business, and in organization to pay for any number able to define and justify its position Part IV, I shall talk about the "ex- of goods or services. Add to that the on each of the issues discussed here, pense side" of the system, especially fact that any particular good or ser- and a good many more similar finan- production efficiency. vice can be purchased and paid for cial issues which space limitations Most people recognize that there will not permit me to discuss in this is an important relationship between income and expense. But what series. p by Alan Jameson Financial aspects of an ALS separates the men and women from system's operations are probably 42 MAY 1983 jems more interdependent than any other worth is that it gives the system some approximately one year's ulsa's EMS organizational concern.m success gement worth, he room. system can urovtive bad budget. ysttem will spend example, out$2.1 million one area p financial o offset management bad luck, an next year including replacement must be applied to offset a failure in times, or rainy days, another. In the end, everything you occasional mistake, and for a while, fund hde approximately deposits, ant's$c 1 rentlioet do adds to or subtracts from the even bad management. A declining That means Tulsa's em 1 million. in fairly same bottom line.Worse than that,a net worth is the same thing as falling but failure impair in one financial in is several blood h pressure. eclines your system's f nant good ould continue to build neteworth to impair performance for a few more years. I other financial areas. Little failures cial death is inevitable. tend to compound themselves. Every manager who thinks about This brings up the question of net I, For example,sick a mistake policies is mana- net worth about at ut how much has some net worthris systems trend. e have worked with started ging employee sick leave policies may feeling abo show up perhaps years later, as a enough to prevent loss of sleep. The out with zero net worth or with a net whopping and unexpected contingent bigger the heeded system,allow the more manager worth welwith below a new zero. This is ooften worth long-term liability. Overall net worth is th ase a major overhaul.Plane worth is then less than expected, to worry about something else. experiencing financing messing replacement ac a planned partial work the advise s system into a clients position to build those vital signs over pursued four- The Y achieve a safe' period to ach Thencin g replacemns equipment. ual to to-eight year p g worth e The change of plans in funding where it has a net q replacement equipment depletes operating capital reserves, and that �'MOne comes in, money goes out — but messes up the whole cash manage- .y ment program, costing the system a yy jet yppens in between counts too.reduction on the income side at a time depressingly in line so.. with the compounded increase in silly itt And it all started inr handling with just a �NCoM�N G silly little mistake in handling sick r leave! If the above scenario somehow � Wiz,, seems very foreign to your EMS �\ system, it is probably because there . to ies to \_� 11)�aren't any such plans ors stra g e V go wrong. If you didn t plan on a ■g50,000 increase in net worth next �.year, then you won't be disappointed . 4 ■ ,in a $10,000 increase, and you won't . �■ ` /� — be trying to find out what went 7l wrong so that you can fix it. And if MI Nig you don't even think about net worth i t `at all (and many EMS managers don't), you may not even be sorrl when it declines, because you didn .know it.Whether your system is public or conce t of net worth 4i !�v private, the p r i . 111 . r O ' i4 � should be employed as the single lRr�, most useful indicator of the financial kg," �� health of your EMS system. Annual . . � �61, ',� � , �, �,1�,��changes in your systems net worth ■_ 1 ,,, �. ,+ will tell you whether you are coming r d i,��/, out of the woods or going down the "Sett 44*tubes. Net worth is your systems '�� ..► (kit ''►� s �,�`A� most important financial vital sign, a 'V.so let's start there. I OUT 01 NG 0,0Aott, Accountants don't think like ,i1,r 0' human beings think, so let's avoid �a accounting terminology as much as �^ — ,�, �a;.. �. ' i possible. If you add up the current __-i ` ,! ..elrj"•••r dollar value of everything your ya �' !4, system owns right now, and then y ' subtract all the system's debts and r,�; v",, -'0 current financial obligations, what's �;�:�;��; { �e left is net worth. The value of a big financial net jems MAY 1983 43 ..., ,1i.'. t x ," see or touch or know anything else really useful, the cash flow projec- rf;Q 1 �y about that patient except blood pres- tion should extend for about three 1 sure,you might know that something years into the future, and should 1,• �� / is terribly wrong with the patient, but project on a month-by-month basis F► ,.\ ; J what? If the pressure is extremely all income from all sources (strictly I `.� '\11 �N, _ �, / ,�!. low or even extremely high, and that cash), all expenditures in all cate- '`�%71:11P,„, ��l<,rl•,;", i •is all you know about the •patient, gories (cash again) •including •contri- ,� ti ' � t , ► you would know practically nothing butions to replacement fund deposits , �., that would help you diagnose the and other cash outlays that are not � � ,�� /,,�%� 6 problem or decide upon corrective actually "expensed" in the tradi- i j,ri Jihlii r action. Furthermore, if all you knew tional accounting sense, and with ..<„,.......__ 14 _ about a patient was that his blood both monthly and cumulative opera- "`-- pressure was within normal limits, ting fund activity shown as the "The hand-to-mouth you couldn't even be sure that he was bottom line. financial The financial breakdown on both perspective of most ALS systems makes it impossible to demonstrate. the income and expense sides should medium or long-range financial l' 11 _WHAT WE 601' be fairly detailed, and projected expenditures should relate to the stability.” 1 annual budget. That is, if you added net worth level. During this critical COS A 'A WHAT WE O E up all of the month-by-month expen- time of growth, all the signs and 'is.'��; u�,� ditures projected for fuel for a g 11 �'J 12-month period, clorseltoms must be monitored ! V11, ''f,,, q p od, it should about ,,,,11 c I�, El Wirt! equal the or anizations s projected Y Management must be ready ,,,, ;woo g +•q1 041 0.4,1 annual fuel budget. (As a practical to make numerous mid-course �,,t i. PK �; matter, the traditional annual budget corrections. At this critical stage, the system has no breathing room — 1oi!..-'i%? can be abandoned if the month-by- i.e., too little net worth to survive ! month expenditure projections are many mistakes. authorized in much the same way as All by itself, net worth is a useful a budget is authorized.) concept for checking out an EMS `IJ you add up the current value We advise our clients to keep a system, and annual changes in net dollar of everything your system tight focus upon cash flow for a worth probably t you more about owns right now, and then subtract variety of reasons, mostly related to the all your system's debts and current the fast-paced nature of our financial health of your e EMS system financial obligations, what's left is industry, and the complex and often ystem than any other single indi- net worth." delayed collection third- cator. process in third- But net worth can come in several otherwise okay. Monitoring his forms, not all equally desirable. This blood pressure changes over a period brings up the important question of of time would help some, and might if ; PRp�EC1E0 . "liquidity."The most"liquid" form even allow ou to rule out a variet p ` of net worth is cash in the bank — p variety h�' CAS-.. Ail of possible problems. • _ rhil. more specifically, in the checking That's about how it is with -rd' ' t� !' W� ".�� . P <.1\_.,+ VARIANCE _•1 account. At the other extreme might monitoring net worth. If net worth N� v 444.1R I be money tied up as equity in the and its changes are all you know � "' ��p; W��,,,�,mq ' ? ambulance facility — a facility so about the financial condition of a ; ,s 1�1 located,designed,and equipped as to system, you may sometimes be able •' NSW+ make it nearly useless to anyone who to tell that a huge problem exists, but 3'• is not in the ambulance business. you won't know what it is or what to The entire question of net worth do about it. And even when net "To liquidity is far too complex to discuss worth falls within the "normal projection be really useful, the cash flow here, except to say that some judg- limits," you can't be certain that the three years nto th uture. about ment is necessary to achieve a good system's financial condition is three years into the future." mixture of assets and liabilities sound, but you might be able to rule party reimbursements. Cash flow which, combined, create net worth. out a few possibilities. projection and monitoring provides Monitoring the Vital Signs To monitor the financial health of management with the essential infor- As valuable as sea w igh is as an the system adequately, you will need mation necessary to make mid- routine access to the following kinds course corrections before it is too indicator of your system's financial of reports: well-being, it falls far short of provi- 1. Detailed Cash Flow Projection latWhat do we mean by "too late?" ding adequate information for a and Variance Report. If you could If replacement fund deposits are diagnosis. There aren't any very have only one piece of detailed building more slowly than the related good analogies to patient care, but routine reporting on your system equipment is wearing out, you might the closest one I can think of might (other than net worth analysis), it find yourself without equipment, be blood pressure. If all you knew should be a regular report showing replacement funds, or even borro- about a patient was that patient's projected versus actual month-by- wing power if the problem isn't blood pressure and if you couldn't month cash flow in the system. To be noticed and corrected months or 44 MAY 1983 jems even years in advance. If the unad- justed collection rate that was origi- , „ Figure 1 nally projected isn't panning out, or , if gross billings are down due to Ambulance Authority Assets lower than projected utilization, rate Current Assets structure or collection policy adjust- Petty Assets $ 50.00 ments will have to be made seven or 30 750.00 eight months in advance of the Cash in Checking 31,728.10 critical impact, due to the lengthy Replacement Fund Account 644,725.00"collection lag" associated with Marketable Securities third-party ambulance billings.* Accounts Receivable-Trade $ 695,384.67 2. Income Statement. Monthly and (Less)Bad Debt Reserve 992,192.21 annual income statements for the Total 3,104.89 system should be prepared using Travel Advances 13,104.89 normal accounting procedures with Inventory only minor modifications to Total Current Assets $ 1,153,343.24 ... accommodate the peculiarities of our property and Equipment i industry.Staff members tend to pour Furniture and Fixtures 2,907.22 over the more management-oriented Depreciation Allowance 19.00 2,469.66 '' information of the cash flow projec- 178,208.18 9. dons, while board members or other Truck Chassis 8,208. 8 173,72229 policy makers can usually get by with Depreciation Allowance looking at the bottom lines on the Patient Compartments 221,905.63 income statements and balance Depreciation Allowance 1,849.21 220,056.42 sheets. The income statements and Communications Equipment 211,357.95 216,141.51 balance sheets tell us about our net Depreciation Allowance f worth and how it is changing, while On Board Equipment 127,127.19 the cash flow projections and Depreciation Allowance 2,995.86 1sa,os1.32 .__ variance reporting help management 2,139.23 , diagnose any problems and design Maintenance Equipment Depreciation Allowance 46.01 6,088.92 solutions. Of course, it is entirely 545.00 possible that the growth of net worth Other Equipment a 00 291st may be perfectly on schedule, while Depreciation Allowance the entire cash flow projection is in a Leasehold Improvements 12,137.99 shambles. When that happens it Amortization Allowance .00 12,137.99 means that you are succeeding, but 222,225.37 not the way you intended to. We Total Property and Equipment should all have such problems. 1,970.213.21 3. Balance Sheet. The income TOTAL ASSETS statement essentially summarizes income and expense, and reports the Ambulance Authority Liabilities difference. It tells you, in conven- Current Liabilities $ 1,028,633,13 tional accounting terms,whether you Accounts Payable-Trade 21,633,53 made money or lost money for the Contracts Payable 141,560.57 reporting period. Keep in mind that Current Maturities $ 1,1s3,ss3.7o it is possible to"make money"while Total Current Liabilities running completely out of cash. The Other Liabilities balance sheet looks at the system in a slightly different way. Reported 11,328.00 Deferred Income-Subscriptions 11,328.00 monthly and annually, the balance Total Other Liabilites sheet tells you how the system's all- Long-Term Debt important net worth is changing, and what form the net worth is taking. 721,082.71 Equipment Lease-Long Term 760,885.71 The balance sheet contains a wealth Total Long Term Debt of information, not the least of TIES 1,970,e07.41 which is providing the number to TOTAL LIABILITIES Equity calculate the system's debt-to-equity *(If there are accountant readers,you may be inter- Equity ested in knowing that an accrual approach can mask m Petained Earn 1,758.29 prior Earnings 6,042.91 several kinds of income-related problems for months, ings(Current) while a conventional cash approach can do the sa e 7,842.91 on the expense side.Thus,for management accoun- Total Retained Earnings 7,801.20 ting purposes, a hybrid cash/accrual combination system which emphasizes cash on the income side and, Current Net Worth to some extent,accrual on the expense side should be $ 1,879,608.61 employed. The result is a primarily diagnostic TOTAL LIABILITIES AND EQUITY budgeting and reporting system that bears only slight relationship to a conventional income statement or balance sheet.) jems MAY 1983 45 _-. .._.,,.......a..,,', .- r. --,.---...r,. -.-;,+-•...a. •'fir:_1 .. ,:_. A . ratio.This ratio presents still another projected and to a great extent measure of the system's stability ,,� �q !i ` controlled; apart from net worth. Like the ques- A 11 tion of "liquidity," the debt-to- a,..• III c/t • As soon as a new piece of gear equity ratio tells you something more �'/� i arrives, plans should be laid for a financing its replacement; about the remaining• borrowing W t .�` ` �� • Maintenance incentives from to power of the system, and how far it INCH Yo,:-,%,, AI to bottom must be created• p has stretched itself financiall . Ina •% oti \:y �,�- t ,\\ • We all wish we could afford more new or recently-overhauled system,it !% ,\ 1 . P ♦,, s'`is— equipment. is likely that the debt-to-equity ratio �1 r .,\\ will be very high, and it should PP— A i' m �) is ��r lit,V'A'i If each piece of equipment in the become agoal of competent manage- '��I wis fj i \\;. , ,"„ , , \\;,',� ,�„ system each set piece on its own estimated ment to gradually reduce that ratio 150, Oh- ."•`�\:::°< replacement timetable (and it should g y - ,. 1 = be), then nearly every month one or LI while simultaneously building net .WJ — '" !;��,\ worth and establishing reasonable M.-lum ';! �,i\NN..,,,,��4,4\�� more pieces of equipment will reach life expectancy, and the plans that liquidity. U►+- ; \\`\\\\\, have been laid to finance the replace- As Figure 1 shows on a monthly -:- ment should have matured. When balance sheet prepared for a recently that happens, funds are transferred, overhauled system, the debt-to- usually, from replacement fund equity ratio reveals a situation which `7n many systems the process of investments and/or proceeds from will take considerable improvement budgeting and planning for equip- p before any new commercial ment purchases and replacements loan or lease arrangements to the borrowing can occur. resembles a child s Christmas list, capital equipment budget. Thus, the 4. Capital Equipment Budget. The with prices added.” capital equipment budget balance fluctuates monthly, or at least importance of having adequate equipment budget derives its income quarterly, as money becomes avail- quantities of very high quality equip- from various sorts of financing able for new or replacement equip- ment will be discussed in more detail arrangements, replacement fund ment and as funds are encumbered later in this article in the section on deposits from earned income, or by or paid out for equipment purchases. equipment financing. In that section, some combination of these. In more If maintenance incentive programs you will learn that our industry, for poorly managed systems, "emer- are effective, the capital equipment the most part, is sadly unsophisti- gency equipment purchases" are program may actually show a sort of cated in its understanding of both the financed by raping the operating "profit," as equipment life is value of good equipment and the budget or the operating capital fund. extended beyond scheduled replace- benefits of various forms of equip- A good manager will find such prac- ment dates. However, such a ment financing. And in many tice an embarrassment, while a bad sophisticated orientation also systems, even the process of manager may see the same practice requires that the cost of maintenance budgeting and planning for equip- as "business as usual." incentive bonuses, as well as ment purchases and replacements Assume the following: extended maintenance costs, are also closely resembles a child's Christmas • Very good equipment is essential; paid out of the capital equipment list, with prices added. • Insufficient quantities of equip- budget, since the"net savings" from Money used to come into the ment create expensive emergency these programs must reflect full cost. equipment budgeting process by way repairs and scheduling adjustments; (More on maintenance incentives in of federal grants and gifts from local • All equipment wears out and the Part IV of this series.) government. Increasingly the capital timing can be reasonably well- To keep track of what is happening with the capital equip- ment budget, the reporting must Figure 2: show not only a budgeted amount in each equipment category, but must Capital Equipment Report also keep track of equipment that has been ordered but not received, BUDGETED RECEIVED& ORDERED,BUT RECEIVED,BUT UNENCUMBERED received but not paid for, and that PAID NOT RECEIVED NOT PAID UNDER(OVER) which has been ordered, received, Ambulances $ 271.448.00 $ 277,203.56 $ -0- $ 4,089.72$ (9.845.28) and paid for. You can see, therefore, Propane Conversion 12,000.00 10,000,00 '--0- 3,658.24 (1,658.24) that in each equipment budget On Board category, there are several budget Equipment 112,000.00 87,854,87 46,154.91 17,943.12 (39,952.19) balances: true surplus funds (i.e., Maintenance '50,000.00 4,808,04 -0- 64.35 45,097.61 funds which have been accumulated Communications 240,000.00 14,420.22 48,763.80 113,782.00 63,03327 and are not earmarked for the Dispatch Center replacement of any specific equip- CAD System 20,000.00 -0- .0- . -0- :' 20 000.E ment item); earmarked fund balance Miscellaneous 44,552.00 921.00 -0- -0- 43,631.00 (i.e., unencumbered funds ear- Purchase of . marked for known equipment Existing Equipment 150,000.00 -0- -0- 150,000.00 o purchases); and encumbered funds 600,000.00 $ 395,207.69 $ 94,918.71 $ 289,567.43 $ 120,306,17 (i.e., funds reserved to pay for equip- ment which has been ordered and/or received but not yet paid for). A 46 MAY 1983 Jens tge ��' ie.,fieAda, ka �y the life expectancy of the item, �p� sample display of this kind of infor- over P �e S >,,, j, mation is provided in Figure 2. then your approach to equipment �e�� `� All of this probably sounds more budgeting and financing is deficient �� complicated than it really is. The and amateurish — the sort of ' thing to keep in mind is that the business practice that was epidemic capital equipment budgeting process throughout our industry in the 1970s. l must anticipate and plan for both the Good Equipment, Plenty of It, today, and of equipment needed that and No Excuses A COMPLETE today, and the replacement of that same equipment years later. And if It is now almost ten years ago that LINE OF BASIC i the system intends to expand the I heard colleague Jack Stout makin g range or quantity of its service deli- fun of the way the Feds were spending AND ADVANCED very, the capital equipment program grant monies in EMS. Stout was must also manage and account for saying that a financially stable EMS LIFE:SUPPORT net increases in the system's total system could get its own equipment, EQUIPMENT equipment inventory, and must then and that a financially unstable EMS plan to replace that equipment when system needed to concentrate on it wears out. getting stable— not on getting more From the company that If your capital equipment budg- equipment. I even remember him thinks servicing its eting process is working properly, telling Dr. David Boyd that all of the you should be able to get fairly accu- federal money put together wouldn't customers is as important rate answers to the following kinds pay for one year's depreciation on as selling them! of questions: the present equipment in the • TRAINING AIDS, IV • Is our equipment being replaced industry, much less purchase Trainers,i : CPR Mannikins,k, r Arrhythmia° more rapidly than we had antici- America a new ambulance system. Annie I ,OB aann Models, pated? And now I read in the January Anatomical Models, and Slides, • How much do we plan to spend 1983 Almanac issue of ferns ("The Anatomical Tutor Models, and Slides, during the fourth quarter of 1985 on EMS Universe") that ". . . nearly Cassettes. r Deno ula equipment replacement? $250 million will be spent during • RESUSCITATION AND .i • How soon will the financing be 1983 on replacement ambulances SUCTION DEVICES, , accumulated to replace the chassis on alone." And that's just the ambu- including: Port/Cart Assemblies, Unit 121? lances at an estimated $30,000 Demand Valves, Aspirators, Port • How are we financin g the equip- apiece. Battery Suction, Port/Manual Aspi rators, Bag Mask Resuscitators, Air- and we must purchase next month, Stout's point had to do with the way Management Aids and how do we plan to change our fact that, if equipment purchase and way Management T Aids equipment financing arrangements replacement is viewed in a more • including: Ambulance Cots, Scoop by 1986? businesslike manner, the true cost of Stretchers,Ambulance Cots,types), • What percentage of our total equipment, even sophisticated and Splints(all types), Extrication/ annual operating cost is attributable exotic equipment, is simply not a Cervical Collars and Accessories, to the true cost of purchasing and major piece of the annual operating Kendricks Extrication Device, replacing equipment? expense of an ALS system. Further- MAST, anti-shock trousers (If your system "expenses" equip- more, the difference to the operating MEDICAL INSTRUMENTS AND ment purchases, rather than capitali- budget of having mediocre equip- EMTIPARAMEDIC AIDS, zing such purchases, chances are ment versus excellent equipment goes including: Blood Pressure Devices, your management has no idea of the practically unnoticed. To be blunt, Stethoscopes, Laryngoscope Handles and Blades. Endotracheal true cost of equipment in your there is just no excuse for forcing Tubes, Sissor Hemostats(all system.) highly trained ALS crews, who must types) Appropriate capital equipment work under some pretty adverse budget reports, combined with conditions anyway, to have less than • TRAUMA AND DRESSINGS AND A KITS ANANDAGES, equipment inventory sheets which superb equipment. including: 727, 747, Multi-Trauma keep track of replacement schedules Let's take an extreme example — Dressings and Surgi-Pads, Adhesive for every equipment item in the Tulsa, Oklahoma. The Tulsa EMS Bandages, Ace Bandages, Kling/ system, and future financing policies system has no BLS ambulances — Topper Gauze Sponges, Leather and goals, with documentation and only ALS ambulances. Every ambu- L AL TS FOR reporting on any maintenance incen- lance in the Tulsa system is equipped YOUR NEEDS.CALL THE EXPERTS ARE R AL tive programs, all add up to an effec- with practically every mechanical tive capital equipment program. If and electrical gadget known to the AND PARAMEDICS.WE KNOW you don't plan for the replacement industry. There is even a full WHAT YOU WANT! of each piece of equipment at the keyboard computer terminal, screen Emergency Medical and time it is acquired, taking positive and all, in every ambulance. Tulsa's Safety Supply ca steps to save up for the replacement EMS dispatch center looks like r. or to arrange for future financing of Steven Spielberg's game room. If 10475 Ga rd Dr. 33410 the replacement (a combination is there exists a gadget that could Palm Beach usually the case), or if you fail to possibly do some patient some good, FL only (305) 622.6974 take into consideration the estimated it is in the Tulsa EMS system. Unless U.S.A.WATS (800) 327.2038 inflation in such replacement costs you have visited Tulsa, nothing I can Circle#37 on Reader Service Card jemS MAY 1983 47 tell you will prepare you for what of having equipment (excluding means that if Steve Williamson you will find there in the way of maintenance costs)in the Tulsa EMS (Tulsa's director) could somehow hardware. system, all you have to do is add up figure out how to run ambulance Some of that equipment was the replacement fund deposits for the services using no equipment at all, he originally paid for by the city, some year. The funding of replacement could reduce the cost per run by by DOT, and about half of it from a costs — as opposed to original costs about $23.40. In other words, the commercial bank loan we helped —is the safest and most conservative extreme difference between no equip- arrange. That's history. Now, every way to look at equipment financing. ment and great equipment is only piece of equipment in the Tulsa If you know what true equipment about$23.40 per billable run, so you system is set up on its own fully costs are in the Tulsa system, then can see that the difference between funded replacement schedule, with you can be pretty sure that your mediocre equipment and great equip- projected replacement cost inflation system's true equipment costs (as a ment is hardly worth talking about, ranging between 6 and 15 percent, percentage of total operating costs) particularly when you consider the depending upon the type of item. won't be any higher. For Tulsa's awful effects of poor equipment That means each month Tulsa's fiscal year 81-82, the total throughout the system. management takes some of its "cash-out" cost of system opera- Shabby equipment ruins employee income from fee for service billings tions (including everything) was morale. How can you demand and deposits that income in replace- $1.776 million. During that same superb performance from ment fund investments. Enough accounting period, Tulsa's equip- your money is deposited each month so ment replacement fund deposits and equipment for them to work hwitth? that sufficient funds are built up over comparable debt service totalled How can you justify the rates that go the life of each equipment item to $302,688. That's about 17 percent of with user-financed high performance completely pay for its replacement. total annual operating costs. ALS service, when all the customer (Tulsa also has an effective main- What does that mean? We can can see is crummy equipment? How tenance incentive program that look at it several ways. It means that can you expect physicians to have tends to extend equipment life, but if Tulsa utilized crummy equipment, confidence in the field performance this will be discussed in Part IV of perhaps even 50 percent as expensive, of your organization, when they see this series.) Tulsa's annual cost per billable run If you want to know the true cost would drop by only about $11.70. It patientlin a vehicle thatccoughs and Advanced Paramedic Training Program INDEX TO ADVERTISER We want people like you... S people who want to make a career of caring for others. By enrolling in our comprehen- To receive information on the products advertised in this issue, sive, 9-month program, you will be prepared for certifica please fill out one of the attached reader service cards. tion as an Oregon EMT-IV and National EMT-P. Our physi- cians trained in emergency Service Number Page Number Service Number Page Number medicine and experienced paramedics...will emphasize 17 AAOS 49 19 Hurst pre-hospital emergency care, 23 Actronics 45 g y � 56 48 Johnston&Holloway 35 viewing the patient in total 49 Adsco 31 13 Laerdal perspective, employing an in- 44 Allan Allman 27 35 25 Magnasync Moviola Y7 terdisciplinary approach to pa- 11 American Agency 5 39 Mediked tient care, and understanding 36 Bashaw Medical 13 56 MHP 21 the resources of community 29 Boundtree 50 emergency medical services. 41 California Design 37 52 Minto 53 Prospective candidates should &Marketing Corp 52 Muster&Asociates 53 have EMT-A/EMT-I certifica- 24 Davenport Colle e 24 35 New Yom Medical MCocal 4 tion, one year of medical expe- 55 Direct Safety g 24 38 North gency Supplies Medical � Y 26 &Emergency Supplies 24 rience and a high school 30 Dixie 19 58 Oregon Health Sciences 48 diploma. College background 53 Egen Polymatic 26 46 Omnicron in the sciences is 53 preferred. 37 Emergency Medical & 54 Our Designs 53 Deadline for applications to the Safety Supply 47 15 Physio Control 15 program: MAY 31, 1983 14 Emergicare 12 45 Power Group International 31 EMS Today 9 27 Rescue Services 32 For more information and an application, 26 Evars,Inc 16 47 Rico write to: Emergency Department—Univer- 40 Everson Ross 61 city Hospital Advanced Paramedic Training 28 FACT 11 57 Sun Valley Emergency Program, Oregon Health Sciences University, 11 Wheeled Conference 64 3181 S.W. Sam Jackson Pk. M., Portland, 16 Frontline 7 12 Wheeled Coach 64 18 Horton 2 Oregon 97201 Circle#58 on Reader Service Card 48 MAY 1983 jems 1 g' A (gE T Emergenc rectum Splint OneepersoiPapplication ifree r ten years, depending upon the item 'sccon itechniciat1 to ma this financial strategy requires many Othee" ri0ritie5 0 . P tr. ry, years to reach its goal. However, the ,A..V — system is structured to show progress �' a ,` /r` + �� 'lj every single year, and to help safe- : ,,c'i% % i4 '4 s a?� ' ik,�,,. l �, guard the future we have made I � ■' t ,,rr, / ,(4 ei portions of this long-range financial • War,---01.�fy i 4s; .�'' plan legally binding under the terms �� if C ( of the current financing contract. , o� " - Even in Tulsa,the original bank loan 1 A,„ .1:$1,4 „, �� `' P ° allowed the bank to hold a lien on ��"�.: '.,, replacement fund deposits with the 1 .. stipulation that these replacement...„,...,,w4 funds may be used only for replace- .1 1p, . Wow can you justify the rates that ment hardware and may not be go with user-financed high y < performance ALS service, when all diverted by some future manager the customer can see is lousy who wants to make a name for him- equipment?" self in the short run at the expense of A'. - long-run stability. °`° " sputters, using a monitor/defibril- We have used revenue bonds, lator that looks like something out of straight loans, leases, and the hybrid an old Frankenstein movie, and financing arrangement called a muni- using antishock pants with so many cipal lease to finance our various k patches you'd be afraid to let your clients' start-up capital equipment kid use them for an innertube in the needs. Which device is best depends 4 swimming pool? upon the locality, the legal structure 0,, , x; ,,' 0";Zn •r,'' If your system has no respect for of the system, market interest rates, its equipment, then the employees and a variety of other considerations won't either. Employees take better too complex to discuss here. How- i , f care of equipment that deserves ever, if you wish to consider some better care.Mediocre or worse equip- form of equipment financing fog ,' °1 ment costs the system in morale, your organization, I suggest keeping witlyshociiii p image, money following points in mind: reputation, ima a and even mone the followin F� in a thousand ways. These costs far 1. Demonstrate Long-Term Sta :00 . �- . '. o , exceed any paltry savings you may bility. If you can't furnish the kinds ' .hi rkifonre realize in monthly payments and/or of documentation, projections, and ,, ,. i 'tom replacement fund deposits. Tulsa's financial management strategies pp tonal system is now almost five years old suggested in this article, chances are bilateral_capabili. p° ,R and has had time to establish a fully you can forget about any substantial funded replacement program. In a commercial financing of capital 1 angE TM `` i --- couple more years, the original equipment requirements. This • One splint fits �, . commercial bank loan will be paid includes realism on the income side adults or children ' off, and Tulsa's equipment financing of your business, and some ability to . ° Lightest of all T (and net worth) will be fully funded show how you intend to keep your traction splints -r'- and stabilized. share of the market over the term of • Stainless steel• newer systems, or newly over- the loan. j construction „ - ' hauled systems, managers must rely 2. Track Record. Somehow you • Minimal ' ; i more heavily upon various forms of will have to demonstrate that your ! overhang loan and lease arrangements, organization is controlled by people • gradually converting to fully funded who have already demonstrated their Single ankle harness replacement programs in accordance ability to develop and follow sensible 1 adapts to all sizes P P g Y P • Permits monitoring of r,ry . . with a long-range financial plan. The financial plans. That's one of the i ' all pedal pulses . Fort Wayne system, for example, reasons why various ambulance c • ! had to finance all of its current authority boards of trustees are Application i : equipment, nearly $1 million, and I , without movement r ; P Y populated with successful representa 1 of the patient 1 has established a partly funded tives of the local business 1 * replacement program designed to community. Dynamic traction provided by `1. known selected tension debt finance two-thirds of the initial 3. Tax Exempt Interest Rates. replacement equipment and one- Whether your system is operated by 'Safe for proximal-third fractures t third of the second round of replace- a for-profit company, a not-for- Find out more about this unique i 1 ment equipment. Hopefully, none of profit corporation or a government 1 spina. Circle reader reply card or cast: , -: I the third round of replacement agency, you can save almost one per 1 I National Sales Office 619/449-7264 + equipment will require debt cent of your annual operating costs t financing. Since each equipment item by financing your equipment at tax- 15'A! �" ! - •• ••...- is set up on its own replacement exempt interest rates. In today's schedule ranging from two years to economy, there isn't as big a differ I Circle#34 on Reader Service Card 1 50 MAY 1983 jems , ,nce between tax-exempt interest (These and other basically sensible rates and taxable interest rates as �..f! ,� business arrangements work to —• greatly frustrate a local government there once was, but the savings are �I4 ilip^.i��1!mum. '\� —••_ _ trying to decide whether a private still substantial. Some minor organi- _- I �� : company's rates and profits are zational restructuring may be neces- I reasonable or excessive.) financing,to take advantage of tax exempt )W ; , fil /�Q- j' The main thing is to acquire a cen- will. . but where there's a Wt 6 tral facility that makes day-to-day will. . . � ill I.;, "+ management, crew changes, vehicle 4. Borrowing May Be a Better `r ;�� j'�j checkout, inventory control, paper- fully The main reason for pursuing a �i _ ,�,� flow management, and all other day full funded replacement program is = lit to-day operations convenient and Y i 1 Y A t, Ills to improve the net worth of the 11��, easy to monitor and account for. In organization, its liquidity, and its 4� o iv my opinion, it doesn't make much debt-to-equity ratio — i.e., its long- `�� range financial stability. But even \\ difference whether that facility is owned or leased. 1� after you have reached the enviable "The main thing is to acquire a position of being able to pay cash for central facility that makes day to Retirement, Vacation, till find replacement equipment, you may day operations convenient and easy Sick Leave, and Comp Time ; 1 still find it desirable to continue to monitor ... it doesn't make There isn't space here to go into managing your replacement fund much difference if the facility is compensation plans and benefit investments while debt-financing the owned or leased." compensation in detail. Hand benefit you finvestments equipment, using your replacement fund investments as security to same two million dollars at a higher should keep in mind that the way obtain a rock-bottom tax-exempt interest rate than you are paying on these various plans and programs are interest rate on your loans or lease your loan until the equipment was structured can have a substantial arrangements. That's because you delivered and had to be paid for,you impact and n the oorgang ation'sta net be able to borrow money at a could be practicing arbitrage. By lower interest rate than you are paying attention, it's pretty easy to lity. By the time one of our clients currently earning on your replace- pick up enough money to buy a few called us, ment fund investments. If that's the extra monitor/defibrillators, even a lated over $40,000 in comp time case, then you would be stupid if you new ambulance, or to make your owed employees. This liability had pulled money out of your replace- first loan payment. Whether what developed to such an acute state that ment fund investments and paid for you did was legal or not depends comp a me employees other wereees taking the equipment with the cash. This upon following a set of pretty combination of tax-exempt financing complex IRS rules. About all I can assigned mandatory overtime, which and making income from say in the space available here is that created more comp time. Thus, for investments may save nearly two you should be aware that the issue each hour of comp time taken, one percent in total annual operating exists, that your system can benefit and one-half new hours of comp ut costs. Two percent of annual oper- from it, and that you must be careful time hat here created. stage aced to The eesnly ay one ating costs in most systems can pay to follow all the rules. the salary of an entire paramedic entire system, refinance everything in position, or can raise wages to help Facilities the place, and pay off accumulated attract the best. If a manager could Financing comp time in cash. (The comp time save two percent but doesn't, he's Over the very long term, an argu- program was eliminated entirely.) simply not doing his whole job. ment can be made in favor of having However your retirement, vaca- 5.Arbitrage ord "arbitrage"Isn't e French Resort. the opposed to a lease its arrangement.facility, l mandatory leave, overtimecomp arra arrangements The word "arbitrage" refers to any as app financial activity wherein money is The short and medium-range pers- are structured, you must take care to made through simultaneous transac- pective furnishes a less powerful structure them in a way that creates a tions at two different market rates. argument in favor of facility owner- known and maximum, not open- For example, an investor who moni- ship. In fact, if your system is ended, liability. Any such arrange- tors a stock or commodity that is partially not-for-profit or govern- ments that create an open-ended listed simultaneously on American mental in structure, you may be able liability, such as unlimited sick pay, and European exchange markets to lease less expensively than you can endlessly accumulating vacation pay, may make money by watching for a purchase, because a private lessor etc., eliminates the possibility of difference in the two markets, and can benefit from depreciation write- accurate forecasting and casts a then quickly making simultaneous offs, interest payment tax deduc- cloud of contingent liability over any transactions in both places. tions, and in other ways that your net worth you may accumulate. Some forms of arbitrage are legal EMS organization, being nonprofit Cash management is one of the and some aren't. The question comes in the first place, cannot benefit easiest and most often overlooked into play in EMS hardware financing from. If your EMS organization is a tools an ALS manager can use to in a variety of complex ways. For for-profit corporation, the owners stretch the dollars available in an example, if you'd borrowed a couple will probably find it makes more entirely painless way. Effective cash of million dollars at tax-exempt sense to hold the facility personally management assumes a very accurate interest rates, then ordered a bunch or in a partnership while leasing the knowledge of projected cash flow. of equipment, and then invested that facility to the EMS corporation. Without such accurate knowledge, it jems MAY 1983 51 will be impossible to move available you don't, then probably you are there usually are a few,), then you cash into and out of the most profi- vocationally misplaced and should have two choices: don't change table available investment vehicles. consider another line of work. That anything and continue to use A great deal can be done to struc- is because you started this whole amateur financial management prac- ture this system's purchases, process off by figuring out what tices; or, figure out how to eliminate contracts, income, and compensa- people are likely to pay for the kind those barriers to sound business tion plans to make it not only possi- of service you want to provide.While practice. ble to more accurately project cash elected officials,the press,taxpayers, A purely private operation can't requirements on a month-to-month third-party payers, and private make good use of several tax exempt basis, but in fact to actually paying patients are likely to grumble financing benefits, and a purely manipulate, to the benefit of the about the cost no matter what it is, it public system will, in most cities, be system, the average size of cash is also true that a community will unable to take advantage of good reserves available throughout the pay, one way or another, something cash management practices, replace- calendar month. More precise inven- like a "fair market" price for the ment fund deposits and investments, tory control systems also help to kind of service you are capable of unusual incentive programs, and so enhance the power of a good cash producing. (Some cities pay a whole on. management program. In one case, lot more than a "fair market price" The high performance ALS we even managed to create an for EMS services, but probably not systems of the future are bound to arrangement whereby the EMS forever.) incorporate a variety of hybrid Authority was able to mingle its cash public/private mixtures to allow the reserves with the investments of the use of sound business practices while local city government to obtain a 1 -1jr taking advantage of the public ser- substantially higher rate of return, `J '" vice nature of our industry's services..rit without allowing the income realized , I , ,►1 ,t rl Chances are your system's present to go back into the city's general � O t �1 structure was never designed with g Y g iilj , ��:�,�1�l� �:��1 g fund. �''{� �'1 • tuning-up may well be in order. ctural Backing Into Your Budget ? �':{�� J 9 9 High performance ALS systems ns �� g P Y In the past, EMS managers often survive on an extremely narrow budgeted by figuring out what it cost "Somebody out there can make it income/expense margin. The differ- them last year, adding some known work, and if you can't, be prepared ence between breaking even and increases, and then making a "wish to change your system's ways or be going down the tubes may be only a list" for more stuff. Then, hat-in- replaced by a higher performance small percentage of annual cash hand, the manager made his pitch to organization." flow. If your operating capital is city administration, the city council, small to start with, and if you have and perhaps one of the sources of Therefore, if you based your no replacement funds built up and grants-in-aid. projected fee structure/subsidy no borrowing power to boot, a small Today, and probably for a long combination and your projected percentage loss can put your system time to come, you are much better collection rate upon some sort of completely under. And if you are off working backwards. That is: comparison with the experience of forced to beg the city council to bail • Define the quality, response time other similarly qualified and reason- you out, you may get what you want performance, range of service and ably efficient ambulance services this year and a whole new EMS volume of service you are going to throughout America, then by defini- system next year. (We consultants deliver; tion, somebody out there can make it circle like vultures over the carcasses • Figure out how much you can sell work, and if you can't do it, then of dying EMS systems.) that kind of service for(i.e., fees and you should prepare to change your Acting like part of the American subsidies) and discount bad debt — system's ways or prepare to be health care industry, as opposed to then you know how much money replaced by a higher performance just another local agency, as alluded you're going to get for the work you organization. (No one ever called us to in Part I of this series, is the first are expecting to do; to say that their EMS system is step. Learning to play in the fee-for- • Figure out all of the fixed costs of working wonderfully, but would we service arena that characterizes operating a system of that size, help them replace it anyway.) America's health care financing quality, and range of service delivery system is critical (see Part II of this (e.g., facility lease, fuel, equipment We Can't Do It Here series).And next month in Part IV of payments, forms, the postage on the I can't say I blame you if your this series, I will talk about a whole billing statements, and all the other tendency is to discover all the really range of techniques for controlling costs that are going to be there no great reasons why almost none of costs and improving production effi- matter what you do); these financial techniques would ciency while maintaining extremely • Subtract all those fixed costs from work for your system. But I encou- high performance all at the same the income, and you've got a pretty rage you to think again. Most of the time. But in the industry of high fair idea of what you have left to techniques discussed above are EMS performance prehospital care, work with to cover vehicle mainte- adaptations of conventional business management cannot afford to nances and to pay street people, practices borrowed from mature overlook all of the less exciting, more dispatchers, yourself, and so forth. industries. If there truly are struc- complicated, and certainly less fami- Then, the only question left is tural barriers that prevent you from liar tools and techniques discussed whether you think you can do it. If using tested financial practices (and here. ❑ ‘ „. . The Misinformed Pu blic A Study Measures Public Knowledge of Emergency Medical Services process of public education. The Starting in this month's issue of jems,we will begin a series of articles on economic findings here are intended to help survival in the 1980s. In essence, the series will deal with the need for user fees EMS planners better understand the people they serve, so they may ass to replace disappearing tax-based sources of revenue for EMS. Any imposition of user assist fees, however, requires a high degree of consumer information and understanding. these people in making better in How does the typical consumer feel about the local EMS system? What does he know informed decisions during medical emergencies. about it? Where did he acquire the information he has about EMS? How accurate is that information? If he is misinformed, will that affect his willingness to support a new In the present study, the authors or different method for financing the EMS system? sought to explore s held attitudinal and The following article by Professor Gary Selnow and co-authors Dennis Myers knowledge differences held r ation who and Scott Hayes breaks new ground in EMS. They report on public reactions to about have ions hand information about operations of the local emer- many of the more important questions about EMS. The questions were posed to gency rescue service, and those who members of the public in a scientific format; the assembled answers represent a came to know about the service only body of information that we all need to pay attention to. Myers and Hayes, both EMTs, through second-hand sources. As this became interested in the issue of public communication for EMS.With the input of Dr. review will show, in this survey of Gary Selnow,assistant professor of communication at Virginia Tech,they conducted a nearly 600 people, there were marked public opinion survey which serves as the basis for this article. distinctions between these two groups of respondents. The first group was operationally defined as those who claimed to have phoned local EMS for assistance during the past several Thousands of times every day significant, are those general percep- years. Members of the second group people face medical emer- tions people hold of the emergency were identified as those who claimed gencies who must make the medical service and of the emergency no first-hand knowledge of the rescue decision whether or not to seek the medical technicians on staff. The service, but instead came to know assistance of emergency medical per- greater the confidence people have in about that service and its members sonnel. In some instances the height- the emergency service, the greater the from other sources. A few in this ened level of confusion and general likelihood they will call on that group learned about the rescue service lack of personal experience in such service for aid. People are naturally from the mass media (10 percent), matters may bring about a distress more inclined to seek assistance from but most credited friends, word of call for cases which do not require those they trust and hold in high mouth and other unofficial channels. professional attention. A more dan- regard. Analysis of the data suggests a gerous error in judgment, however, In serious medical emergencies, the number of problems inherent to this is found in the decision not to call initial decision whether or not to "folk instruction" about the service for assistance when it is needed, activate the EMS system is critical and demonstrates that information perhaps resulting in an unnecessary, to the success of treatment, and any acquired from such sources is asso- and even life-threatening delay in information which can be used to ciated not only with misconceptions emergency treatment. help people make the correct choice about EMS operations, but also with A variety of factors influence at such times will be valuable in the lower opinions toward its services and those early decisions. Most obvious its members. are the extent of the injury or illness The investigation of these issues and the medical skills of those in by Dr.Gary Selnow,Dennis began with a review of knowledge a position to administer first aid. Myers and Scott Hayes differences between the groups con- Less apparent, but perhaps rio less cerning an objective point of fact. #r..1. MAW:, i 45 The rescue service in this test area accurate responses. The important avoided calling the rescue servic operates with volunteers and does not finding here, however, involves the past medical emergencies beca,.,,;, charge for calls; this first review other group where just over half they incorrectly believed the service sought to learn if respondents correctly said they thought the service would be costly. While data gathered were aware the service was provided was free. Why were these people so in this study does not attend to free of charge. Of those with first- unsure of the compensatory arrange- this issue, it is reasonable to suggest hand experience, 82 percent re- ment of the service? Perhaps infor- such decisions may be so affected. sponded correctly. Among those in mation disseminated through second- If this should be the case, there is j the second group, only 62 percent hand channels was somehow deli- clearly a need for better provided a correct response, and cient. The mass media is a potential communication. Public nearly one-third (31 percent) said they source of accurate information, yet, In a second series of l did not know whether or not they in this instance, appeared to provide the study sought to measure how well would be billed for the service. little or no information (only 10 informed respondents were about One would expect those who have percent claim to get information on specific services provided by the local called on the rescue service to know the EMS from mass media). rescue unit. According to the data, the assistance is free and therefore It is important to discover if those who obtained information from should be able to provide more many people in this group have second-hand sources were consistently less successful in I providing accurate responses to objective questions. For Information Issue instance, they were less likely to know Information have you learned about the Attitude Issues that home prescription delivery was I services provided b Overall rating of personnel not a service provided by the local y your local rescue service?° 700 97% EMS. They were also less likely to 100 0 -o 90 know the service did, in fact, provide so °o 80 79% transportation of a patient from local 80 72 r cc o a 70 small hospitals to larger medical 0 70 60 facilities. so 2 r -50 Here, too, the findings reveal that 50 a those who have only indirect infor- 0 Hand Second Hand mation about the emergency care unit 'a', 40 {- Knowledge Knowledge g Y 30 #.--,-.: generally know less about its servic 16/ - Rating of quickness in responding to a and procedures. k -- 10% 10 call r � 0 - a) Personal General Mass o-o n 700^ 88% The Study Experience Knowledge Media a m 0 90 (First Hand (Second Hand o a 80 - fis i This article is based on data gathered 70— in a telephone survey of 578 respon- Knowledge) Knowledge) dents selected using systematic random 8 50 - sampling procedures. The survey was First Hand Second Hand conducted in southwestern Virginia Knowledge Issues Knowledge Knowledge from February 8 to February 12, char- "Do you have to pay for the rescue 1982. Respondent demographic char- services in your c ay for t t acteristics were representative of the y " Attitude Issues population at large;there were slightly 100 Medical Expertise more females (54 percent) than males _Y 90 82%i 100 (46 percent) in this sample. Analysis 80 `o 90 89 involved descriptive statistics using a o 70 62 i o m 8 80 programs of the Statistical Package a v 60 �o O for the Social Sciences (SPSS). 65% a a 50 o° 70 Statistics reported here have an error o c0> 60 margin of plus or minus 4 40 o : - percent �, 50 with a confidence interval of 95 per- First Hand Second Hand a First Hand Second Hand cent. Knowledge Knowledge • Knowledge Knowledge "Does your rescue service provide The credibility of EMTs is a crucial delivery of medicine from the drug store to your home?" Trustworthiness issue dealing with public perceptions of both EMTs'. medical skills and 100— 100 90% their trustworthiness and concern for `o 90— a 0 90 patients. Credibility ratings demon- o ° 8° c� 80 72% strate the confidence people have in 0 o - 70— a 60— 59 r C' oo 70 the emergency care system during n_ U c3 - 60 times of crisis. These ratings, one cc 50 oar a 50 could argue, may also shed light on 40 - First Hand Second Hand ublic motivations to support pport volun- First Hand Second Hand Knowledge Knowledge teer services. It is likely that organi- Knowledge Knowledge zations held in high g public regard will be more successful at drawing 46 MARCH 1983 jems . t public financial backing. perceived credibility.' In fact, several nor have they directly witnessed the , , The importance of this credibility studies have concluded that people interest EMTs have in helping people.on w issue led the authors to focus on have more confidence in someone their opinions are e basedand heat respondent perceptions of the two they trust than in someone who they credibility component characteristics believe has high expertise, but low information channels, it seems, are mentioned above — the EMTs' med- trustworthiness.' The authors not successfully conveying the level ical expertise, and their trustworthi- explored this issue by asking respon- of eedi al skillsirorhthe degreev of ness (measured as interest in helping dents to rate the interest rescue per- others). sonnel have in helping people who have witnessed. While most sources When asked to evaluate the medi- use emergency care services. Here, ofyon second-hand an h of information anon are cal skills of local EMTs, there was too, high ratings were provided by medindl system, facilities of the mass generally a favorable rating from all nearly all respondents in the survey, media are not, and yet these of the im ass respondents. There was, however, a but the authors again found a note- media channels and information have notable difference between the worthy split between the two groups. almost of information m in the in have responses of each group. Of those In the case of those with first- played s. with first-hand information, 89 per- hand information, 90 percent of mation disse sesmo a io other squestions cent provided a score of good and respondents provided a good or very very good, while the rating among good rating of_ the interest rescue assessing public impressions of EMTs those who got their information from personnel have in helping people. follow the same pattern described for second-hand sources gave a positive This rating dropped nearly 20 per- the medical skills and interest issues medical skill rating of only 65 per- centage points among those in the described above. When asked about cent. Such a difference suggests that second-hand information group who the quickness with which the EMTs first-hand experience has, indeed, had gave rescue personnel a 7 2 respond to a call, 66 percent of an impact on the opinion rating of percent score of good to very good. those in the eisedo second-hand information the EMT's medical skills. Information Findings on this important credi- group provided high ratings, obtained through second-hand chan- bility issue hold some valuable lessons 88 percent of those with first-hand nets appears to be less convincing. for emergency care systems. Those experience offered high ratings. A Many social psychologists claim people dealing with only second- question asking about the overall that trustworthiness of an indivi- hand information have neither seen marks o om all EMTs r yielded ntpos positive is a critical component of his the medical skills of the EMTs, ( J A L D) )1. -1_1, D -----),_yOyL, 0 I-( `r ( ) H� ( J ( - Dependability. It's yours in a van or modular ambulance by TEC for as long as the vehicle is a vital part of your emergency team. i t . Our good-looking, functional, ambu- "'"'�' '� lances are designed in anticipation i ,,, r` E, ■" of every patient need. . .and your , -„ response to them. Efficient emergency systems com- plement r '� _ --- a spacious, well- .; ----- t interior. Storage and "`.. U s • accessibility are stressed �. 4311: inside and out. Exteriors ��' are of durable aluminum i - � �,......,,iiL," and styled for maneuver- �� ability and cost-efficient operation. • For more information and how budget-easy it MINN p EE B S O COACH CO. is to put a dependable TEC ambulance to work Goshen, Indiana 46526 for you — call or write today. Phone(219)533-4161 Circle#29 on Reader Service Card jems MARCH 1983 47 again, those with first-hand ex per- companion to these impressions were Furthermore, these public dia ience offered substantially higher more positive. One likely ` ratings (97 percent) than the second- tion of these observations suggests heu credibility l oo the EMS to el by hand group (79 percent). factual flaws in second-hand infor- telling hoEMTs undergo extensive While the data reveal differences mation received by those who have (expertise issue), in response patterns for participants never had the occasion to seek help and f how they have ga strong interest in this survey according to a variety from the local emergency service. in providing aid in times of medical of demographic characteristics (age, While little can be done about the emergencies. income, education, etc.), there is accuracy of information borne by With the dissemination of accurate, no split so dramatic as the differ- informal communication networks, first-hand information, it might well ences seen between respondents who EMS systems throughout the country be expected that the general public get their information second-hand do have access to mass media than- will learn more about what to expect and those who have had a first- nels which can help deliver first- from the emergency care system. hand look at EMS. The difference hand information about the services Moreover, those who have previously between these two groups is clearly and resources of emergency care chosen alternative means of seeking one based on the source of informa- groups. Nearly all radio and tele- assistance during medical emergencies tion. One group is operating with vision stations and many newspapers may be more inclined to turn first the vagaries of someone else's impres- will provide free public service adver- to EMS for help. ❑ sion (and even this may be third- tisement opportunities which give or fourth-hand information), while rescue services a forum to describe Footnotes the other group forms opinions from how they operate and stand ready I. Brewer,M.B.,&Crano,W.D. "Attitude Change 4 information which has not been to assist in times of medical emer- I synthesized and interpreted by some- as a Function of Discrepancy and Source of p Y gencies. Emergency services can pro- Influ- ence."Journal of Social Psychology, 1968,76,pp• one further down the information vide factual information about how 1818 Also, Moreland, C.I., &Weiss, un W. "The Chain. Influence of Source Credibility on Communication they can be reached by phone, and Effectiveness."Public Opinion Quarterly,1951,15, : With few exceptions, impressions they can tutor people on thins to pp 635nies, based on first-hand knowledge were consider when making a decision 2. Tian Righ t:ETrustworthiness. and Expertise as more accurate on the factual items whether or not to phone for l'a`t°^ in Culled, dealing with EMS, while the opinions assistance. P.467l° t' Bulletin. Vol. 6,sNo,l3, Scp;,1980 PP.a6�X71. Enjoy working under pressure? INDEX TO ADVERTISERS To receive information on the products advertised in this issue, please fill out one of the attached reader service cards. Service •Page Service Page Number Number Number Number 23 AAOS 9 40 Mediked 8 B ecome a 35 44 4 54 Muster&Associates 54 44 Allan Allman Products.19 38 National Nursing 12 American Agency. . . .29 Review 15 ■ 41 New York Medical D11111_IVIIJip e 21 AXIProMedical 53 College 49 Bashaw Medical Inc. .43 50 North American 15 Braun Ambulance. . . ..34 Hyperbarics 48 _ Critical Care 42 46 Omnicron 43 28 DavenportCollege . . .49 56 Our Designs 61 57 Direct Safety 36 22 PhysioControl 7 31 Dixie 13 37 Plano 17 55 Egen Polymatic 54 45 Power Group 1 39 Emergency Medical and International 22 Training Available Safety Supply 33 30 Primary Care Products 23 i 11 Emergicare 25 27 Rescue Services 14 Professional Diving School of New York 32 EVARS 56 47 Rico 3 20 Frontline Ambulance 50 13 Sager Traction Splint. 10 North American Hyperbaric Center 48 Johnston Holloway 19 36 S-SCORT 222 Fordham Street, City Island, N.Y. 10464 18 Laerdal 11 1 Call Toll Free 800-223-8000 63 17 Survival Technology. . 2 1 or (212) 8850600 in New York State 19 Life Support Products, 29 T.E.C. 47 Inc. 16 26 Univ.of Nebraska Request our new 64 page catalog. 14 Little Brown&Co. 5 Cont.Ed. 12 24 MCI 57 16 Wheeled Coach 64 Circle#50 on Reader Service Card 48 MARCH 1983 jems 1 f s 1 1983 Salary Surve 1 -)i_ Survey(continued) �i Figure 4: Average Annual Pay Figure 7: Amounts of Life Ir EMT EMT-P surance Provided to Surve Fire Department Su ervisor Administrator $21,768 $23,046 Respondents Private $28,010 $34,455 $13,756 $17,281 $20 682 Note: 113 respondents (87 percent) ir, Separate Municipal Service $12 700 $29,017 benefitpac insurance was part of their fringe Separate Hospital-based Municipal $16,559 $17,520 $23,160 benefit package. $13,204 $17,879 $18,783 Overall averages $25,526 Amount of $15,357 $18,691 $21,248 $28,039 Insurance with Number of Respondents Covered in Parenthesis $ 3,000 ( 1) $12,000 ( 3) Figure 5: Availability of Major Figure $ 4,000 ( 1) $15,000 ( 3) Fringe Benefits Fi ure 6: Amounts of Malprac- $ 5,000 (11) $20,000 ( s) is' Survey Provided to $ 5,900 ( 1) , $25,000 ( 1) E I Item yes no Y Respondents $ 6,000 ( 2) $50,000 ( 5) 11 i • Note:95 respondents(73percent)indicated $10,000 19 Malpractice Ins. ( ) $80,000 ( 1) 95 35 malpractice insurance was part of their $11,000 ( 1) 4 (73%) (27%) fringe benefit package. Life insurance 113 17 Life Insurance ' 20,000 accidental (87%) (13%) Variables death Medical insurance 124 6 Amount of •= to salary •$10,000 per a (95%) ( 5%) Insurance With Number of Respondents •1.5 x salary employee plus p •2 x salary •$20,000 accidental Dental insurance 65 65 Covered in Parenthesis •3 x salary death i (50%) (50%) $ 100,000 4) •65 percent of salary •$10,000 per i Uniform allowance ( ) $ 1,500,000 ( 2) •1 percent of salary employee plus f 118 12 $ 150,000 ( 1) $ 2,000,000 ( 4) toward private $1,500 per (91%) ( 9%) $ 200,000 ( 1) $ 3,000,000 ( 5) premium dependent Meal allowance 47 83 $ 250,000 ( 2) $ 4,000,000 ( 3) (36%) (64%) Travel allowance 56 74 $ 300,000 ( 5) $ 5,000,000 ( 3) (43%) (57%) $ 500,000 ( 6) $ 5,500,000 ( 1) Figure 8: Variables in Medical Education allowance gi 39 $1,000,000 (23) $10,000,000 ( 3) and Dental Insurance (70%) (30%) 81 49 (62%) (38%) Note: 124 respondents (95 percent) in- dicated medical insurance was part of their Malpractice $3,000,000 with fringe benefit package. Sick days 114 16 Insurance Variables $13,000,000 Medical (88%) •$500,000 per umbrella • • $50,000 major (12%) employee plus •$5,000,000 per Major medical medical Vacation days 124 6 $1,000,000 carried employee self- Group policy • $250,000 major emplo • P Polic (95%) ( 5%) by company insured for first provided by city medical/$100 Overtime 100 30 •$1,000,000 per $50,000 • $10 deductible deductible ° occurrence •$1,000,000 while on • 80 percent paid • Blue Cross/Blue (77%) (23%) •$300,000 per claim duty only after$100 Shield plus Retirement pckg 104 26 •$5,000,000 umbrella •Unlimited 0 ,o deductible (80%) (20%) •$1,000,0oowith •$3,000,000 per prescriptions p $1,000,000 • 100 percent Profit sharing 8 122 $5,000,000 umbrella claim lifetime benefits accident,80 •City is self-insured • Blue Cross/Blue ( 6%) (94%) percent Shield-Family hospitalization • $200 deductible • Health • Only for Maintenance management Organization • $20/month paid • Complete, While the amount of uniform allowance varied by employee includes optical Note:65 respondents(50 percent)indicated widely, 91 percent of all respondents indicated they dental insurance was part of their fringe did have some, with 30 benefit package. percent saying the entire Dental cost was covered. • Blue Cross • $1,000 • 80 percent • 100 percent • Blue preventive, Cross/Blue 75 percent 1 Shield repair,50 • All percent • $10,000 I appliances 42 JANUARY 1983 jems _ k il_I , � 3 Figure 9: Amount Provided Figure 12: Variables in Travel Figure 14: Number of Sick and Respondents as Uniform Allowances Vacation Days Given Survey Allowance Respondents Note:56 respondents(43 percent)indicated Note: 118 respondents (91 percent) indi- that a travel allowance was part of their Note: 114 respondents (88 percent) in- cated a uniform allowance was part of their fringe benefit package. dicated they were given sick days,and 124 fringe benefit package. 100 percent • While on depart respondents (95 percent) said they were Amount of • for out of town ment business given vacation days as part of their fringe Allowance with Number of Respondents conferences • $500/year for benefit package. Receiving this Amount in Parenthesis • only on air flights supervisors only #of #of $ 70/year(1) $200/year(6) $375/year( 2) • $0.22/mile • $0.15/mile # respondents respondents $ 90/year(1) $225/year(2) $425/year( 1) • $3.00 when • $0.17/mile Vacation in Sick in $100/year(1) $240/year(2) $450/year( 2) transferred • $0.19/mile days parenthesis days parenthesis $125/year(1) $250/year(5) $500/year( 2) between stations • For continuing 5 ( 2) 4 ( 1) $150/year(9) $300/year(3) $670/year( 1) • Travel provided education 6 ( 3) 5 '( 4) $175/ ear(2) $350/ ear(3) ALL (39) • When over 100 sessions 7 ( 4) 6 (11) $175/y ear y miles from home • For conferences 8 ( 2) 7 ( 2) $180/year(2) • 1 course per • $0.23/mile 9 ( 2) 8 ( 3) year • $250/year 10 (12) 10 ( 4) per paramedic 12 ( 7) 12 (32) 13 ( 4) 13 ( 2) Figure 10: Variables in Uniform 14 (18) 14 ( 5) Allowances 15 ( 8) 15 ( 6) Figure 13: Variables in Educa- 18 ( 1) 18 ( 3) • replace as • no footwear,all 20 ( 5) 24 ( 3) needed else furnished tion Allowances 21 (10) unlimited ( 1) • city buys all • 2 uniforms plus Note:91 respondents(70 percent)indicated 24 ( 3) • as needed patches that an education allowance was part of their 30 ( 1) • furnished • paid for if fringe benefit package. 49 ( 1) • $150/year plus destroyed replaced as • initial uniform plus • for required • dependent upon needed $300/year courses budget • $15/month plus • 2 complete • 2 courses/year • 80 hours of Figure 15: Variables in Sick and all shirts,pants, uniforms/year • all overtime/year Vacation Days jackets furnished • all uniforms • for continuing • $4/3-hour credit, • half cost furnished plus education up to$120 Vacation days weeks after 15 • built into salary $100 laundry sessions • All job-related • 1/month plus 3 years;5 weeks • furnished plus allowance • for special courses for over 10 years after 20 $20/month • uniforms and classes only • Education cash service plus 5 • 6 uniforms/year cleaning provided • $1,200 for an AS bonus for for over 15 years Sick days as needed • $5/shift degree,$1,800 degree service • can accumulate • $2/shift • 100 percent for a BS degree • all initial certifi- • 1 week in first up to 15 • 1 pair shoes and except footwear • 50 percent of cation costs year;2 weeks in • 5/yr-accumu- 2 uniforms/year costs • 2.25 percent of 2nd through 4th late up to 20 • $150/year annual EMT years;3 weeks • 4 hrs/month • 1 course/year wage/5.5 after five years • 6/year based on < • EMT courses percent of • 5/year-accumu- 24-hour shift only annual EMT-P late up to 20 • 15 hours/ Figure 11: Variables in Meal • $200/year wage • 20 hours/month month Allowances • $500/year • Tuition and • 2 weeks at start; • 18/year/ Note:47 respondents(36 percent)indicated • up to overtime 3 weeks at 10 120 maximum that a meal allowance was part of their fringe $1,000/year • Tuition refunded years;4 weeks • Unlimited benefit package. • unlimited after successful at 20 years • 144 hours/ • 50 percent for completion • 2 weeks after one year • city pays subsidy discount on EMTs,full costs • 104 paid off-duty year;3 weeks • Sick and annual for food for shift hospital food for paramedics hours per year after 6 years;4 leave combined personnel • $300/year • out of town meals • $5/person on paid for transfers over • $5/day 100 miles Many services indicated educational allowances for • All meals • For seminars,etc. provided • $120/month 4 6approved" or "related', courses, and some offered • $4.50/meal when • Reasonable/all ' on a call • $100/year incentives for training whether it was related to the • $22/day • $2.50/meal when job or not. • While in school on out of county • 10 percent transfers jems JANUARY 1983 .o i Is i ), 1�I o 1983 Salary Survey(continued) Figure 10. Note that some are very the feeling of being cheated w Figure 16: Variables in Holiday Bonuses clearly defined and others use working a holiday.Some of the va nebulous terms like "as needed." bles in holiday bonuses are listec Note:81 respondents(62 percent) Some include cleaning of uniforms. Figure 16. they were given holiday bonuses as part of Some include footwear;many do not. The issue of overtime is a vola r their fringe benefit package. Some limit the number of uniforms subject in EMS primarily due• 1.5 x hours y ue to e: y • $180/year per year. Some give an allowance for individual service's definition of w 11 wage • $900/year each shift worked. • 2.xh l • 2 x hourly • $500/year Meal allowances and travel tyofsertvices offer time-nd a hal overtime. By far a maj y • $100 for allowances may be big selling wage Christmas for a fringe benefit package since few the similarities working Figure 17 h Th • 3 x hourly wage • extra day off the similarities end. Figure 17 she services seem to offer any.The benefit what constitutes overtime in some } 'many employees may be several hundred the services responding to this sale dollars a year. There are probably as survey. Figure 17: Overtime Wages any variables in meal and travel Retirement packages can be trar allowances as there are services that fated as security,and thus are very it 1' Note: 100 respondents (77 percent) indi- offer them. Some of these variables r i catedthatovertimewasgivenaspartoftheir are listed in Figure 1 1 portant to employees. In fact, 80 pc fringe benefit package. allowances) and Figure 12 (travel they h daretiremen�package f sot. After How #of allowances). Travel and meal kind. Of the 26 respondents who d Overtime rate Many Hours Respondents allowances may be needed incentives 1.5 56 14 for increased participation in continu- not have a retirement package,22(t i.5 4o P P percent) worked for a private amb 1 5 43 ing education programs. lance company. 58 1 Education allowances can help en- was not designed ed to do so,it would I 1 5 42 4 sure employee satisfaction and quality interesting to see if this lack of retir, 1.5 1.5 42 1 patient care.Continuing education is, ment packages in private ambulant 1.5 60 2 of course, critical to high quality pa- companies results in a higher attritio 1.5 60 1 tient care. Registration and travel rate.) 1.5 54 1 costs often present obstacles to conti- 2 not given 1 nuing education. Some of the many Pate i sharing is possible only i; 1.5 24 1 variables in education allowances are incentive nforsteemployment but is ndcelle( listed in Figure 13. P et and goo( people do not buy their own coverage While many services offer educa- companies respond ngt(30 86 percent 1 in people areas,most(especially own v they tion allowances only for"a Y or "related" cours s, some offer n„ do offer profit sharing. have families) recognize the dollar value of these forms of insurance. ornotto heirem employment. related Summary Some medical insurance packages in- g P Ytnent.Recogniz- Even from this cursory view o P g in interests beyond emergency care fringe benefits, it is obvious that it dude these items,many do not.Their has helped create high levels of evaluating rates of compensation, value is measured by the deductible, employee satisfaction in these ser- ve definition of what is covered and total vices. Such "unlimited" incentives A gfringe benefit ac amount of coverage. Figure 8 shows help attract highly motivated, well- A good oodisi fringe a benefit is not enough. some of the variables in dental in- educated people. P pert may or some of Orthodontia is often part of provide benefits equal to 20 percent y. P It is rare not to find vacation days A poor package lma employee's provide nnual ealary. this coverage.Optical care w not in- this co as ge. of the care was so no and sick days. The number of days equal to less tan 10 ercent. benefits listing is available from respondents. listed ainlFigure 14. Some of the many receive$25,000per year and It is possible, then, that John can Allowances variables are listed in Figure 15. The than Bob, whose salary is$19,000. If While the amount of uniform mportantdassis available ability touac- fringe benefits lately,haven't taken a look at your allowance varied widely,91 percent of cumulate days from year to year.Sick should. How much would it cost you all respondents indicated they did Y, perhaps you Y days and vacation days are expected to buy the insurance, etc. that your have a uniform allowance. Thirty- by employees.They are not big selling employer is giving respondents (30 percent) in- points,but can hurt a service that does that your employer is "paying"that either all uniforms were g you? Is it possible provided, or all uniform costs were not offer any, paying more to you than you had ever provided,In every uniform requiring a The holiday bonus is important in Iss it possible that you are being"paid" uniform, it is money out of the Though the aluepla placed individual survey will g Pard employee's Y you can say. We hope this pocket if a uniform holidays varies give you some of the is is not provided. y greatly, most em- to make those decisions. It is in- allowance e amounts o f uniform ployees feel they"lose"something by teresting to note that many employees not having the day off. Compensa- are surprised to learn that their allowances for respondents are listed tion,whether in the form of extra pay in Figure 9. Variables are listed in or time off, helps reduce or eliminate fringe benefiits�ng as much as he is for CI i 44 JANUARY 1983 jems i i r System Status Management The Strategy of Ambulance Placement upon paramedics and medical System status management refers to the formal or informal systems, protocols, and control physicians to "invent" procedures which determine where the remaining ambulances will be when the next call algorithms on the spot used to be a comes in.Whether elaborate or simple,written or remembered,every system has such matter of"professional preference." a plan — the question is, does it make sense and does it work? While the debate is bound to go on, Author Jack Stout is a regular contributor to jams and will have a monthly column Cayten's evidence is powerful and on beginning in the June issue. He has long been involved in designing and implementing the side of planned and documented EMS systems, most notably the public utility model concept. With his company, The procedure. Fourth Party, he has been involved in the establishment of sophisticated ambulance clinical systems in Little Rock, Arkansas; Tulsa, Oklahoma; Kansas City, Missouri; and most As our infant hat some ways s�are recently, Fort Wayne, Indiana. are learning than others, and that everything isn't a matter of opinion. Eisenberg showed us that, for certain patient conditions, both fast BLS and slow ALS are deadly. Dr. ome of the most earth shakin g performance ambulance organiza- Cayten and his colleagues have now concepts seem merely interes- tions, and even entire classes of shown us that well-documented ting when they first emerge ambulance systems, have been clinical algorithms not only help into view. Some go nearly unnoticed. dramatically shortened by the new paramedics retain their technical The force and impact of the idea may knowledge. Almost unnoticed, the skills, but actually can be traced with change our lives without our ever forces have been set in motion. statistical significance to changes in knowing that it was that idea that did In the February 1983 issue of patient outcome. it. Medical Care, Dr. C. Gene Cayten Gradually, very The well-known Eisenberg studies and others upped Y some gradually, pe and certainly caught our attention, but further with the d the ante even learning what some have suspected certainly you know that those attention, but further publication of a all along. We are learning that life- did you know w that project summary entitled, saving system performance is hard to powerfully impacting the "Clinical Algorithms for Prehospital come by. Not even money can neces- very structure of the entire ambu- Cardiac Care."This well-written arti- sarily buy it. Smart people with good lance industry? Legally imposed cle describing a truly fine response time standards are no research is, g Y piece of intentions and expensive equipment longer arbitrary or entirely subjec- than the Eisenberg s studies, another like pro-football, go buain ar is e, or tive, and the courts are upholding blockbuster. Whether an EMS gorilla warfare, or ordinances with stringent response system should go to the trouble of heavy rweather sailing this writer) — time requirements based, in part, developing and documenting detailed upon first recognizin that all a variety depend upon the Eisenberg studies. The right step-by-step procedures for patient of events are going to happen very of private ambulance companies, or care versus relying more heavily quickly, your responses to those public agencies for that matter, to events must be perfectly selected and deliver life threatening response times has been seriously weakened. by Jack L. Stout executed, and that you can't possibly predict what's really g The life expectancies of low- going to happen. Then with painstaking 22 MAY 1983 jemS diligence, you try to predict Figure 1 everything that could happen anyway, and you figure out what you would do if it did happen, and you HOSPITAL DROP TIME BY HOSPITAL write it down and you think it through and prepare yourself and FOR MONTH:12/82,SYSTEM:KANSAS CITY MO/MAST EMS you practice, practice, practice. HOSPITAL:ST.JOSEPH KC When things do start happening,you Ave Time Arrive = Ave Time Arrive hope most of what you do goes _E :Hospital To in Over 15 Mtn Hospital To in Over 15 Min according to plan, leaving you and count service-tst Resp Count Per% "service—All Count Per% your crew free to concentrate your Prwriryone 15.51 _"12 "343 2204 1s 503 Piloriry Two - 24 �12.25 7 `29 2 ' 3404 583 intelligence and creativity upon a Priorityoneandiwo '° 59 1419 19 32.2 26.93 4 . .55.9 limited and more manageable set of privity Three 22 16.23 • 8 '364 1477 12 84.5 unforeseen circumstances. Priority Four 0 0.00 0 0.0 0.00 0 -.0.0 The concept common to all of Priority Three and Four 22 14.23 8 384 1877 12" X54.3 Priority Alt 81 d 14.74 27 33.3 24.72 45 55S 6 these activities is the goal of >. a reducing, as much as possible, the need to invent protocols and proce- dures on the spot. Think it through dramatically improved by similar mation and to advise the caller with before it happens. Plan the response refinements in the control center. prearrival instructions, and in multi- while the pressure is off, while the I remember a conversation I once tiered response systems, these same advice of others is available, while had with an experienced dispatcher protocols extend to guide the selec- mistakes can be made and corrected in a large urban system. I was tion of ambulances and first- in the hypothetical — not in a ditch watching the operation of the responder units. All essential, but under a car in a foot of water dispatch center late one night when I what about the management of the covered with a shiny film of gasoline. heard the dispatcher say to a system itself — the system whose And practice. Cayten noticed that telephone caller, "what is your configuration when the phone rings the number of paramedics treating telephone number?" Later I asked can often make the critical differ- the patient influenced patient out- that dispatcher if the caller was ence? What about the management come, and had to adjust the analysis phoning from the caller's own home. of system status? to account for this and other vari- The answer was, "no." The dispat- "System status management refers ables. But having lots of paramedics cher had asked, literally, for the to the formal or informal systems, at the scene doesn't automatically caller's own phone number. What protocols, and procedures which help the patient. You can't out- the dispatcher wanted to know was determine where the remaining number an attack of ventricular the callback number. I suggested that ambulances will be when the next call fibrillation. Paramedics make a if you want to know what number comes in."Whether formal or infor- better team because they all know the caller is calling from, then you mal, elaborate or simple, written or what's going on, what's next, and should say the words, "what number remembered, every system has a how to help.But how many two-tiered are you calling from?" No other "system status management plan." systems have even written down, words are as good. The only question is, does your much less practiced, team task There still exist throughout the system status management plan descriptions and protocols so that country major ambulance service make sense and does it work? BLS crews know how to really join systems, some even ALS, where the Effective Unit Hour Utilization the team when assisting an ALS conversation between the dispat crew? cher" and the caller is more like a Think of it this way. Every ambu- chat than anything else. Each dispat- lance system can afford to place only High Performance in Dispatch cher has his or her own approach to a limited number of ambulances on The term "dispatcher" is used in the conversation — a far cry from the street. Because ambulance the commercial trucking industry, the orderly and reliable telephone demand patterns usually follow a the taxicab industry, and defines the protocols (i.e. information gathering weekly cycle, I like to think in terms job of the 18-year-old clerk who algorithms) of Dr. Jeff Clawson's of "unit hours per week." A "unit sends out the Xerox repair man, the Salt Lake City Fire Department hour" is simply a fully equipped and plumber, or the exterminator crew. operation (see Dr. Clawson's article, manned ambulance on the street for And back when "as soon as we can, "Medical Priority Dispatch — It one hour. A dispatcher trying to ma'am" was soon enough . . . the Works!" February 1983 ferns). match supply with demand must same era when "in the best of Sloppy and extemporaneous utilize the available "unit hours" in hands" and "all that could be done telephone protocol makes for the best way he or she can to squeeze was done" was the measure of good misunderstanding, faulty informa- the highest response time perfor- medical care . . . dispatchers dispat- tion, and missing information; yet mance possible out of the unit hours ched ambulances, too. the system's entire initial response is available. But just as we are learning that based upon that information. At the most basic level, there are highly ordered and practiced action In some of our better managed two extreme forms of unit hour in the field makes for better manage- EMS systems, medically trained deployment. At one end of the ment of patient care, we are also dispatchers employ clinically sound extreme, the system could run the beginning to learn that the manage- and thoroughly thought out tele- average number of unit hours ment of the entire system can be phone protocols to gather infor- available per week all the time, i.e. jems MAY 1983 23 the same number of ambulances on December 1982 in Kansas City, then left available in the system. the streets 24 hours a day, seven days Missouri. Look it over and think Maps "A" and "B" show the a week.At the other extreme, but not about how you might spend unit location of all emergency requests in much more foolish, you could put all hours on Thursdays in Kansas City. the City of Tulsa over a period of the unit hours on the street at the Taking surplus unit hours off the several weeks. The difference is that same time for one hour, if you street when they aren't needed, and Map "A" shows the geographic owned that many ambulances. adding these unit hours during times emergency demand pattern for the Since all of the calls don't come in of overload or wild fluctuation time between 9:00 a.m. and 10:00 during one hour a week, it would makes sense. But the question of a.m. Thursdays while Map "B" obviously be stupid to use up all of where to put these ambulances shows the geographic demand pat- your precious unit hours during one remains. If you assume that the terns just one hour later on the same 60-minute period each week. But at geographic pattern of demand is day of the week. (This is not a the same time, demand for ambu- fairly constant, or completely computer model, but rather an actual lance service fluctuates wildly by random, chances are you will be plot of real emergencies experienced time of day and day of week, so it wrong, and from some patient's by real patients.) wouldn't be much more intelligent to perspective, dead wrong. If you see a "G" on the maps, it run the same number of units all the Every_ ambulance system has means a life-threatening emergency time. Somewhere in between is a strategy for placing its ambulances, where the system responded in eight solution that makes sense. The De- ranging from the Pollyanna minutes or less. If you see a "B" (i.e. mand Analysis Report for Kansas approach of giving every ambulance bad), it means a life-threatening City (page 30, from the American a permanent "home base" and emergency with a response time over Ambulance Abstract Service — leaving it there except when dispat- eight minutes. An "0"means a non- AAAS) illustrates the normal and ched, all the way to automated life-threatening emergency with a unusual patterns of fluctuation, by deployment systems which utilize response time under ten minutes, time-of-day, and day-of-week, for different deployment plans for each while a "P" (i.e. poor) refers to a life-threatening emergency calls, hour of the day and each day of the non-life-threatening emergency with non-life-threatening emergency calls, week, complete with mini-deploy- a response time over ten minutes. and non-emergency calls for all the ment plans within each hour depen- (Other maps use different response Thursdays for four months ending ding upon the number of ambulances time tolerances for different purposes.) Notice that during Hour 10 on FINALLY COLD THERAPY heavily along the west end of Skelly Drive, with scattered activity in the southcentral part of the city, while So Convenient, and So Simple almost nothing happens up north It makes others Obsolete! during Hour r on that with what Now compare that with what goes on during hour 11. Not much hap- pening on Skelly Drive, but you'd better be ready to head north. You can't cover the north, however, at the expense of the near south. xi s "A" /% Ma P and "B" show how i different things look in the same city, - , ! A on the same day, just two hours apart. Now let's look at the same hour (i.e. Hour 11, 10 a.m. to 11 y '7/v,, a.m.) during Fridays. Map "C" y shows the plan that worked for Hour �j 10 on Thursdays will be absolutely ,.. "/; '',,;,,,,,e wrong for Hour 10 on Friday. Hour ;/ 10 on Friday is not only tougher � geographically, but Tulsa's Demand s. ,, Analysis Report (not shown) also Cold Flex cold therapy wrap is so advanced. it sets new standards tells us that this geographically scat- in convenience and quality. Wrist or Knee injury, Cold Flex instantly tered demand will fluctuate in conforms to the surface ... try that with a bulky volume as well. Hour 1r oe ues a is y pouch reusable too. For more information about -"I.-, . Cold-Flex is expensive to cover, revenues are this inno�, ,ve product write or call today. mediocre, and you can expect to � k /illEX move the crews around more than usual to keep things covered. Nationally distributed by: North American Medical and Emergency Supplies. Inc. A more sophisticated system status plan is simply a plan for dealing with 113 Spring Bars Road Falmouth, Massachusetts 02540 (617) 540-6964 • different demand patterns by basing the around-the-clock deployment of Circle#38 on Reader Service Card 24 MAY 1983 jems Q ' 1 1 unit hours, and the geographic then four, and so on. Response time limits (call received to arrival): deployment of remaining units avail- Then we figure out, at each level Priority 1: G= 0-8 min. B= 9-over min. able upon the historical, geogra- of remaining capability, which Priority 2: 0= 0-1 0 min. P= 11-over min. phical and time-of-day fluctuations ambulance posts have the lowest in demand patterns. Of course, for priority, and should therefore be e� some hours in some areas there used for dispatching non-emergency almost is no pattern to be found.The calls.This effort helps to preserve the "O's," " " "P's" " , >> �° the B s, and G s best possible remaining coverage F scatter all over everywhere, and while minimizing post-to-post / demand volumes hit everywhere moves. �• ,., °•° except on the average. But this is a While we are at it, we recheck the ,. type of pattern itself, the toughest of demand fluctuation for that hour, B o all to deal with, and so we are forced and ask ourselves what level of oG o co o s•" I to get out the checkbook, spread out vehicle coverage is so low that non- G o G our units,and when the last unit is all emergency dispatches should be ' • we've got, park it near a freeway suspended until another unit comes / P .'\y exchange where it can't get to any back into service. Finally, we "make 1 1 location very fast, but can cover the a wish" as to how many ambulances ,,whole city with some reliability. we think would be necessary for safe �� o P G When I go through this process, I and effective coverage during that sl get my latest AAAS Maps and hour of the day,that day of the week I Demand Analyses,along with several — i.e. how many "unit hours" shall °I other useful reports and sit down we "spend" on this one of 168 hours Map A: For Day 4 — Thursday; for Hour 10 with the most experienced dispat- of the week? chers and street people I can find. I When this is done, we move on to show them the maps and the demand the next hour, and 167 "plans" later, °/ analyses for one hour of the day,one we have a pretty good idea of what day of the week, and ask them the the best and most experienced dispat- following question: "Knowing the chers and street people in the system z'• frequency and fluctuation of demand think should be done. We find some / for this hour, and seeing the maps of hours where the volume of demand o °'°-°o o "; historical demand and response time fluctuates so wildly, and where the G G GOB performance, if you only had one geographic distribution takes on no ambulance left in the system, where pattern at all, and during these hours a would you like it to be located?" we know coverage will be expensive ° G This, as it turns out, is an amazing and difficult; we will have to make G question. The "system status up for the losses somewhere else. / 00 G `\ committee" may often argue and But we also find other hours where I struggle for some time to come up demand volume is highly predictable r --��--- with an answer. They pick a spot and and where geographic patterning is o� then someone notices that, at that relatively concentrated. During these 11 time of day,the ambulance would be hours, coverage is easier to achieve il I upstream of the hotspot,and in rush- and if the system is heavily depen- °I hour traffic. Someone else notices dent upon fee-for-service revenues, Map B: For Day 4 — Thursday; for Hour 11 that another location would be the "profits" made during that hour downstream from traffic relative to a will help cover the "losses" incurred potential hotspot, but would have a in other hours. •l helluva time reaching the occasional If the whole thing sounds difficult, call on the other side of the city. But boring, frustrating, and sometimes notice carefully: if it takes that much seemingly not worth the effort, you / -- -1 analysis and discussion to make the are beginning to understand. High / decision when the pressure is off, performance is hard to come by °•„°,° when all the data is available, and unless money and "unit hours” are •f o o when the most experienced people in no object, and even with a blank town are making the decision, how check on unit hours,real high perfor- P G on earth does anyone think a single mance may still elude a system. In 0, G 0 ••°"o G Po dispatcher, under pressure, with no any case, when we are done with the G ,,, time and limited information, and process, everything is written down / ma.\ with six calls in progress is going to and displayed in a flipchart or G do any better? entered into a small computer When we are done figuring out programmed (i.e. Micad or Minicad) j where one ambulance should be, if as a system status management aid, is G '' it's the only ambulance left and it's and the result is the beginning of a QI 4:30 in the afternoon on a Friday, "system status plan." s i then I ask what should be done if you When complete, this plan serves had two ambulances left.Then three, dispatchers as a sort of algorithm for Map C: For Day 5 — Friday; for Hour 10 l. Free Catalog of Safety Aids �� ieaa Gatti on-line management of system around. Unfortunately, most are far deployment, just like a clinical closer to the old Kansas City model . algorithm guides a field paramedic. than to the higher performance end t ,� _;� It minimizes seat-of-the-pants of the spectrum. � ., redeployment, and benefits from the �., experiences of many instead of a few. Deployment Isn't Everything ,,:,,,;k..( Perhaps best of all, its effectiveness Our first experience with really can be measured and evaluated, and sophisticated system status manage- 1 � the plan continuously improved and ment was the result of being squeezed • fine-tuned. As long as every dispat- between a stringent city-imposed . `..._4� cher does his or her own thing, there response time requirement and a -- is no "plan" to evaluate — only several hundred thousand dollar Direct Safety's new catalog is a complete dispatchers. one-stop source for all of your safety equip- increase in union wages. Revenues ment and supply needs. Features first aid Every System Has a Plan, were fixed, costs were going up, and kits, oxygen supplies, eye, ear, head and response time performance had to be hand protection, traffic control signs and However Silly It May Be maintained. We had no choice except equipment, fire extinguishers, emergency Before we first began our work in to squeeze more performance out of lighting accessories, and many additional Kansas City, the plan then in use, fewer unit hours per wee)c. items to help you comply to OSHA regula- though not exactly written down Our second experience with system tions. Send for your free catalog today. anywhere, went something like this: status management occurred when Safety is our middle name There will be 14 ambulances on the street,24 we were asked to help a system doac� safety hours a day,7 days a week,for a total of 2352 equalize an otherwise good response ©om� unit hours of coverage a week. Every ambu- time record throughout various -�innw lance crew shall be on a 24/48 hour shift,and neighborhoods of the city. An effec- Department 171 assigned ambulance post,and shall relieve the tive and primarily black consumer 7815 South 46th Street crew on duty either on time or whenever that group demanded an investigation of Phoenix,Arizona 85040 crew returns to its post. There shall be no that system's response time perfor- 1 rules governing suspension of non-emergency mance in the poorer neighborhoods , transfer work or out-of-town dispatches. If there are 13 calls in progress and only 1 of the community. We were initially Circle#55 on Reader Service Card ambulance left in the system,even though the called in to perform that investiga- emergency load may be about to peak, it's tion, and the data showed that while N EVACUATION FOR okay to send the last ambulance out of town or to dispatch it to a non-emergency transfer the black community was receiving THE DISABLED call.Furthermore,if the only ambulances left comparatively good response time in the system are stationed at the most remote performance, it could be better. But •faster and least active posts, while all the other surprisingly, there was a remote and ambulance crews in the system are working wealthy neighborhood experiencing k •safer their tails off, it won't be necessary to *easier relocate any of the remaining ambulances, chronic response time performance especially if it is late at night and the outlying problems. than any crews are asleep. Finally, whenever any respon etime performance could be i-- stair-chair or ambulance completes a run, its crew shall :\ return to its permanently assigned post, better equalized throughout all areas `� hand carry regardless of whatever else may be going on of the city using some of the deploy- hand the system at the same time. (If a dispat- ment and management techniques we cher would like to experiment from time-to- had then recently R time by relocating ambulances during a shift, developed no rules would prevent such experimentation, elsewhere. E VA C CHAIR EMERGENCY DESCENT no policies would guide such experimenta- We went through the whole tion,and if the crews got mad because of the process with dispatchers and field smooth, easy descent with ex- inconvenience, or if the fuel bill were to rise people just as discussed above, and elusive Poymatic Traction'.15 lbs noticeably, lord only knows what might after some reshuffling of crews, light yet with 250 lb capacity,ship- happen.) pea via UPS fully awn all offers posts, and shifts, a new system status nstant access down ail fire exit The multimillion dollar ambulance plan was installed. The result was an stairs,risk mngt approved company that used that plan is now improvement in overall response 1982 Award Winner, Industrial out of business. But the "plan" is time, and even greater improvement Designers Society of America not all that uncommon. It is easy to in equality of performance through- see why systems using system status out the city. had "A lightweight,easily stored wheelchair to help plans like Kansas City's now discarded focused its attention, partly by the elderly or handicapped persons down high-rise fire-exit stairs handicapped case of emergency.down A high-rise plan usually don't write them down. ordinance, upon average response invalid can easily be evacuated by one assistant. This plan and variations on its theme, time TIME magume had been used in Kansas City for years, which performance e now know results in practice more Write or call now for more m/ormanon even in the presence of a million-dollar life-threatening response times for plus federal grant to centralize dis- patients at the dangerous end of the EDEN POLYMATIC CORPORATION patching of the old multiple provider distribution curve, and also 17 EAST 67th STREET system, promotes geographic inequity in NEW YORK, N.Y. 10021 Most systems use formal or infor- response time performance.) PHONE: (212) 734-6222 mal plans that lie somewhere in Everyone was generally pleased EVACtCHA1R is a registered trademark of Egan Polymeric Corp between the old Kansas City model with the initial results, and after a and the most sophisticated models few months of operating with the Circle#53 on Reader Service Card 26 MAY 1983 jems _. ..rte. i new system, fine tuning began.Using ambulance, hire another crew, and are obscured by the fact that where more AAAS maps and reports, we add another "unit hour" at the right the response time problem is occur- began to identify problem times of time and place. Sometimes that will ring will change depending upon day and neighborhoods which solve your problem,and sometimes it when it is happening. Since only a needed extra attention.We started by won't. handful of systems have a way of locating areas and times of day where Ambulance system response time combining and displaying this infor- we apparently had surplus produc- performance is not "good" or mation for analysis, and since most , tion capacity. (AAAS "solution "bad," in general. If you are having systems rely heavily upon i maps" highlight geographic areas response time problems, they are "averages," few of us have learned I and times/days where response times almost always occurring at some to see response time problems in a I j are unusually fast and where the times of the day/day of week but not diagnostically useful way. eight-minute maximum is virtually at others, and problems often repeat If I have a response time problem, never exceeded. The purpose is to themselves in fairly predictable and have no prospect of increasing locate surplus unit hours which can geographic patterns. These patterns system costs to solve that problem, be reassigned either geographically or by time of day to cover peaks and overload conditions.) _ As we proceeded with this fine- ? i tuning process, we ran into some ' P really stubborn performance i i problems that didn't seem to be , , solved by any amount of ambulance d, coverage. Looking more closely at ' the records of these specific runs, we 1" began to learn that the problem .�a.�.-- 0 ,, wasn't always a lack of ambulances, •"'�`'i . or even a lack of nearby ambulances. i I. �ti .". . -.2 ` With the help of our little MICAD computer aid, we were able to IL— - recreate a record of the status of the Your local Magnasync repre- system at the time any given call sentative will be pleased to dem- „. came in. That is, we can produce a onstrate the budget-stretching report which tells us, for example, HOW TO GET capabilities of Magnasync corn- that when the problem call came in at munications recorders. 12:35 a.m., there were seven ambu- A 30-CHANNEL RECORDER lances in the system, one with ON A 10-CHANNEL BUDGET. Magnasync/Moviola Corporation, mechanical problems, two on ' 5539 Riverton Avenue, North emergency calls, one on a non-emer- With the Magnasync 2000-Series, Hollywood, California 91601. gency call, and the remaining three you can buy a 10-channel. ma- Phone: (213) 763-8441. Cable: ambulances were available for MAGNASYNC Telex: 67-3199 dispatch — one at Post 12, one at chine today, and expand it to 20 MAGNA/MOVIO. A Subsidiary of Post 13, and one en route from or 30 channels later...when your ry County Hospital to Post 3. With that traffic warrants the extra capa- Craig Corporation. kind of information available to us, city, and when your communica- we could then take a look at the tions budget can provide for it. _ .r dispatcher's vehicle selection, the • conformance of the system with the The 10-channel TR-2010 is really 0'16".. original plan, and when we really a 30-channel machine, less the a were short of ambulances when a call extra plug-in electronics, the i, $, 4 came in, we could begin to find out 30-channel heads and selector ,__ why. panel, and the hubs, guides and — Sometimes the problem was posts for 1"tape. Nothing is corn- A simply a lack of sufficient ambu promised in the expansion, and — �,,. the lances to achieve coverage, or the 0 communications placement of remaining ambulances the result is a TR-2030 in every ► t recorder in the wrong locations. But not respect, with all of the advanced a 4 4 specialists always. We began to identify a whole features, the reliability and the list of factors which impact response performance you expect from .n.,,,,,∎ ■ time performance, some of which Magnasync. cost money to deal with, but most of rnaflaSYflc® which do not. If money is no object and you have .0,-, a response time performance problem in some neighborhood or during some time of day/day of week, you can simply buy another Circle#25 on Reader Service Card jemS MAY 1983 27 i then I must exhaust every possibility Was the dispatcher out of ambu- chers may sometimes spend less time for solving the problem before I lances when the call came in? Were in black neighborhoods than in other resort to simply adding equipment the available ambulances too far parts of the city, and therefore may and crews, or even to going through away?If so,why?Where were all the be less familiar with primarily black the hassle of revising schedules and other ambulances at the time, and neighborhoods. If that is the shift assignments. I must first in- point the time and location of the pin- what were they doing? problem, no amount of extra ambu- point and then proceed l d to of - 3. Plan followed or violated?Did lances will solve it.) problem,the causes. then can gI the problem occur because the 5. Are unit hours being wasted? devise a solution. The process I use system status plan is faulty or Are there plenty of ambulances on relies extensively upon statistical because the plan wasn't being duty that hour, given the number of relies axle from the AAAS re dal followed? calls received, but for some reason p 4. Dispatcher error? Was the availability is lacking? Figure 1 ting service, and I follow a step-by- nearest ambulance dispatched? Were shows a sample "Hospital Drop step path that is too lengthy to be the routing instructions accurate? Is Time" report from the AAAS detailed here. However, several of the crew or dispatcher unfamiliar service designed to detect hospitals the most productive steps can be with that neighborhood? (One whose method of receiving patient described as follows: HAAS report analyzes response time excessively delays ambulace crews. 1. Define the problem specifically. performance by dispatcher by district As a result of this particular report,a I must know exactly when and where or neighborhood, to detect perfor- "uniform hospital drop polic y may the response time problem is occur- mance problems which may be the be developed and adopted by all ring before I can begin to diagnose it. result of a given dispatcher's lack of hospitals, reducing unnecessary out- Is there a pattern? familiarity with a specific neighbor- of-service time to the tune of 2. Bonafide system overload? hood. For example, white dispat- thousands of dollars in lost unit hours per year. Figure 2 Figure 2 analyzes "Hospital Drop Time" too, but this time by senior HOSPITAL DROP TIME BY EMT paramedic. There is no "right" time FOR MONTH: 12182,SYSTEM: KANSAS CITY MO/MAST EMS at the scene, and there is no "right" hospital drop time either. Every call Senior Ave.Time Arrive Ave.Time Arrive is different. But when you are Priority Hospital To In Over 15 Min Hospital To In Over 15 Min. EMT hill #1 42 1&2 Service-ist Resp Count Per% Service-All Count Per% looking m d or 50 runs per meong 204 14 7 , 21 13.90 7 33.3 15.00 9 42.9 and one medic averages twice as lo ng 247 17 11 - 28 15.54 258 22 11 42 - 15.54 24 35.7 22.86 15 53.6 at the hospital as everyone else in the 20 258 :.q i 2 57.1 19.29 29 69.0 5.00 0 0.0 11.20 1 20.0 company, it's worth a conversation. 2s, ' ° 1 '$.°° , 188.8 6.0 , 100.0 Most medics in our systems are used 262 3 1 4 8.25 0 0.0 ` 11.00 264 ,6 8 - 14 18.25 3 20.50 7 50.0 1 25.0 to these reports, and posting alone 266 0 3 3 8.00 0 0.0 ' 264 6.00 0 0.0 seems to do the trick. But believe me, 417 2 2 4 8.25 0 o.0 250 ° a.0 the first time we ran these reports, 419 7 8 `15 13.20 4 26.7 22.60 7 46.7 the numbers were all over the lace. 213 Y 2 17 :29 13 72 0 34.5 214 15 15 30 20 53 8 48 18- 62.1 p 20 66.7 2580 21 738 If you think all hospitals are about 405 24 17 41 1000 7 f 17.0' 4.66 17. 41.5 the same in hospital drop times, 215 18 15 31 13.18 8 25.8 256 16 11 27 1418 4.74 10 32.3 think again. In one city, we found a 209 23 10 i t 40.7 18.63 18 66.7 27 1447 8 40.2 25.85 19 87.7 hospital that averaged triple delays in 217 16 13 29 73.24 10 34.5 217 '14 6 10 1324 37.66 19 65.5 drop times, no matter who the 407 22 16 38 6 60.0 9.60 8 80.0 medics were. This added up to over 407 17.92 21 55.3 19.39 22 57.9 Q 17 14 '31 `14.45 10 . 323 3023 14 45.2 $150,000 per year in lost unit hours 219 22 14 36 1517 16 44.4 19.89 due to that hospital's methods of 220 26 19 ;45 13.6725 69.4 259 2 0 2 14.50 7 378 18;49 26 57.8 accepting patients. Other reports 221 21 14 3s 1450 a io.a 29.50 ; '�o detect bad habits which hurt system 203 12 16 28 17.82 11 '393 2021 '13 40.4 performance. I call one such report 252 4 2 6 867 0 18.00 2 33.3 the 257 22 12 38 13.67 11 260 "paramedic honey locator" 210 15 15 30 19.70 17 56.7 21.18 26 68.4 .223 6 8 21.93 21 70.0 report, since it can detect a 14 11.79 5 35.7 '17.86 250 5 4 9 1388 2 222 15.44 6 57.1 paramedic who is normally fast in 4t5 2 2 4 10.75 0 0.0 1175 3 33.3 hospital turnaround time, but who 207 t2 10 22 - 13.41 4 18.2 - 22.64 14 63.5 routinely takes longer at a particular 205 24 15 39 13.26 226 11 26 37 1 282 18.54 22 56.4 hospital that is normally fast for 253 .13.22 9 24.3 15.14 --14 37.8 4 5 _9 13.89 4 44.4 16.67 6 66.7 everyone else. I presume the presence 227 0 1 1 37.00 1 100.0 37.00 p 231 0 1 1 1 ,00.o of a "honey." 231 12 21 33 14.0000 15 40.0 .17.00 19 100.0 6. Equipment failure? Are we 235 12 7 19 14.58 10 526 19.63 t3 68.4 plagued by equipment failures? How 239 7 5 12 16.67 6 50.0 18.92 6 500 long does it take to get a unit back in 241. 13 10 23 `14.96 8 34.8 21.04 12 52.2 service? How often does one ambu- 413 25 19 44 . 15.52 20 45.5 17.07 242 2 0 2 9.00 0 0.0 10.00 23 52.3 lance assist another because the 249 19 12 31 13.71 10 32.3 18.26 18 1 50 58.70 former's cardiac monitor won't totals: 534 453 987 14.44 350 35.5 19.73 541 54.8 work, etc.? 7. Demand pattern change? Has 28 MAY 1983 jems I li the demand pattern begun to change Most of the time, you can do better might be that you finish a difficult for this location and time of day/day by simply abandoning the past struc- two or three months of initial experi- of week? Was there a seasonal fluc- ture in favor of an initial system status ence only to find out that, whatever tuation that we can prepare for?Was plan developed by your most expert- else you may have done, you have there a special event that we failed to enced dispatch and field personnel, not actually implemented the SSP, account for? utilizing the process discussed earlier and you can't be sure whether the 8. Traffic flow problem?Were we in this article, together with the problems you are still having are the upstream when we should have been essential displays of demand pattern result of the SSP or the result of not downstream? history. following the SSP. If you don't 9. Out-of-chute time? One stan- Every time we have tossed out an follow the SSP, you can't fine tune dard AAAS report routinely displays old deployment plan and replaced it it. average times from unit alert to en with a new system status plan Fine tuning your system status route status, organized by senior designed that way, the improvement plan is, I think, fun. In the first paramedic name and number. For has been instantaneous and round of planning, everything was life-threatening calls, this time dramatic. Kansas City, for example, based on the expert judgment and should be under 30 seconds on the (a 100 percent paramedic system prediction of the most experienced average, and never over one minute. providing both-emergency and non- people available, with benefit of Lost time leaving the chute can never emergency work), has managed detailed demand maps and demand be made up, no matter what you do. consistent improvements in response analyses. The second time around, In one case, we found what should time performance, both citywide and adjustments to the plan can be based have been obvious to everyone—an by the city's mandated councilmatic upon the initial plan's actual results. ambulance post location where the districts, while shrinking unit hour During fine tuning, you can shift crew quarters were on the second coverage from 2352 unit hours per some posts around, shift some unit floor and at the other end of the hall week down to the level currently hours around, and take numerous from where the ambulance was reported at 1600 hours per week. For steps to simultaneously reduce parked. With brilliance, we moved financial reasons, the system had to unnecessary post-to-post movement the crew quarters and solved the drastically cut either unit hours or while squeezing out any remaining problem. Sometimes our work isn't wages, due to a declining city subsidy performance problems. very sophisticated. and a badly needed commercially In most systems, you will need 10. Dangerous non-emergency financed $2-1/2 million total equip- about three months of data per fine cutoff level? Is the problem repea- ment replacement. In that city, late tuning cycle, which means that you . tedly happening when several non- runs cost the operator$10 per minute must stick with the current plan as emergency transfer runs are in in payment deductions, and chronic closely as possible. Of course, the progress? Could the problem be late runs would cost the entire initial plan should be watched very fixed by simply raising the non- contract. Under such circumstances, closely during the first few weeks to emergency cutoff point to a safer performance is almost inevitable, or detect any obvious glaring flaws level? at least mandatory. (Jay Fitch, which may need midcourse correc- 11. Change post locations?Could manager of Medevac's Kansas City tion. (In this case, it is good to "stay we solve the problem simply by operations, believes that 1600 unit the course," but not at all costs. The moving an existing ambulance from hours is about rockbottom for that important thing is that, if a mid- a less frequently utilized post loca- city, and future fine tuning will focus course change is necessary, it should tion into the problem area? This is upon stabilizing coverage, seasonal take the form of a change in the plan the simplest move, since it requires fluctuations, and reduced post-to- — not an authorized departure from no reshuffling of shift schedules. post movement.) the plan. That way, subsequent data However, care must be taken since Implementation of the first can be used to assess the effectiveness you may simply relocate the response sophisticated system status plan of the revised plan — not the old time problem to the other side of (SSP) usually requires a major plan that was abandoned.) town. The AAAS "solution maps" reshuffling of everything from With enough time and experience, help make this decision by locating ambulance post locations to shift and enough quarterly fine tuning neighborhoods where problems schedules, compensation plans, crew efforts, the plan will begin to take on rarely occur and where response change methods, inventory control, seasonal variations, and will account times are extra rapid. We will and just about everything else that is for special events such as Fourth of deliberately adjust the system to sacred in any established ambulance July, Christmas, New Year's, and eliminate emergency response times service. It is traumatic. Rolling Stones concerts. After a year over eight minutes, even if doing so Furthermore, during the earlier or so of development and fine results in a slight increase in either stages of the plan, there will be quite tuning, you will have squeezed, overall average response times or a few seemingly unnecessary post-to- poked and prodded about all of the slightly decreased coverage in an post vehicle movements, mostly performance you can get out of your apparently overserved neighbor- occurring in the middle of the night system, at least in terms of response hood. when a 24-hour crew is trying to time performance per unit hour. When first starting out, the past sleep. The tendency will be for From then on, small semi-annual plan of deployment is normally so dispatchers to delay a post-to-post adjustments should do the trick, and poorly documented, poorly concei- move if another crew is nearly ready probably without fanfare or too ved, poorly followed, or all three, to clear from a hospital;to the extent much gnashing of teeth. that it makes no sense to use the past that the delays are frequent, the SSP The reality of instituting sophis- system as a basis for refinement. isn't being tested at all. The result ticated system status management is jams MAY 1983 29 considerably harder than you might absolutely involve extensive off-line over- think. Dispatcher duties and respon- simulations. Our system status haul labor contracts, shift schedules, sibilities are more than doubled. manager certification test covers Salt We have had to completely over- Dispatchers of moderate ability will Lake City-type telephone compensation programs, and shift bonus bite the dust. (The new job is so medical vocabulary,protocols,a plans, and we adapted way a shift bid different that we hate to call these compressed 200-run system simula- flights for flight attendants. process from the way TWA bids people "dispatchers," •we prefer tion covering every conceivable eight-hour "system status managers.") The complication. Certification requires shifts, u12-hur shifts,h124/48 10-hour dispatcher training program") must zero-defect g performance. hybrids. In one city there was nearly Ail`d�yS15 Report "'' how much fee-for-servtce income goes during Hour 11 k. with the hour, while those"high aver- Kee ,You will rs Iays Most people have never seen an ages" and 'maximums" tell you how look rpnuch like Mon ays,laSunda,t s11'1 analysis )eke this, and some much you are going to have to spend to don t surprises are usually in store.On look like Sy has its and so forth G`uy's reports,Priority I'calls are "life- fou d coverage during that hour,'if Every community has its own patterns,°:,` threatening emergencies"; priorit II You don t want an response time both geographically and around-the- Y failures, that is. If you break even clock. -Jack Stout calls are "emerge-threatening"ewer- geneses"; and Priorities III and IV are . �' two kinds of non-emergency transfer. ' 'DEMAND ANALYSIS REPORT FOR DAY 4-.THURSDAY "Total average" means the rounded ' ' PPRRIOR I pert' a row PRIORITY II off average calls per hour during that ;our Average ratat TOTAL EMERGENCY Igge Loa hour on several months of Thursday Average Max MM ray Average Average Average Max Mtn Average 3 0 map To calculate the-"high average," 01 E ',1.00 1.00 4 0..00 0 0.50 1.00 0.00 1 0 '1.50 3.00 000 0 - 0.50 1000 0.00 1 0 '0.50 1.00 000 1 0 0.50 1.00 Average 1 0 pick one Thursday out of each month 02 b oso 1.ao °"0.00 1 0 0.50 i.00 p.00" 1 0 o.so 100 0000 a' 0 having the highest number of calls that ;03 1.00 100 . 000 2 0' 0so ; 1.m 0000 t 0 1:50 100 hour, and then average those together. 04 o� �:� ono 1 0; 0.00 0000 0.00 0 0 100 goo o �' o "Hi gh average" is basically a normal 05 �, 000 0:00 0.00 R 0 1.00 zoo 0.00 2 A high volume-you won't get it all the 06 0.50 1.00 0.00 t 0 1.50 100 0:00 2 1 150 300 100 2 1 time, but you will get it about once a 08 1.00 2.00 0.00 2 0 0.50 100 0.00 1 0 1.50 2.00 1.00 "2 1 month. 1.00 200 0N 2- 0 1.00 200 0.00 2 0 150 3_.00 X000 3 ,Low average" is fike""hl O.4007 9 0.50 1.00 0.00 1 0 2.50 400 1.00 4 1 3.50 ,5 Q 200 5 0 age," w a t we ,,high aver- 10 1.50 3.00 0.00 3 0 o.5r ,1.00 0.00 1 2 p pick out.the lowest 0 200 4.00 0.00 . 4 0 1.5� 2.00 1.00 2 1 1.00 2.00 0.00 2 0 2.50 4.00 1.00 4 1 volume Thursday of very month and Y2 1.50 a:00 0.00 3 0 2.50 5.00 0.00 5 0 4.00 800 000 'e o average those. "Love average"is sort of 13 1.50 2.00 0.00 3 0 1.50 3.00 0.00 3 :0 200 400 0:00 3 0 a normal fluctuation too. 14 1so 2.00 1.00 2 1 t. The "maximum" 15 2.00 3.00 1.00 00 2.00 000 2 0 250 3.00 000 3 2 and "minimum" 3 1 140 2.00 0.00 2 0 2.00 5.00 200 5 1 columns simply list the most and least 17 1.50 3.00 000 3 0 1.50 x.00 100 2 1 2.50 4.00 1.00 4 16 1.00 2.00 000 2 0 1.50 3.00 0.00 3 0 200 400 000 4 ',2 calls we have had during a s Of alI the Thursdays• g specific hour 19 1.50 3.00 0.00 3 0 - 1.50 300 0.00 3 0' 3.00 5.00 100 5 1 0 4.50 3.00 0.00 3 0 1.50 3.00 0.00 3 0, 2.50 r 5.00 0.00 5 -(0 To help understand how to read this 20 41.50 3.00 0.00 3 0 1.50 2.00 100 2 1 250 4.00 1.00. 4 :`1 report,let's look at hour 12(11 a.m.to 21 1.50 3.00 0.00 3 0 2.00 400 0:00 4 0 4.so 7.00 2.00 7 -2 noon On Thursdays;. They've been 22 1.00 200 0.00 2 0 2.00 Zoo 1.00 3 1 3•00 5.00 1.00 5 i averaging I A life-threatening emer. sTo 23 1 0 3.00 0.00 3 o 1.00 2.00 021 2 0 2so 4 0 t:oo a_ 1 gencieS, 2% non-life-threatening emer- roE�s 1.13 2.13 0.13 . 3 0 1.19 2.17 0.21 gencies, and only one non-emergency TOTAL EMERGENCY 5 0 221 3.79 0.p 8 0 call during that hour. tam High , p T� P H R N T�TOT N-RESPONSES Looking at "averages" this hour Average age Average Max Mm Average Average Average Max Min A Average PO, Parted seems pretty easy to deal with. 00 1.50 3.00 0.00 3 0 0.50 1.00 0.00 1 0 30 A000 Max o terms of fee-for-service revenues things 02 a5° 00 200 0.00 2 0 050 1 00 00 00000 1 0 �� 2.� 000 1 0 0.00 3 0 Look pretty steady during that hour.But 03 1 0 3.00, 0.00 3 0 050 i.00 0.00 i 0 1.50 3000 am look again. Once a month the life- 04 050 1.00 0.00 1 0 0.00 0.00 000 0 0 050 7.00 0.00 2 1 0 threatening emergencies will double, o•� 2 0 1.00 2.00 0.00 2 0 0.50 1.00 0.00 1 0 050 '200 1.00 2 t 0 and so will the non-life-threatening o 1i50 3.00 100 3 1 0.00 10000 0.00 0 0 2.00 3000 ioo 3 'o emergencies. These fluctuations will be pretty emergencies. and If they begin to 08 130 3.00 000 3 0 1.50 0.00 3 0 1.00 2.00 1.00 2" 1 prett at the 09 3.50 5.00 2.00 5 2- 3.00 0.00 3 0 3.00 400 200 4 2 same tune, You're in 10 2.00 4.00 0.00 4 0 2.50 4.00 1.00 4 1 3.50 6.00 3.00 6 3 3.5o s00 i trouble. 71 Let's look further. Hour 12 isn't too 12 4:00 8.00 0.00 8 0 2.00 2.00 0.00 2 0 5.50 10.00 1.00 6 1 rough as far as non-emergency transfers 13 2.00 4.00 0.00 4 0 2.o0 3.00 0000 3 1 4.5o 7.00 2.00 7 1 go, and non-emergency work is pretty 14 2.50 3.00 i.00 3 2 1.00 2.00 0.00 2 0 3.50 6.00 1.00 10;2 steady. Furthermore, non-emergency 15 3.00 5.00 1.00 5 1 24°00 3.00 Q� • 450 6.0 2.00 6 3 demand both earlier and later in the day 16 200 4.M 0.00 4 o 1.50 3.00 0:00 3 0 soo 6.00 0.00 6 0 usually goes higher,so you should have 17 2.30 4.00 1.00 4 1 0.50 1.00 0.00 1 0 2.50 4.00 1.00 4 1 some extra unit hours available if your 19 3.00 500 1.00 5 1 1.00 S s 2.50 5 00 0.00 5 0 0.50 7.00 0.00 I. 0 4.00 7.00 7.00 7 ,1 system,like Kansas City s,•is an all ALS system. In general, Hour 12 is going to 4.50 7.00 2:0000 4 2 0.5500 1.00 0.00 1 V 0 300 600 0°° 6 1 0 be a problem,but some hours ale much 22 8.N 5.00 1.00 5 1 0050 1.00 0.00 1 0 3.00 5,00 1.00 5" 1 worse. One more thing: those "total 50a 700 3.00 7 3 2 4 1.00 4 1 1.00 2.00 0.00 2 0 2.50 4.00 averages" will tell you, pretty reliably, Totals 1.90 3.79 0.63 8 0 0.85 1.71 0.17 4 0 1.00 4 7 2.33 4.67 Loa 10 0 30 MAY 1983 jams 4 4 `( r f i k a strike due to the loss of some 24/48 always the average response time to system status management, and you shifts, while in another labor got hide behind. will get it. mad because some eight-hour shifts System status management, done As I always say in pre-bid confer- were being lost to 24/48. In another properly, takes a whole lot of work, ences when asked by private ambu- case, crews had actually purchased requires constant attention, may lance operators how my client city homes near their permanently strain labor relations, and is really wants the dispatching done, no one assigned posts. We eliminated easy to screw up. No wonder no one cares how many ambulances you put permanent post assignments. developed it until they had to. on the street, how you dispatch But the ultimate purpose of There are probably hundreds of them, or what you do with the I'I sophisticated system status manage- ways to prove that system status money we pay you. When the phone I ment is very simple: we want our management won't work in any city. rings, we want a qualified paramedic ambulance crews and equipment to But there are four ways that are talking to the caller, we want a full- be they located where and when the are guaranteed to fail: blown paramedic ambulance on the needed as often as humanly possible. 1. Try buying part of it. An scene within eight minutes 90 percent What's the alternative? Being organization will make system status of the time, we want superb equip- somewhere else. management work when its financial ment and performance, and no one stability and very existence depend cares how you do it. If you can put a • Failure Guaranteed Four Ways upon it. Under any other conditions, guru on a hill who can get two ambu- If system status management is system status management is just too lances to handle thirty thousand calls such hot stuff, where has it been all much trouble. If your city wants a year, go to it. But screw up a little this time? The uncomfortable but good system status management, and it's ten bucks a minute. Screw up grownup answer is that organizations turn over your dispatching and field a lot, and you're out of business. I ', learn to do what makes money or operations to a qualified operator, 2. Separate dispatching from what it takes to survive. You can hold that operator financially• operations. The absolute key to count on one hand all the cities that accountable for every late run, forget system status management is the fine their ambulance providers for average response times and focus operation of the dispatch center and poor response time performance. upon maximums, and be ready to the quality of dispatch personnel. Government operations almost never bury the operator for chronic perfor- The company that does the dispat- compete for survival, and there's mance failure. Then forget about ching and the company that runs the = a �Kee our defibrilltor ' The reliability you expect. The quality we insist on! doing more good thpfl iarrrt. At ADSCO we are dedicated to one goal. To provide you with the best quality product possible, at a �- reasonable cost, and service second to none. ' Ortho-Board features; Quality President ADSCO '- s • Six coats water proof resin finish ® � �� • Serial numbers for identification t,�,, • Nine ply mahogany hard wood ® .� 4 �' ,. 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Allowing for extended specifications and prices,call or write:DONALD ,'' L.CARLSON DESIGNS,Emergency Medical PR ER ��` product life and cost effectiveness! 9 GROUP Division,12809 Eagle Ridge Drive,Burnsville, 2 ,� $65.00 includes shipping. MN 55337.Phone:(612)890-1360 or call toll free �t`o 0- 4.`'' ADSCO with order 1(800)328-3773 �N`E'N J er Box 173 Eden, Utah 84310 )...,,,,,,,~74 (801) 745-2611 DEALER INQUIRIES INVITED Circle#45 on Reader Service Card Circle#49 on Reader Service Card jems MAY 1983 31 i r ambulances have got to be the same about their company. People get they will jeopardize their own patient company, and it's that company that used to the old ways. Low perfor- to make a point. must be responsible for developing, mance is less work than high perfor- These are the same people who, revising, and implementing the mance. I know for a fact there are rather than helping to work out the system status plan. It's just too ambulance personnel who have bugs, wag their fingers at dispatcher complicated to work any other way. deliberately delayed an emergency error, who make anonymous calls to If you think it isn't that complicated, response for the sole purpose of reporters in hopes of making their then you clearly don't understand, "proving" that the new plan won't company and its effort to improve and you will probably never know work and that more unit hours are performance look foolish, and who what went wrong. needed. These people are, perhaps were recently caught driving 35 mph, 3. Try it with employees who care without realizing it, dedicated to red lights and siren on an open road little about their patients and less their own company's failure. And and light traffic, on the way to an EMERGENCY FIELDCARE emergency. If you have such people in your company, get rid of them or you cater have to them.a choice:So long as they are on your payroll,they A is\ ,, , , have the power to prove you wrong. I have seen them do it. ,,, 4. Try computer simulation. I do � 17 not recommend or support the use of $ computer simulation models to �� determine ambulance coverage t patterns and post locations. Such �� models rely too heavily upon theo- retical travel times to optimize �� . distribution. Our experience has convinced us that a committee of experienced dispatchers and street people can outperform a computer • .., simulation every time if they are provided with the demand pattern statistics, demand maps, and other informational tools which, when combined with human judgment and –1 aik-41111111111h t, experience, take into consideration ,�,; ✓ ,i ;, traffic flow patterns, complex street names/numbering systems, familia- rity with area, and a hundred other factors that go far beyond the scope The Rescue Services Pac. . , of practical computer simulation. Conclusion � When thinking about system '� v. status management, keep in mind pFkq#z&+ � uX MMtfL�T - �� r --- z ' that regardless of how you staff and .. 0 "� deploy your ambulances, you are • ��, _ � ' using a system status plan. System It NQ%I, status management isn't "good" or L! c-� ice$°it j "bad" — it is inevitable. Your plan r �� r may be simple and stupid, complex . n and stupid, simple, yet effective, or r � 1/4t.ii. f � > yr . + �, `),f a �� ii! possibly even complex and even ..., ® '-,Jul , ��, 1 more effective. There are many good reasons for sticking with a more simplified ��,...,, m �.A ..z a_ ter.., approach to system status manage- The RSI Field Pac Kit ment. Only the best managed organi- zations with the most dedicated personnel should even attempt to use the most complex and sophisticated RESCUE SERVICES INC, models. But almost every system can ! • benefit from thinking things through — QUALITY EMERGENCY EQUIPMENT — with the maps and the demand anal- P.O. Box 16 • Auburn, California 95603 yses and the other reports,even if the 1.800-824.8568 In Calif.,Alaska&Hawaii.916.823.8672 Collect result is an elegantly simple but more effective approach to deployment. ❑ 32 MAY 1983 jeniS Circle#27 on Reader Service Card A a • i ■ .I , 42x4 ;� ' Jack Stout's Ten Standards s of Excellence -1 Measuring Your System I Jack Stout has long been involved in designing and implementing EMS systems. With ,, :, ,, his company, the Fourth Party, he was the major force in implementing the Public Utility exists, yet no individual or certain t za- I tion is at fault, you can be certain that Model concept for providing prehospital care in Tulsa,Oklahoma, Little Rock,Arkansas, the organizational structure itself is Kansas City, Missouri, and most recently, Fort Wayne, Indiana. He has lectured seriously flawed. In many EMS sys nationally on the topic of the Public Utility Model and EMS system design,and will be a terns today, it is entirely possible to I regular columnist for jems beginning this spring.His latest article in jems was an account have each element of the system per- of the Hyatt Regency Hotel disaster in Kansas City, which he witnessed. The following article is based on a presentation he made at the November 1982 forming its task admirably well, while meeting in New Orleans of the American Ambulance Association. the overall system performance fails miserably. In such cases, there is no point in looking for someone or some organization to blame. Instead, the ome months ago I had the When I was later asked to present reorganized so that accountability system itself must be restructured and pleasure of visiting the Syracuse, "Stout's Standards of Excellence" at New York operations of Eastern the November 1982 New Orleans meet- exists for every important aspect of system performance. Ambulance.Eastern's Chief Executive ing of the American Ambulance Asso- Officer, Marty Yenawine, had invited ciation, I decided to put some real How to Use This Rating System me to go salmon fishing, but the effort into analyzing my own thought It depends upon your purpose. If weather turned sour, bitter cold and processes,and the result is this modest blowing snow, so Marty asked me to attempt to apply numbers and scores to you your simply interested in system to look over Eastern's operations with a a process of judgment that is,in truth, out your better nl EMS system t of critical eye. During my stay in far too complex for this kind of sim li- gain a hings personal going, the t there is Syracuse,I talked with people working fication. Even so, as I review the P how things are going, then there is in all aspects of Eastern's business and contents of this article, I find that the nothing ards yourself.wrong with using Stout's Stan- in operations.Eastern's people were _.various criteria are, in fact, those that dards disagree unusually relaxed, open, and offered really matter.Other things matter too, If weighted the vari usth the way I have their own observations and construc- but not as much. And while I might weighted the various criteria, reassign tive criticisms in a casual and relaxed quibble with myself concerning how I your own weights. For personal use, manner. Obviously, Eastern is a com- have distributed scoring g raise Stout's s Standards are a good be over- pany where it is okay,even encouraged the various criteria, I have to admit looked. However, if you may Stout's out's for an employee to identify a problem that this evaluative instrument comes Standards to rate your own system, do in plain English so that solutions can awfully close to describing how I look not try to compare the�co e you gave be pursued. at and evaluate the performance capa- your system with the score someone Weeks later,Marty was still squeez- bilities of modern prehospital EMS ing free consulting out of me by trying systems, regardless of t else gave another uystem.that to get me to talk more about m "find- YPe or design. comparisons require that the same ings" over beer. In the course of his Excellence" are intended tto evaluate evaluator rate both systems being efforts, he observed that I apparently the performance of an entire prehos- compared. employ a fairly elaborate, though per- _ being haps informal,set of criteria for evalu- company, not an EMS aDepartment, strictly as an internal assessment tool ating a prehospital care system. I said not a fire department EMS operation, You can use Stout's Standards that was probably true, but I assured P , do"before"and"after"comparisons that was s probably ob way u looking but I at pre- not any single component of an EMS of the same system.Your scores maybe Marty that systems would bear system. In far too many American way off compared to scores for other resemblance to the federal govern- nizatio n lthat there is responsible single forr all son ofstheusame sys etm, "before"ompar ment's "Fifteen Components." (The aspects of way you look at a problem has a lot to Such communities can expect to find valid as a measure should by reasonably m improvement or do with your ultimate ability to solve very low scores on several criteria while deterioration that problem, and I have always felt scoring very high on other criteria. >mprovement or that the federal and Mandatory deterioration, provided erf same Components," as a way of looking ry When a serious performance problem both or organization performed at p both assessments. While metropolitan or large regional an EMS System, did almost as much damage to our industry as the federal EMS systems stand the best chance of money did good.) by Jack L. Stout scoring high, Stout's Standards can and should be used to evaluate rural 84 JANUARY 1983 jems EMS systems as well. Rural EMS a system were entirely free to its users third-party payors, or even the heirs. systems, even fully regionalized sys- and to the taxpayers. Complicated terns, can rarely achieve the response recoveries, premature death, and Summary of Criteria time performance or clinical excellence astronomically expensive long-term Stout's Standards of Excellence of a highly organized metropolitan sys- disabilities are the by-products of poor employ ten general criteria of system tern, simply because the low popula- prehospital care EMS performance.At performance, several with multiple tion density, poor economy of scale, any price, these consequences are no subcriteria,with a possible score of 100 and relatively low frequency of life- bargain to the consumer,taxpayer,the points for the"nearly perfect"system. threatening emergency cases work against high-performance system development in rural areas. On the Summary Scoresheet other hand, many of these barriers to rural EMS development can and have Stout's Standards of Excellence been overcome by more aggressive regionalization of production,finance, Name of Prehospital EMS System: ' and operational control. Therefore, Stout's Standards can be applied to the Organization Performing Assessment: rural EMS system, sometimes as a means of demonstrating the true costs, Supervisor in Charge: in terms of lost performance,of main- taining a hodgepodge of tiny but nearly Dates of Assessment: From To autonomous municipal, county, and even township based operations. On the other hand, the more effectively organized rural systems can use Stout's Possible Group Standards to demonstrate their ability Score Score to approach some of the best known urban EMS systems on all but a few 1. Clinical Performance 15 criteria. 2. Medical Accountability 6 A Warning About Efficiency 3. Dispatching and System Status Stout's Standards, objectively and Management 15 expertly applied,can give you a pretty 4. Access, First Responder and clear idea as to your system's perfor- Citizen CPR . 15 mance capabilities. But Stout's Stan- dards tell you nothing about your 5. Disaster Capability 8 system's efficiency. As Alan Jameson 6. Personnel Management Practices 10 is fond of saying, "An idiot with enough money and enough time can 7. Stability, Reliability and produce performance." (The federal Fail Safes 7 EMS grants programs demonstrated 8. Pricing Policies, Billing and that such is not always the case.)In this Collection Practices 5 writer's opinion, questions of per- formance are more important,because 9. Response Time Performance 15 the nature of this industry's work is 10. Public Accountability 4 critical.But performance at any price is certainly not the answer,and perhaps a TOTAL SCORE 100 sequel entitled "Stout's Standards of Efficiency" may be in order someday. In any case,efficiency is directly related to performance; since an expensive Additional comments and observations: system may still be efficient if it per- forms extremely well, while an inex- pensive system may be a bad deal, financially, if it performs more poorly than its equally inexpensive counter- part. In short,how your system scores on Stout's Standards of Excellence tells "' you nothing about whether your system is a "good deal" financially. Exception: Any system that scores poorly probably creates more costs than it could possibly save even if such jems JANUARY 1 oS it u. • r � ,, Stout's Standards of Excellence(continued) 1 ``�� t 3 a 1 • 1. Clinical Performance(possible 15 points) ( ) An ambulance system's actual clinical performance is extremely physicians who has responsibility for monitoring I difficult to evaluate,except on a diagnosis-specific and case-by-case directly our system's street performance.(zero or 1 point) basis.Many systems handle certain kinds of cardiac cases very well, B. Medical audits are regularly but tend toward poorer performance when faced with serious g Y(ysi several each week) SCORE 2A trauma.Some may do well with emergency childbirth, but not so conducted by an emergency physician who is not affil- well when dealing with diabetic coma or insulin shock. Realizing affil- iated with or on the payroll of any ambulance provider these complexities,this scale resorts to simplifying by determining organization.(zero or 1 point) whether clinically sound medical protocols exist at all;whether on- C r widely known and convenient procedure exists SCORE:28 tf board equipment,communication systems,and inventory control ^hereby physic ane1ornfield medic can request that personal receiving facility physician, patient's systems are compatible with sophisticated medical protocol; and formal physician-supervised audit be performed relative finally whether field crews are even potentially capable of clinically to a given case,and such audit shall be performed.(zero excellent performance. or 1 point) 1 I The rating scale favors systems where all field crews are paramedic,and where each crew handles both emergency and non- D. At regular intervals,the physician(s)responsible for SCORE:2C emergency work,since other types of systems result in a community medical monitoring and clinical quality control in our served by a combination of "elite" emergency crews and less capable so-called non-emergency crews. The overall clinical per- system reviews multiple cases of a single problem- oriented or diagnosis-specific basis in order to assess our I formance capability of a fully professionalized service system is system's roble s. (An to deal effectively with dor specific"good"in obviously greater than that of a system which is only partly problems. (An EMS system is not"bad"or"good"in professional. general — it may do well with some types of emer- gencies,but not with others.)(zero or 1 point) A. Select the sentence which most nearly describes Score E. The findings and recommendations resulting from SCORE:2D • your community's ambulance system. our independent physician-supervised may call for changenmedical pro ocols,specfic in- • All ambulances in the system(emergency and non- call 1 A service training for individuals or the entire organization, emergency are capable of full paramedic performance call for equipment additions or deletions or change,or at all times. (Score 10 points) may require the suspension or termination or other • Paramedic units are dispatched to all emergencies; restrictions on personnel, and such findings are not policy and BLS units handle non-emergencies.(Score 4 points) merely advisory,but have the force of binding must be implemented.(If your physician ovens ght is not • Paramedic units are normally reserved for life- fully independent of the provider organization(s),score threatening emergencies; all other emergencies and non-emergency transports are normally handled by BLS this zero. Similarly, if medical audits are not regularly crews(Non-transporting performed by a physician expert in emergency medicine, BLS transport crews rate the parsame)c(teams 2 assisted points) by or are merely "paper audits" conducted without the mandatory presence of crew members involved in the B. Select the sentence which most nearly describes case,also score zero here.)(zercor 1 point) your community's ambulance system. F. Emergency physicians a' the principal receiving SCORE:2E facilities in our area are not allowed to provide medical • Medical protocols are current, clinically sophisti- SCORE:18 control(via radio)to field personnel without first demon- Cates, not unreasonably restrictive, and are detailed strafing knowledge re of the EMS system's operating and extensively documented. (Score 3 points) policies and procedures, radio protocols, medical pro- • Medical protocols are:not current,overly restrictive, tocols,personnel capabilities,and on-board equipment vague or not well documented. (Score —SUBTRACT 2 and medical supplies.(zero or 1 point) points) SCORE:2F C. On-board equipment, medical communications system,medical control,and inventory control systems YOUR TOTAL SCORE_SECTION ii are state-of-the art, fully compatible with medical protocols in use,formal,and documented.(If true,ADO 2 3. Dispatching and System Status Manage ment(possible 15 points) points,if not,SUBTRACT 2 points) The scale favors systems with fully centralized and complete control SCORE:t C over the placement and movements of all ambulances in the system at all times. The scale also favors systems where control center YOUR TOTAL SCORE—SECTION,: 2. Medical Accountabilit trained nand specifically t train d in more sophisticated aspects medically y (possible 6 points system status management, that is, a system that is continuously A critic might fairly comment that if a system has no bonafide controlled by a single group of medically trained personnel, and medical accountability,then by definition it must be impossible to which is controlled in a manner that allows the system to assess that same system's clinical performance,and to some extent continuously maintain and constantly re-establish the best possible that makes sense.On the other hand,a system may be performing beautifully without being able to document the fact,and so I have emergency response terns and configuration given the level of emergency elected to separate the quesiton of clinical performance from the area's demand any point in time,given the capacity remaining in the system at the moment. production question of medical accountability. Each of the characteristics listed below count one point toward Select the sentence in each group below which most your system's total score, if your system substantially nearly describes your community's ambulance system in exhibits that feature.(If you are tempted to say something like,"we sort of have that feature, but it's more informal , all of the following categories. probably don't have the characteristic and should score your system A. Span of Control: zero on that feature.) Give yourself one point if your system shows strength in • All ambulance(s)operating in the community,emer- gencyandnon-emer non-emergency, SCORE:3A any of the following areas;zero points if it appears weak. is Y.are exc/usis control ntrolllud by a single ambulance dispatch center.This control includes A. Our medical protocols are developed by the same all vehicle movements including dispatches,post assign ments/reassignments, i.e. complete and direct control 86 JANUARY 1983 jems If •« A over all ambulances.(Score 8 points) ing response capacity to estimated demand patterns,but not to the level of sophistication described under the first • All emergency requests are managed by a single description in this group.(Score 1 point) facility, and all emergency ambulances are under the exclusive complete and direct control of this single dis- • Ambulances are assigned to their respective posts patch facility. Non-emergency ambulances are con- and generally remain at those same posts throughout a trolled by others.(Score 5 points) shift,unless dispatched to a call or released for meals, repairs, shift change, or occasionally provide back-up • A single control center receives nearly all emergency coverage for another unit or post at dispatcher's discre- requests(e.g.a911 center)and assigns those requests to lion.(Score 0 points) ambulances or multiple providers,but does not possess exclusive, complete,and direct control over all move- • Ambulance posts and post assignments are largely ments of all ambulances.(Score 3 points) the result of historical accident,or a result of a relatively static plan of vehicle placement,and only modest effort is • No single EMS control center receives and manages made to control vehicle placement on a "real time," nearly all emergency requests. The system is charac- "even driven" basis to preserve the best possible terized by multiple control points and multiple providers. d response capacity at any given level of remaining (Score 0 points) resources.(Score 0 points) r. B. Quality of Dispatch Personnel: YOUR TOTAL SCORE—SECTION III' SCORE:3B • Persons receiving telephone requests and dispatch- ing ambulances possess the verbal skills and didactic knowledge of a field paramedic. They also have com- 4. Access,First Responder and Citizen CPR pleted additional training in System Status Management, disaster response management,and clinically oriented (possible 15 points) telephone protocols.(Score 3 points) Highly organized and reliable citizen access methods are favored,as • All persons receiving telephone requests and manag- are effective organized first responder programs and citizen CPR ing system response are basic EMT's with additional programs. dispatcher training in system status management,dis- aster response management,and telephone protocols. Select the sentence in the following categories which (Score 2 points) most nearly describes your community's ambulances system. • All persons receiving telephone requests and manag- ng system response are basic EMT's with little or no addi- A. Access: tional training in system status management, disaster SCORE:4A • response management,and telephone protocols.(Score All telephone requests (both emergency and non- 1 point) emergency)for ambulance service terminate at a single EMS control center. These may enter via 911, a well- • Most emergency requests are received by"911 corn- publicized standard number,or by combination of these. plaint takers"or by other 911 communication center per- If 911 is employed,the"complaint taker,"immediately sonnel (e.g. police or fire dispatchers)who gather the upon discovering that the request is ambulance related, information from the caller,terminate the telephone con- hands off the caller to the EMS control center personnel versation,and then"hand off"the request to an"ambu- who speak directly with the callers, non-emergency lance dispatcher"who is located either in the same facility requests employ a separate number—not 911.(Score 5 or elsewhere.(Score 0 points) points) • A regional EMS agency receives most telephone • All emergency requests are handled as described requests,and"hands off"the calls to multiple providers. immediately above,but non-emergency requests termi- (ScoreOpoints) nate elsewhere. However, persons receiving non- emergency requests follow strict protocols for referring • Any other configuration of control not described in the calls likely to involve emergency conditions to the EMS list immediately above.or any configuration wherein per- Control Center and are monitored and regulated to insure sons receiving telephone requests for ambulance compliance.(Score 3 points) services are not basic EMT's or paramedic trained. (Score 0 points) • Emergency calls are handled as described under the first sentence in this group and there is no regulation or C. System Status Management: significant monitoring of calls received by non- SCORE:3C emergency providers.(Score 2 points) • All ambulances in the community(i.e.emergency and non-emergency)are continuously located and relocated, • There exists in our community multiple telephone in strict accordance with a detailed master plan so as to numbers for accessing emergency ambulance service. maintain the best possible response capability at any (Even if 911 is present in your comet°unity, give your given level of remaining ambulance availability taking into system zero points if more than 10% of emergency consideration time of day,day of week,historical demand ambulance requests enter the system via a telephone • patterns and demand fluctuations, traffic flow patterns number which is not 911 and which does not terminate in and congestion,special events and weather conditions, the EMS control center which would handle a 911 and other factors.Such system status management plan equest.(Score 0 points) also allocates quantities of ambulances to be in service by time of day,day of week and special event to adjust pro- B. First Responder: y, y P 1 P SCORE:4B duction capacity to fit demand patterns and demand fluc- • Our community has a formal police and/or fire depart- „'°,. tuations.(Score 4 points) ment first responder program capable of placing a trained • Emergency ambulances are controlled as described first responder team on the scene of 90% of all life above.but non-emergency ambulances are not.(Score 2 threatening emergencies within a maximum 4-minute points) time limit after receipt of request at the EMS control center.The decision to employ a first responder is made • Our system makes some effort to adjust both temporal by a medically trained EMS dispatcher,using physician and geographic ambulance distribution to match remain- approved telephone protocols,and who is in direct com- jems JANUARY 1983 87 • '1 -4: ��j�� Stout's Standards of Excellence(continued) munication with the person requesting service.The first responder team is trained and equipped at essentially the change to effect a switch to"disaster mode,"give your basic EMT level,but need not be EMT certified,and has system a zero on this criterion. had additional paramedic-assist training to better partici- pate in highly organized multiple crew ALS team pro- cedures. Some integrated/first responder in-service where in between these extremes,as most do.(zero to 4 training is routine and first response team members do points) participate,when requested,in medical audits of cases in which they were involved.The EMS data system is cap B. Normally working production capacity and able of capturing and documenting arrival times of both reserve capacity: ambulance and first response teams as well. (Score 5 points) Again,judgment must be employed to assess this cri- scoRE:SE tenon An all paramedic system(both emergency and • Our community does have a police and/or fire first on a day-to-day basis obviously hasthe ultimate ernoamal responder program which is employed on nearly all life- working production capacity for immediate disaster threatening ambulance calls, but which lacks the for- mality or performance capabilities described immedi- ately above in one or more significant ways. (Score 3 capacity for an extended mass-disaster,since off-duty points) crews are fully ALS capable as well.At the other extreme are multiple provider BLS systems employing'many • Our community either has no such police or fire first crews who rare) responder program,or the program we do have is signi- rarely perform under life-threatening emer- ficantly deficient,when compared with the first sentence gency circumstances.(zero to 2 points) n this group,in more than a few ways.(Score 0 points) C. Disaster site communications, supply sys- tems,and support services: C. CPR: Considerable attention was given to these issues in the SCORE:5C • Our community currently has—not on paper but in fact SCORE:4C article on the Hyatt Regency disaster,jems,Vol.6,No 9, —a functioning CPR training and annual recertification September 1981.This is essentially a binary criterion— program which has achieved and currently maintains i.e.either you have it set up or you don't.(zero to 1 point) CPR certification for not less than 20% of our community's adult population,or our community has in D. Integration of communications, equipment, place a CPR training program which,at present levels of and procedure with neighboring participation,will achieve the 20% bare minimum adult Again, either plans have been made throughout the level within two years.(Score 5 points) SCORE:5D region to effect fully integrated communications among • Our community has a CPR training program that we all neighboring providers,and to insure that,where possible like very much and are very proud of, but we haven't and practical,on-board equipment is compatible or that crews have been cross-trained in the use of each other's achieved the 20% minimum adult level,and at present equipment;or these steps have not been taken.Federally levels of participation, we don't know when we might. sponsored regional EMS groups have all worked to (Score 0 points) establish such regional coordination, and a few have • Our community has some really involved people•with been effective.Having a plan to provide such actually p na- some impressive credentials and financial contribution, and we have or are developing a CPR training program or lion in disaster situations,and being able to actually pull it • i plan e 0 points) n will knock everyone's eyes out some day. alfone can distinguish sh be9weenPhetwo.(zerodto judgment t (Score 0 points) • We don't have any CPR program and there is no plan for one.(Score 0 points) YOUR TOTAL SCORE—SECTION V YOUR TOTAL SCORE—SECTION IV: 6. Personnel Management Practices (possible 10 points) 5. Disaster Capabili O The scale favors heavily those systems which recognize that the t�/ (p ssible 8 points) caliber of field personnel and control center personnel is extremely Keeping in mind that we are discussing the disaster capability of the important to system performance.Smart,well-trained,creative and prehospital EMS system only, the scale favors those communities resourceful personnel have been known to make some reap whose day-to-day field operations are so effective and so flexible really poor that theyar day-to-day to function with little change in adisas flexible systems perform pretty well,at least for awhile.Similarly,there are anon.Similarly,the scale favors systems which have the capability probably no system designs that can squeeze consistent high and cate- mance out of low caliber personnel. The scale looks at and cate- of focusing large forces of advanced life support production gor1zes recruitment methods, initial screening of employees, the capability upon a disaster event without resorting to exotic or ela- interview process,and systems suffer reputation.fer on The scale, whereas inbred stems borate plans and procedures which are not tested on a routine(i.e. that actively recruit systems suffer d the scale,favored. systems daily or weekly) basis. A system's ultimate disaster capability is that actively recruit the best in the industry are favored. more difficult to predict and probably requires the judgment of the sentence in more experienced evaluators than other areas of the scale. which t most nearly describes o the Y community's eamrbu- A. Application of day-to-day working systems of lance system. control and coordination. A. Recruitment Methods. • If the communications,dispatch,and control systems SCORE:5A When ajob position becomes available in our system,the which function normally on a day-to-day basis are cap- employer(s)seeks and attracts the best possible person SCORE:6A able of effecting and coordinating a system-wide response to a single disaster without change in person- g protocol, for that job by utilizing recruitment and screening nel,equipment,or operatin cedures generally as follows: gro- ,ADD 4 points. • If much of the system's routine control network must • A continuous national advertisin insures a steady incoming flow of applications,and gthe advertising 88 JANUARY 1983 jems • +w • f 16,---... 14%.,,,-------941* ".N is concentrated to impact in American communities lence is not widely known or recognized, and so our which enjoy ambulance service of the highest reputation. reputation doesn't play much of a role in recruiting and (Score 4 points) retaining good people.(Score 0 points) • A continuous recruitment program is in place with • Frankly,our EMS system isn't all that great,but we tell nationwide advertising,but no real effort is Made to attract applicants with good credentials that we need them to applicant's from the most respected ambulance sys- help us do better.(Score 0 points) terns.(Score 3 points) • Our EMS system really isn't as bad as a lot of people • A continuous recruitment program exists,but it con- think it is,and if you think it is that bad,maybe you should centrates on applicants from within our regional area,and work somewhere else.(Score 0 points) very few of our new personnel have experience in remote metropolitan ambulance systems of high reputation. YOUR TOTAL SCORE—SECTION vI: • (Score 2 points) • • Our recruitment is intermittent and most of our new hires are graduates of one or two local training programs, 7. Stability,Reliability,and Fail Safes and if they have previous experience,it is usually with a (zero to 7 points) neighboring provider organization,and as a result,our Here again we have an area that requires expert judgment to eval- EMS system is somewhat"inbred."(Score 1 point) uate.Many systems appear to be stable and reliable,only to prove • We have no formal recruitment program,so when a extremely vulnerable to a shift in majority leadership on the City position opens up, "word gets out" and someone's Council.Some systems are heavily dependent upon the leadership friend,relative,or classmate is usually hired as soon as of a single individual,upon hand-to-mouth financing from the local possible to avoid too much overtime pay to cover the tax resources of a single unit of government,or are entirely depen- unfilled vacancy.(Score 0 points) dent upon the financial stability and integrity of the present owners of a single private ambulance organization.An additional one point B. Initial Screening: each can be given to the system which displays significant strength in SCORE:6B the following areas: • After a good number of qualified applications have been received,a professionally oriented,fair,and rea- Give yourself one point if your system shows strength in sonably objective process is used to narrow down the any of the following areas;zero points if it appears weak. applications to the most qualified applicants for inter- A. Financial strength,soundness of business practices, views. References and work histories are thoroughly rainy-day financial reserves,and system net worth,the checked out before interviews are held.(Score 2 points) debt to equity ratio of the system,and general insulation • The"boss' looks over the applications and interviews from local politics.(zero or 1 point) whoever the boss likes best, but 3 or 4 people are scoRE.7A normally interviewed for each job and references and B. Soundness of hardware financing and replacement work histories are usually thoroughly checked.(Score 1 practices,favoring those systems which employ heavily funded depreciation programs,or some equally sound point) commercial financing mechanism backed up by a solid • Sometimes only 1 or 2 applications are received cash management program.(zero or 1 point) before the boss interviews and selects, and the boss SCORE 7B checks out whatever he thinks is necessary. (Score 0 C. Performance security in the form of performance bonds or similar security, equipment ownership in the points) public sector or protective lease arrangements, and a • The"boss"says he can tell mostly by the look in their variety of devices to insure uninterrupted field perfor- eye,and he will hire whoever he wants to hire,even if only mance even during an emergency changeover from one one application has been considered, if that's what he operator to another or from one type of system to another. feels like doing.(Score 0 points) (zero or 1 point) D. Insurance against fraud and mismanagement,such C. Interview Process: SCORE 7C SCORE:6C as a well-managed company being sold out to owners of • After thorough checking and screening of applicants,a questionable character,ability,or intent.(zero or 1 point) minimum of 2 or 3 applicants are interviewed by a review SCORE 7D team whose collective decision is final,or whose advice E. Empire building inhibitors such as prohibitions against an oversight agency becoming an operator of the concerning selection is given to"the boss,"who normally b system,a training organization taking on an evaluative but not always accepts the judgment of the team.(Score2 role in the system,or other tendencies of organizations to points) assume functions and responsibilities which are inher- • Applicants "tour the facility," chatting with several ently incompatible with those already being carried out by people,and before deciding,"the boss"usually asks for that same organization.(zero or 1 point) opinions.(Score 1 point) SCORE 7E F. Public relations efforts designed to help insulate the • The boss usually talks to people before he hires them. system from uninformed and misguided press coverage, (Score 0 points) non-constructive and damaging attacks by opportunistic local politians, or other unfair criticisms which may D. System Reputation: damage the system's reputation,the morale of its person- . scoRE:6D nel,or which may even result in the demise of the system • Our system is widely known and respected as a high and its replacement by an inferior but better sold system. performance ambulance organization that demands (The better and more accountable EMS systems are the excellence from its personnel and gets it a place most visible and the most open to criticism, both where only the most qualified people are employed and deserved and unfair.Responding to thousands of emer- where peer group pressure demands professional con- gencies each year,and under the most adverse of condi- duct. clinical excellence, and skill maintenance. This tions, while dealing with patients, families, and by- reputation is deliberately employed to attract and retain standers who are upset and sometimes out of control,an the best,and to deliberately discourage applications from EMS system is, perhaps more than any other service others.(Score 2 points) organization, vulnerable to unfair yet damaging attack. • We think our organization is pretty good,but our excel- Effective public relations efforts designed to counter this jems JANUARY 1983 89 ._. •• r•' %I / ) Stouts Standards of Excellence(continued) unfortunate fact of EMS life are essential to long-term system stability.)(zero or 1 point) • Discourage abuse of the ambulance service in cases t where there is no reasonable medical necessity for emer- i G. Strike protection in some form is essential to system SCORE: 7F stability and reliability especially when the labor force is gency or non-emergency ambulance use; organized.Strike protection can be provided for in a van- • Help educate the public,politicians,and public as well ety of ways without undermining the intent of fair labor as third-party payors as to the need for extensive reform practices,but there is not space here to elaborate further in the ambulance segment of America's health care 11 on this complex area of system management.(zero or 1 finance programs. point) SCORE:7G YOUR TOTAL SCORE—SECTION VIII' YOUR TOTAL SCORE—SECTION VII: • 9. Response Time Performance (possible 15 points) 8. Pricing Policies, Billing and Collection Stout's Standards deal with a system's response time performance Practices(possible 5 points) by looking separately at response times to life-threatening emer- The way an ambulance service system conducts itself financially, gencies, non-life-threatening onse time performance distribution among the various especially its management of revenues, is itself a measure of its an�aborhoodsordistrictsoftheservicearea.Thisscaledeliberately service to the community.More than a few otherwise well-managed nei h ambulance services place an impossible burden upon senior citizens avoids r�f averageomayewell be ach evedeat the cexpensepof life- . ive by failing to accept assignment,where appropriate, by failing sounding ppropriate,and b failin to threatening excessive response times to a sizeable percentage fof • prepare Medicare claim forms for routine mailing with statements patients in more excessive difficult-to-serve areas.(There is not space here to to Medicare eligible clients where assignment is not accepted. go into such matters as response time definition,adjustments for Pricing policies, billing, and collection procedures which reduce local tax subsidies, which minimize no-hauls and turn-grounds,or validation of response time report- expenditures,maximize patients' third-party recovery,out-of-pocket ing, but these issues should be dealt with in depth in any serious make the patients'claim filing simple ands speedy l and which menting its of the s performance relative to this scale is simply incapable of application of the scale.Additionally,a system incapable of docu- system's ability to serve the community.At the other extreme are g p the being evaluated may this criterion,and the attempt should be made to systems which employ token prices and billing efforts, thereby placing an unnecessary load upon the local taxpayer,and systems guess at what may be happening in the field.) which make little or no effort to maximize third-party recovery or to Select the sentence which most nearly describes your assist patients in making third-party claims.The community cannot escape the effects of less service oriented financial management community's ambulance system in all of the following practices,and for that reason the EMS system and its management categories.(Note:this rating assumes presence of hone cannot escape responsibility for this area of evaluation. catty trained dispatch and medically sound telephone Obviously, in a multiple provider system, some patients y Protocols for presumptively defining a life-threatening experience highly effective and professional, yet quite bents ma emergency.If these conditions are not met,utilize your et uite humane emergency response times for all emergency re filling and collection practices,while other patients may experience then both life-threatening and non-life-threateninggemer- pposite.Thus,it is entirely possible for a system to get a"mixed gencies,for both Categories A and B,below.) review"on this area of service. A.Like several other areas of this assessment, the evaluator must havekeleaseasolid basic areas of this assessment,amen , thsetvaluandr must (N Life-threatening Ifyo syste is Emergencies: assign es; (Note:if your system is all BLS,assign zero points to this scone 9A bursement world of an ambulance service health care provider category) organization.(Keep in mind that ambulance services fall under Part B of Medicare,while hospital services fall under Part A,and that • For less than t en of all presumptively defined life- these two programs bear almost no resemblance to each other where threatening emergency requests, the system fails to rate setting and reimbursement practices are concerned.) place paramedic ambulance on life-threatening scene Rate your system in terms of its general compliance with the pur- within 8 minutes or less after call received. (Score 9 pur- poses of sound pricing policies, billing, points) follows: g,and collection practices as • For between 10 and 15%of all presumptively defined life-threatening emergency requests,the system fails to A. Pricing policies should:(zero to 2 points) place paramedic ambulance on life-threatening scene • Maximize third party recoveries while minimizing out- within 8 minutes or less after call received. (Score 7 of-pocket expenditures,especially by insured patients; scoRE:8A points) • Avoid cutting the throats of providers sharing same • For between 15 and 20%of all presumptively defined geographic profile; life-threatening emergency requests,the system fails to • Be capable of covering full system costs,in the event place paramedic ambulance on life-threatening scene of subsidy reductions; within 8 minutes or less after call received. (Score 4 • Discourage use of 911 or other emergency access points) phone number for purposes of a non-emergency nature. life threaten ng emergency requepresumptively ts,the ys emdfailsto B. Billing and Collection Practices should:ould:(zero place paramedic ambulance on life-threatening scene • Provide easy maximum third-party recovery for senior SCORE 8g within 8 minutes or less after call received (Score 2 citizens; points) • For more than 30% of all presumptively defined life- • Insure that most uncollectible writeoffs are related to services delivered which were truly medically necessary threatening emergency requests, the system fails to and provided to persons whose true financial situation is place paramedic ambulance on life threatening scene such that payment of the ambulance bill would produce within 8 minutes or less after call received. (Score 0 an unreasonable hardship.In such cases,the billing points) and collection procedure should be capable of identifying lli B. Non-life-threatening Emergencies: i such conditions early in the billing/collection cycle, so that the responsible party is not"badgered"extensively; • Ambulance response time (paramedic or other) is SCORE 9B under 12 minutes on 90% or more of all non-life- threatening emergency calls.(Score 4 points) 90 JANUARY 1983 jems 4 y« Y . ' I` • Ambulance response time(paramedic or other)is 12 C. Our system is monitored by one or more part or full- minutes or longer on more than 10%but lessthan 20%of time employees of local government who work in a all non-life-threatening emergency calls.(Score 1 point) department which is not also a provider of ambulance services. These officials regularly inspect ambulance • Ambulance response time(paramedic or other)is 12 equipment, assist in the performance of physician- minutes or longer on 20% or more of all non-life- supervised medical audits,and with the help of qualified threatening calls.(Score 0 points) accounting personnel or hired accounting firms,make recommendations concerning subsidy requests, rate C. Non-emergency calls: reviews and approval,and billing and collection practices SCORE:9C of provider organizations.(Score 2 points) • Ambulance response to non-emergency transport p g SCORE:100 requests are reasonably prompt (i.e. within 20 to 30 minutes) for unscheduled requests, except under D. Our community has an EMS council(regional or local) unusual system overload conditions which occur rarely made up of provider representatives, hospital repre- (i.e.not more than 2 or 3 periods lasting less than 1 or 2 sentatives, and other interested individuals who meet hours weekly)and previously scheduled transports are regularly in meetings open to the public to discuss issues almost never delayed. When delayed non-emergency effecting the EMS system.When a problem is reported, response does occur,the requesting party is contacted this group looks into the matter and makes a recommen- immediately,and explanation is given and a revised ETA dation.(Score 2 points) scoRE;i OD is offered and adhered to.(Score 1 point) E. In our system, all quesitons related to clinical • The description immediately above does not charac- terize non-emergency service in our community.(Score performance are handled by a legally authorized,funded, —Subtract 2 points) staffed, and provider-independent physician-controlled organization charged with the authority and responsibility to prescribe medical standards, oversee compliance, D. Geographic Performance SCORE:9D and institute mandatory corrective action when neces- • Response time performance is approximately,but not sary. Physicians expert in and knowledgeable of emer- precisely equal amongst the various neighborhoods, gency medicine and of care being rendered by our quadrants,sectors,or districts of our community.(Score system control this organization.In addition,the financial 1 point) management of our system is overseen by a separate group of individuals who are also informed and expert,as • Certain parts or neighborhoods of our community well as provider-independent, as regards matters of usually enjoy good response times,while other areas in organization and finance. This group is controlled by our community experience chronically poorer response representatives of the local business community who , time performance.(Score—Subtract 2 points) possess the kind of expertise necessary to make sound financial judgments in a complex financial environment, YOUR TOTAL SCORE-SECTION ix and who have no personal financial interests in the EMS system. This financial oversight organization has the power to:require certified audits and financial statements 10. Public Accountability(possible 4 points) of provider organizations; establish or review and approve all billing and collection policies; perform Sophisticated prehospital care EMS is becoming increasingly reviews and make recommendations to local govern- complex and specialized.By default or by design,the type of EMS meet concerning the proper balance among quality of system serving your community is mostly determined by the action service, fees, and local tax subsidies; and where or inaction of local government—more specifically,local elected appropriate,reviews and approves the qualifications of officials. Public accountability is necessary both to protect the potential provider organizations based upon the findings public from a bad EMS system,and to protect a good EMS system related to organizational reputation,integrity,character of from unfair criticism and possible misguided intervention by semi owners and key personnel, and financial stability. informed public officials or even representatives of the press. Furthermore,the data system used to evaluate response "The rates are exorbitant.... Response time was terrible.... time performance is provider-independent, except for The crew was rude to the Mayor's mother-in-law.... The private collection of primary data,and is subjected to periodic provider makes excessive profit.... The city subsidy is out- spot checks for accuracy and truthfulness. our our rageous....The fire department could doit cheaper....Aprivate system imposes severe financial penalties upon - company could do it cheaper.... A fired employee exposes the duals or organizations found guilty of wilful falsification of truth.... Consultant blasts EMS system.... and so forth.The duals organizations for the purpose of enhancing the apparent public must know the truth,and the system itself,especially if it is a performance of the system or organization, and our good one, needs the protection of fully informed, expert, and monitoring systems are so designed to eventually independent oversight. uncover any repeated fraud of that type.In short,system Again, evaluating a system's mechanisms for achieving public performance is assessed and documented, both accountability requires experience and judgment. Score your medically and financially, by qualified individuals and system zero through 4 points depending upon which of the descrip- organizations other than the providers themselves or lions below most nearly describes your situation. their employees. Elected officials, the press, and the general public can rest assured that the system is con- A. In our system, the agency of local government tinuously monitored by qualified and effective people, responsible for all EMS activities is itself a provider of EMS and that complaints are dealt with promptly and fairly,and • services.(For example,a city wherein EMS is operated that the findings from complaint inquireis can be trusted, by a fire department or third city department,and no other even if the issues involved are too complex for easy agency is funded or staffed to oversee operations.) interpretation by the public at large.Similarly,providers (Score 0 points) SCORE.1 OA and field personnel are almost never required to defend B. In our state,ambulance providers are licensed by a themselves against unfair criticism, as these AN. Department of State Government, and our community independent and objective oversight organizations serve relies heavily upon the state agency,regularly referring to insulate this complex and somewhat delicate industry inquiries and complaints to the state agency,and the state from unfair attack.(Score 4 points) SCORE:10E agency normally conducts a prompt and complete inquiry into the matter and issues an official statement of findings.(Score 1 point) SCORE:108 YOUR TOTAL SCORE-SECTION X. jems JANUARY 1983 91