Where Do We Go From Here? - EMS Insider - @ JEMS.com

Where Do We Go From Here?



Jay Fitch, PhD | | Thursday, November 5, 2009

The Kansas City (Mo.) Council recently voted to transition its award-winning EMS systemto the Kansas City Fire Department (KCFD). The move ended a fractious political period in the system's history and permits those involved to now focus on serving patients.

Thirty years ago, the city authorized creation of the Metropolitan Ambulance Services Trust (MAST), an independent entity, to resolve the accountability and clinical care issues of an extremely fragmented and competitive service area. It was designed as a multi-jurisdictional entity, but MAST primarily served Kansas City and smaller adjacent bedroom communities.

The system centered around an ordinance defining operational performance requirements and fully independent medical control and governance. MAST functioned with an independent, city-council-approved board of directors, with clinical oversight provided through the health department.

The concept, pioneered by Jack Stout, integrated emergency and non-emergency service lines to improve care and reduce municipal subsidies by taking advantage of economies of scale. It was designed to operate as a regulated public utility or single franchise model.

Originally, MAST supplied vehicles, collected system revenues and provided administrative oversight. It contracted with a private entity to provide field staff and entrepreneurial management talent to deliver services. The system's "excess profit" was reinvested to fund new technologies, equipment, research and a well-paid work force.

In subsequent years, administrators decided they didn't need the private provider and could operate the system themselves. That approach, coupled with strong external oversight, has worked in other communities; in MAST's case, it became a slippery slope.

Like most EMS entities, MAST experienced performance peaks and plateaus, but its fundamental design and public accountability requirements enabled it to self-correct over time. However, once the system's administrators became internally focused on managing day-to-day operations in addition to maintaining external relationships, the system became deeply mired in the political process.

MAST operated without significant municipal subsidies for the majority of its 30-year history. Doug Hooten, its former director, did an admirable job guiding the system back to fiscal and operational stability through a combination of cost cutting, revenue generation and additional subsidy. However, the infusion of city funds led to city administrators' increased desire to exert direct control over the system. No one debated that the system provided excellent care to its patients, but some claimed savings could be realized by consolidating MAST and the fire department. Employees wanted to be in fire stations and to trade their private defined-contribution retirement plan for a municipal defined-benefit pension program. In the end, press reports described the council "being pressured by the fire union." Other reports indicated the mayor and council wanted support for reelection bids.

Throughout our 25-year history, the Fitch & Associates consulting group has consistently advocated that the "what" (e.g., providing objectively measured, clinically excellent service) is more important than "who" ultimately provides the service. Now that the "who" has been finally settled, everyone involved can step back and look at the hallmarks of an excellent system and determine what needs to happen to continue such a system within KCFD.

There are five common hallmarks of an effective EMS system design. Each is described below in the context of how Kansas City's taxpayers should expect its new service provider to perform:

Hold the service accountable.This includes accountability for clinical effectiveness, response times and customer service. Augmenting, rather than weakening, any of the defined performance requirements in the current city ordinance would promote accountability.

Increased personal accountability is required for the delegated practice of medicine. Many fire agencies and workforces that provide primary EMS honor this principle. The KCFD union has aggressively advocated for its members and may find it difficult to balance that advocacy with the need for increased clinical and personal accountability.

Establish an independent oversight entity.Although the MAST administrative board will cease to exist, the city's medical control board -- with separate local personnel licensing authority through the health department -- should be maintained. This facilitates the medical community's ability to openly address patient and staff issues.

Account for all service costs.Fire departments and private services have debated cost methodologies for years. Requiring the city auditor's office to calculate and annually present the service costs using the financial proforma models endorsed by the IAFF and the AAA would provide a fiscal baseline in future years. If KCFD decides to no longer provide the full range of emergency and transfer services in the future, then the additional costs of providing transfer services through an alternate delivery method should also be recognized as a system cost.

Require system features that ensure economic efficiency.Because labor costs represent the largest component of any system it will be incumbent upon the city's selected advisers to develop operational and staffing models that address this issue. Savings were promised in the heat of the political battle, but they must be included in the long-term design features that could improve both fire and EMS service efficiency.

Ensure long-term, high-performance service.This may prove to be a difficult challenge for KCFD given its historically adversarial relationship with labor. The best mechanism to accomplish long-term high performance would have been to include a sunset provision in the authorizing legislation. In other words, if the system did not meet the performance requirements within the agreed cost parameters then a design or provider change would be required. Renegotiating clinical or operational standards should not be an acceptable alternative. At a minimum, the accreditation by both the National Academies of Emergency Dispatch and the Commission on the Accreditation of Ambulance Services should be maintained.

KCFD will face multiple challenges as it moves through the ongoing system transition. During the times ahead, my hope and desire is that the leaders focus on what needs to be done to serve both patients and taxpayers well.

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