EMS Leadership & Regionalization

Decreasing budgets, higher public expectations and now EMS is being asked to prove that it makes a difference. Is this just crazy talk or a real opportunity to propel EMS into the limelight? I would suggest it’s the latter. But how can EMS show what it’s made of?

The current EMS structure in the United States represents a fragmented delivery system with a lack of oversight and policymaking.¹ The current state of the economy has forced nearly every public safety organization to reevaluate its departments’ mission and whether it can be done better—for employees, the patients and the community as a whole.

Regionalization has been a heavily boasted and feared word when discussing efficiency and effectiveness of emergency services. An Institute of Medicine (IOM) report calls for improved coordination, regionalization and accountability as the cornerstones for developing the 21^st century emergency and trauma care system.² Fears largely swirl about the potential loss of control and loss of identity. If a true systems approach is used when developing a regional, accountable system of care, the fears will appear trivial compared to the potential benefits.

Regionalization is an option to pull multiple autonomous agencies together into one system. If you look at trauma care, you can see how regionalization works. Trauma centers did not put community hospitals out of business; instead they provided a resource which has improved patient outcomes and decreased overall health care costs. With approximately 5.4 million trauma patients being transported in 2007, the updated CDC Field Triage Guidelines saved an estimated $568 million in national health care costs.³ STEMI systems of care have also shown improved patient outcomes and decreased costs.

So systems of care (i.e., a regionalized approach) work for EMS patients, yet we as EMS agencies have not adopted this approach for organizational development. How can EMS get there while alleviating our fears?

First, we must check our egos at the door. Real leadership is about helping others achieve success. If it is about you, you are likely not the leader you think you are. NEMSMA President Skip Kirkwood says most emergency services chiefs would rather be a captain of a rowboat than a command officer on a large battleship. That impression is hard to ignore when you see the numbers and average size of EMS and fire agencies around the country. Every county in the U.S. averages 9.2 EMS agencies.⁴

Now that ego is addressed, let’s better understand regionalization. Typically it refers to dividing an area into smaller areas. I suggest it is the opposite for EMS and healthcare. Historically, EMS is a one-horse show. Regionalization means we can work together with other one-horse shows to put on a real parade. Regionalization is often confused with consolidation. While consolidation is an option, it is not a requirement for regionalization. One can have multiple autonomous agencies working together under an inclusive unified approach.

The benefits or regionalization include:

• Clinical care. If trauma, STEMI and stroke systems of care are any indication, focused, specialized care improves patient outcomes. In a regionalized system, the right resources arrive to the right patient in the right amount of time. Regionalization can help eliminate the paramedic paradox—multiple paramedics are available in an urban area while none are available in rural areas of the system where they are needed most. Sharing resources between urban and rural areas can place higher levels of care where it will do the most good. It also improves paramedic competencies and can be used to avoid burnout and rustiness if paramedics are moved between busy and non-busy areas under a regional joint deployment model.
• Data sharing. Larger systems of care have more data and can better determine what’s working and what’s not; identify unique aspects of the system; and help prove the difference they’re making in their communities.
• Economy of scale. Sharing resources minimizes the need for agencies to duplicate services, permitting each agency to use its limited resources to specialize and improving the level of services in the system at a lower cost. This includes human resources as well as equipment. Having dedicated individuals representing the system allows more people to canvas more specialty areas, rather than having multiple EMS providers sitting side by side in the same meetings representing their own individual interests. Joint purchasing of equipment and supplies also may offer better pricing.
• Influence. There is strength in numbers and you shouldn’t underestimate the potential clout the system will have when multiple agencies all speak with the same voice.

Yes, this is a paradigm change. Intense discussion and compromise are likely necessary to pull all agencies together. Real leadership is required to respectfully and thoroughly work through all the issues and concerns which will be brought forward from various agencies. When things get difficult, recall the list of benefits above and stay at the table. Conflict cannot be resolved if any agency is not communicating.

As the next generation of EMS providers rolls out, we must work smarter, not harder. Regionalization is a wise and proper path for improved patient outcomes and decreased costs. The battleship is much more stable in rough seas than the rowboat. Welcome aboard, Captain!

References

1. National Research Council. Regionalizing Emergency Care: Workshop Summary. The National Academies Press, 2010.

2. Institute of Medicine. Future of Emergency Care: Emergency Medical Services at the Crossroads. The National Academies Press, 2007.

3. Faul M, Wald MM, Sullivent EE, Sasser SM, Lerner EB, Hunt RC. Large Cost Savings Realized from the 2006 Field Triage Guideline: Reduction in Overtriage in U.S. Trauma Centers. Prehospital Emergency Care, Early Online: 1–8, 2012.

4. Mears G. 2011 National EMS Assessment. DOT, NHTSA, 2011.

Troy M. Hagen, MBA is a paramedic and the director of Ada County Paramedics in Boise, ID. He has more than 23 years of EMS experience and is president-elect of the National EMS Management Association (www.nemsma.org).