Regionalization in EMS

EMS is in a state of flux. We’re trying to strengthen our identity, combat decreased revenues, and increase our training in order to keep up with the industry’s demands. All of this is being done with a mix-match of systems consisting of full-time staffing, part-time staffing, paid-on-call personnel, and even some purely volunteer services thrown into the mix.

Issues with recruitment and retention plague many rural systems, while offering worthwhile and competitive pay plagues the middle-ground, and competing with transitioning employees moving toward fire-based EMS systems plagues the full-time services.

How can we “fix” EMS? How can we provide for more consistent rural staffing? How can we make this job worthwhile to our new employees?

The answer: fix the system. Focus on regionalization.

Take a close look at the fire service model for just a moment…every little community with a church, a four-way stop, and a local tavern has its own fire department. While this fire department may only consist of two or three total vehicles, how is it that they can “stay in business?”

These very systems, underneath their aging apparatus, dwindling volunteer rosters, and outdated management structures are crumbling…and what’s scary is that many EMS systems are founded by these very organizations (and may still even operate like them, or as a part of them, too!).

The old adage of building a wall (or river) around your community because of so-called “pride” is showing its battle-wounds; and to be honest, is in a state of hemorrhagic shock.

The fact is, we can’t keep operating our EMS systems like this! We can’t continue operating under the service model of having a different ambulance service in every community, or even multiple small services within one large, lightly-populated, and decreasingly-funded county. Heck, we can’t keep operating under the same cross-staffed institution in larger communities if we want to remain progressive, strengthen our own industry identity, and develop the very institution of professionalism that we’ve been fighting so hard to create.

We need a change in our system. We need to look at working together to build EMS into a strong region…into a system that best fits a number of communities through shared resources, combined operations, and professional standards. We need to regionalize EMS and stop treating our neighbors like neighbors, and start treating them like our own household.

OPERATIONS

When finding good leaders, managers, supervisors, training staff, and preceptors is such a difficult task, why make it worse by only choosing from a few internal candidates, when you can combine services to have a larger pool to choose from?

Regionalization helps your service’s operations by allowing one, single, larger entity develop an actual organizational structure and system design. This promotes structure, accountability, and a career path for current employees/members to follow and build their careers upon. Regionalization also allows a number of smaller services to pool their expertise and resources into one centralized entity; thus, creating a stronger EMS system overall, rather than a weak and scattered individualistic region.

Look at things this way, it makes no sense for a rural county with a total population of 25,000 people, to have five or more ambulance services operating at the same BLS level. No one service can afford to upgrade to the ALS level. No one service can sustain an ALS call volume. No one service can afford to hire full-time staff. Combining these services, and regionalizing; however, can allow this.

Put your borders aside and think about a few things quick: what are your top five challenges as an EMS manager; how can you fix your current staffing shortage with your current means; how can you increase your service’s potential if your boundaries are constant, and your population is unchanged?

The answer in all of these questions is by combining…by merging…by consolidating…by regionalizing.

This means one Director, one service/department, one patch, one standard of ambulance make/model/color/design/layout, one system of financing & payroll, one combined pool for staffing.

OVERSIGHT

Combining with the operational benefits, regionalization also brings a common and consistent system of oversight to your service.

One standard set of protocols with one Medical Director; one primary Training Officer with one set of quality standards; and one level of competency and quality that is expected throughout an entire region; rather than multiple standards and protocols between closely-related neighbors.

While creating a uniform set of protocols, or having a consistent Medical Director, within a given region can be accomplished without combining services, it holds less strength if each individual entity doesn’t train the same or have the same quality assurance standards.

Regionalization, therefore, brings all of this under one roof. Standing orders are coming from one physician; administrative policies are consistent amongst the entire group; and patient care, billing practices, and quality assurance standards are the same throughout a larger geography.

OVERHEAD

Group-buying, purchasing co-ops, and mass-purchasing options are all around us; so why not take advantage of them? Through a larger system, this option becomes a more regular reality.

From a facilities standpoint, one thing that larger fire departments do right is their use of primary and satellite stations. Not every building has a massive training center built-in, and not every facility is designed to quarter the same amount of staffed personnel. This same advantage can exist through regionalization. One, centralized, location can hold your administrative personnel; while others can be more minimalistic and just meet the needs of the personnel that staff it.

When you take a look at the ambulance garage, you’ll often find that each single-station ambulance service will have at least two ambulances. Having two vehicles doesn’t necessarily mean that they can staff them, or come up with a full crew to run a second call with them; it just means that they have one that’s ready to go, and another that’s there in case the other is being serviced on. This overhead cost is a lot and isn’t always necessary.

Just the same is often seen with neighboring fire departments. Each neighboring department needs its fleet of engines, but not everyone needs the 100’ platform aerial that comes with a hefty price tag to purchase and maintain. So, why should we continue to follow this practice in EMS? Why don’t we change our ways and start to protect our bottom line, our overhead costs?

RURAL REGIONALIZATION

“Rural County” is located approximately fifteen miles from its nearest Level-II trauma center on one end, and ninety miles at its furthest point. Its total population is around 37,000 people, and its total land size is just short of 1000 square miles.

This county is serviced by five AEMT services, one EMT service, and one first responder group. ALS patient care is only an option through intercepts and scene-flights by neighboring county services from suburban/urban EMS systems. Both of the county’s critical access (Level-IV trauma) hospitals don’t have ALS-intercept options, and both are located on one end of the county.

Each service in this county faces a daytime staffing problem, especially for second calls within their service district. While one of these services is staffed with full-time fire-based personnel, these two providers make-up their ambulance, so their ability to effectively cross-train, cross-staff, and cross-function can be a challenge if different incidents are occurring throughout their day. For all intents and purposes otherwise, each of the remaining four AEMT services have similar staffing, call volumes, and response district demographics.

Being a rural region, there’s a great need for closer ALS care, but no one entity within this region can support it on its own. No one entity can also support full-time management, or even full-time day staffing.

To remedy this, why not combine to become one? Why not combine to build potential?

Creating a single, regional, service would allow this county to afford full-time management, strategic full-time daily staffing, and strategic full-time ALS capabilities. Again, not all of the communities need ALS care 24/7 and directly within their own little town, but they do need closer care than what they have; so why not have it within twenty miles, instead of ninety?

Strategically placing ALS-intercept vehicles within this county would be progressive. Centrally-locating a fully-staffed ALS ambulance for inter-facility transports from the two local hospitals would be beneficial, and structurally-supporting one single Director would be cost-effective

REGIONALIZATION FOR SUBURBS

A growing trend for a number of suburban communities is transitioning away from BLS-based levels of care and advancing toward ALS-based services. What’s proving hard for these communities, however, is the cost and overall ability to sustain this demanding level.

Why not regionalize? The fact is, not every community needs ALS care directly in it; what they need, instead, is ALS care closely near it.

Take a look at just about any metropolitan area and you’ll see a number of stand-alone ALS entities around a larger city. When you get down to the run numbers and actual needs of the community, it’s often un-deniable how many EMS transports are purely BLS in nature. In an all-ALS system, however, are we really working toward our full potential? Can each of these smaller, single-station, services combine to make a medium-sized system? Can they better share their resources, rather than divide them?

Regionalizing, in this instance, would allow for more variety for the providers by offering more stations to work at. It would also promote a tiered-response system, rather than a single-level response system. Management staff can be consolidated, back-up resources can be shared, and policies can be thinned-down into one uniform standard.

REGIONALIZATION IS OUR FUTURE

Like it or not, regionalization is a must! We can’t keep putting our geographical “pride” on the table as our only excuse for having five of the “same” ambulance services within a single county. We can’t keep fighting the new generation of EMS providers that actually want to make EMS a career, and not just a volunteer hobby.

Budgets are getting tighter, payouts are tightening, and expenses are increasing. We need to start acting-upon the need for change and start by joining communities, rather than just trying to work with our neighbors by talking through the cracks in the fence.

Whether your system is solely rural, suburban, urban, or a combination of the above, there’s a spot in it to combine, consolidate, merge, and regionalize. Building its foundation may not necessarily be as easy as talking about it, but complaining about your current problems certainly isn’t getting your service anywhere under your current system model. So, why not start today? Why not start opening the lines of communications with your neighbors and discuss this option, or, at least a part of this option?

Strength in numbers is what has been a driving force across our country; why not start to bring EMS to this level and start to strengthen its numbers under one unified, centralized, and regional force? Why not regionalize?