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A N D S O L U T I O N S F O R L O C A L G O V E R N M E N T M A N A G E R S
VOLUME 42/NUMBER 5 2010
S T R A T E G I E S
In
Making Smart Choices about Fire and Emergency Medical Services in a Difficult Economy
Despite encouraging indicators in some sec-tors, city and county leaders are still facing tough choices about supplying core services, including police, fire and emergency medical services (EMS). These core public safety services typically represent the largest slice of the budget pie, and thus are an understandable target for cost reductions. But savings cannot come at the cost of lost lives. What evidence and benchmarks exist to help decide what’s appropriate? How does a public official tell the difference between facts and opinions? This report frames the challenges facing local government and offers guidance on effectively assessing fire and EMS, implementing changes safely and, ultimately, effectively communicating these changes to key stakeholders.
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Economic reality
The picture for state and local governments is clear: The current economic problems that took years to evolve will require many years to fix. Even as the economy begins to rebound, tax revenues will continue to lag, forcing communities to struggle to meet expanding demand for emergency services. U.S. Fire Administration officials estimate that once the recovery begins, it will take one to three years for cities to see signs of increas- ing revenue, with fire agencies experiencing a three- to five-year lag.1
In many communities, public safety funding comes from general revenue sources that may rely heavily on property taxes, and many fire and ambulance districts are funded exclusively through property tax assessments. Those agencies have been especially affected by climbing foreclosure rates, falling home prices, and reassessments that reduce property tax revenues.
Impact of municipal budget cuts on public safety
Many communities are dealing with budget deficits by instituting across-the-board cuts or incremental expense reductions. In such a scenario, every department, from wastewater to roads and bridges, might be instructed to cut 5 percent from its budget, with limited assessment of the impact—and without considering whether some departments may be better able than others to reduce their budget. Additionally, in many cases, department heads are told to do this with limited guidance or direction. What appear to be straight- forward changes can have significant unintended consequences.
This is true for a number of fire agencies that are using the “brownout” method to address long-term budget problems. A brownout involves taking stations or response crews out of service periodically to reduce the cost of providing core services. This approach is often used with little or no data to logically and systematically justify brown- out choices.
Brownouts are a form of rotating across-the-board cuts. They are often implemented with the belief that everyone should “feel the pain” equally. Besides being rooted in a sense of fairness, across-the-board–style cuts are a convenient way to avoid making tough decisions. In truth, determining the best long-term solutions requires serious policy discussions that take into account what a community really values (and the sometimes- unintended consequences of funding reduction decisions), as well as thorough data anal- ysis to understand the demand on equipment and personnel.
If applying responsible operational cuts is challenging, addressing the large expense of public safety personnel can be even more difficult. Our experience has shown that public safety services (i.e., 911, fire, EMS, and police, exclusive of corrections and jails) represent nearly two-thirds of a typical municipal expense budget. Although a number of cities generate some revenue through billing for EMS and fire services, severe reductions in revenue ultimately must be addressed through equally severe reductions in spending. The majority of fire and EMS agency costs are typically associated with the labor or staff.
Joseph J. Fitch, PhD, is the founder and president of Fitch & Associates (fitchassoc.com), a fire service and ambulance consultancy based in metropolitan Kansas City, Missouri. He may be reached at [email protected]. Michael G. Ragone is a senior associate at Fitch & Associates and leads the fire service practice. He may be reached at mragone@ fitchassoc.com. Keith Griffiths is the editor-in-chief of Best Practices in Emergency Services and president of the RedFlash Group, providing research and communications to public health and safety. He may be reached at [email protected].
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It is common to find 80 to 90 percent of a fire department’s budget attached to personnel compensation and benefits. The inescapable fact is that any real reduction requires cuts in current and future expenses for personnel.
Compounding the direct wage-and-benefit expense are the costs associated with pub- lic retirement systems across the country. The mayor of the City of Los Angeles, when warning of potential layoffs in 2010, said that soaring pension costs now eat up two of every ten dollars the city spends from its general fund.2 To address the problem, some communities are migrating away from defined-benefit programs to defined-contribution programs similar to a 401(k) plan; others have negotiated more favorable terms via tiered systems that offer less to new public employees or have increased employee contributions.
The need to reduce costs in operational budgets and wages has put some local elected officials in an undesirable position. Traditionally, they have sought endorsements from labor groups such as the International Association of Fire Fighters (IAFF), but they are now encountering a double-edged sword: The public’s negative reaction to what is per- ceived as overly generous salaries and benefit packages in a period of high unemploy- ment is making officials more cautious. The current economic crunch is encouraging fresh discussions about expanded roles and alternative approaches to service delivery.
If you’re considering putting your ambulance service out to bid…
This is a complicated but potentially rewarding process, if done correctly. In the profes- sional experience of this report’s authors in working with municipalities, there are four key considerations to take into account:
• System design — Underlying legal and organizational structure, financing strategy, business and medical oversight structure, and system safeguards
• Politics — Lobbying by special interest groups; expected, but can be diminished if you steer the conversation to a discussion of public policy
• Economy — Economies of scale, socioeconomic trends, system revenue sources, and payer mix
• Medical standards — The standard of care as defined by the medical authority, including response time standards, priority dispatch protocols, medical protocols, destination protocols, equipment standards, and personnel certification requirements.
A structured procurement process takes each of these factors into account in a compre- hensive, step-by-step approach that helps ensure a robust response. The essential ques- tion for city managers is: Should we focus our energies on making government a better producer of EMS, or a better buyer of EMS?
To read a comprehensive white paper, “Going Out to Bid: Why a Structured Procure- ment is Better,” see fitchassoc.com/icma. A special chart on the balanced decision process—highlighting each of the steps and the key questions that government leaders should answer when considering changes to their EMS system—is also available.
If you’re a subscriber, you already know that you get each new InFocus plus access to an electronic database of all reports (including under the previous name, IQ Reports) published since 1999, with easy keyword searches to put the information you need at your fingertips when you need it. If you don’t yet subscribe, click here to start benefiting from the InFocus subscription today! Or send an e-mail to [email protected] or call 202-962-3675.
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A variety of delivery approaches
The history of fire services and EMS in the United States tells a story of incremental change, versus a well-considered, objectively planned process for designing public safety services to meet the needs of customers. From community to community, a diversity of agencies vary in performance and funding from highly sophisticated and reliable to rudi- mentary and unsustainable.
Fire suppression and prevention Fire suppression and prevention services are typically provided by municipal departments
The challenge of fire service overtime
As cities and counties grapple with budget cuts and public employee unions work to retain pay and benefits, firefighters have recently found themselves in the eye of the storm. National news reports have drawn attention to the high salaries of some firefight- ers, mostly as a result of generous overtime and sick leave policies. The Orange County, Calif., Fire Authority paid $28 million in overtime pay in 2008, a 55 percent increase since 2003, according to a recent report in the Orange County Register. In 2008, the median pay for an Orange County firefighter was nearly $138,000, of which $36,000 was overtime.
At the Los Angeles City Fire Department, overtime pay rose by 60 percent from 1998 to 2008, according to an analysis by the Los Angeles Daily News. In 2008, more than fifty firefighters earned more than $100,000 in overtime pay alone—with one person bringing in more than half a million dollars in overtime over three years.
In Clark County, Nev., budget woes and the threat of layoffs have pitted the firefight- ers’ union against some elected officials and members of the community. In 2009, Clark County firefighters earned an average of $187,000 in total compensation, including ben- efits and overtime pay, according to the Las Vegas Review-Journal.
These statistics make some wonder why overtime is paid routinely instead of being reserved for special circumstances. Firefighters, however, see things differently—though even some quietly admit there can be, in individual cases, abuses. A typical schedule for a firefighter is to work ten 24-hour shifts per month. That means firefighters are actu- ally on the job about 56 hours a week—more than the typical 40 hour work week—mak- ing hourly pay rates lower than they at first might appear, said Gary Ludwig, deputy fire chief in Memphis, Tenn., and chair of the International Association of Fire Chiefs Emer- gency Medical Services Section.
Add to that the inherent physical dangers, and “I believe the job that we do, the effort we put out, and the sacrifices we make [are] worth the compensation that our firefight- ers receive,” Ludwig said. In addition, he said, in many cases it’s cheaper to pay overtime than to hire, train, and pay not just the salary but the pension and benefits for new workers. A rule of thumb is that if the cost of hiring and the benefits package exceeds 50 percent of pay, it costs less to pay time-and-a-half to existing workers.
Memphis pays relatively little in overtime: about $3 million of an annual budget of about $162 million. “When we crunched the numbers, we found it was cheaper to hire new employees than to pay overtime,” Ludwig said. To make sure his department is prepared to fill vacancies due to scheduled retirements, they hire and put new hires through firefighter training six months prior to when the position comes open.
Keeping open communications between the fire chief and the city or county manager is critical, Ludwig said. If municipalities want to stop paying overtime, they can do so by hiring new workers.
Source: Jenifer Goodwin.
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in urban and suburban areas and by volunteers in less densely populated areas. There are four common models for the organization of fire services in the United States.
Municipal/county In densely populated areas, it is most common to have municipal or county fire department funded primarily by general revenue or property taxes. The departments typically have 24-hour staffing by either fully paid firefighters or a combination of paid and volunteer or on-call firefighters.
Volunteer In less densely populated and rural areas and even some urban and suburban communities, volunteer organizations provide fire suppression. Volunteer departments may staff personnel at the station on an unpaid or paid-per-call basis, or volunteer firefighters may respond from home.
For-profit A less common method of providing fire suppression is through for-profit companies. A limited number of for-profit fire agencies have existed since the 1950s and currently can be found in unincorporated communities in Tennessee and Arizona.
Industrial/airport In addition to fire services for residences and businesses, specialized fire service units exist at airports and large industrial sites. Municipal fire departments or private contractors may provide aviation fire services. Large industrial sites may provide their own fire suppression personnel or a private contractor.
Traditionally, the fire service limited its activity to fire prevention and suppression and “heavy rescue”–related services. Over the past thirty years, however, the mission of most fire departments evolved to include out-of-hospital emergency medical response care, and in some communities, ambulance transport.
Emergency medical services
The fire service has always had some level of involvement in medical emergencies. Over the past thirty years, however, the mission of most fire departments has evolved to include out-of-hospital emergency medical response and care in a more integrated way. This may range from offering basic medical first response and to providing full EMS and medical transportation.
Six common provider types delivering EMS are fire service, public utility model, third government service, private for-profit agency, community-based or volunteer nonprofit agency, and hospital-based service. (See Table 1 for a description and the advantages and disadvantages of each.) Ambulance transport services have existed in some form for more than a century. Hospitals, funeral homes, private ambulance companies, and fire departments all played a role, but it wasn’t until the late 1960s that EMS systems evolved into organized community programs. This was the result of a major federal report in 1966 on accidental death on U.S. highways and clinical research showing that early interven- tion in sudden cardiac arrest outside the hospital could save lives.3,4 The report resulted in national demonstration projects and the infusion of millions of tax dollars into EMS system development, which lasted until the early 1980s. The fire service was one of the many entities engaged in medical response as a part of this initiative.
Fire departments as medical first responders—and associated challenges
Today the fire service is one of the leading providers of EMS response and transport in the United States. Fire departments are the primary medical first responder organization in most communities due to short response times, skilled manpower, and ability to bring
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Description Advantages Disadvantages
Fire service Typically, fire and EMS agencies are described as either single role—when ambulance personnel operate as a separate (civilian) division within the fire department— or dual role—when the same personnel provide both fire and transport coverage.
• Public confidence in the fire department
• Integrated command and control
• Public officials’ direct control of day-to-day operations; utilization of capacity currently available within the fire department, particularly when cross training and dual role personnel are utilized.
• Primary use of 24-hour shifts, which limits the ability to match resources with demand
• Complexity, lack of flexibility, and required impact bargaining of labor agreements
• Traditionally higher labor costs
• Level of effort (number of stations/units), rather than performance-based requirements.
Public utility model This approach uses a separate governance structure whose members are appointed by, and funding levels approved by, elected officials. Public utility systems use a highly defined business structure in which a public agency provides oversight and either directly provides or contracts with a private service provider for day-to-day operations.
• Performance-based contracts
• Public ownership of essential assets
• Transparent transfer from one contactor to another during a bid cycle
• Flexibility to involve other jurisdictions and services in a regional approach.
• Complexity of the business relationship
• Possible reluctance of local elected officials to develop the redundancy of a separate entity for oversight
• Employees may be required to change employers at end of contract cycles
• A limited number of qualified bidders.
Third government service
This type of service is consid- ered a uniformed public safety service, like police and fire, but typically employs civilians in a separate department or ambu- lance district. Finance, purchas- ing, vehicle maintenance, and other support functions are either directly provided or sepa- rately contracted by the parent governmental agency.
• Increased schedule flexibility and lower personnel cost structure (as a result of utilizing the civilian workforce)
• Single-mission delivery focus
• Direct control of day-to-day operation by local government
• Public sector ownership.
• Cost containment is dependent on the parent entity’s budgetary and managerial process for expenditure control
• Generally no operational performance-based requirements
• May be relegated to a position of less importance than other municipal public safety departments.
time-sensitive, life-saving interventions to a patient quickly. For example, a fire engine company that can get to a scene in four minutes, initiate CPR, and deliver electric shocks using an automated external defibrillator can dramatically improve out-of-hospital cardiac arrest survival in a community.5
The fire service’s role as a medical first responder is rarely challenged. What is often debated is the expense of getting the right resources to the right place in the right amount of time. Citizens are understandably puzzled when a fire engine with four fire- fighters, a rescue truck, a police vehicle, and an ambulance all arrive at the scene of what appears to be a routine call. Isn’t that a waste of resources? Not necessarily, but it
Table 1 Service delivery approaches
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does raise legitimate concerns. While cities report that half of all calls are responded to using advanced life support (paramedic) resources, only a fraction of those are actually life-threatening.6 Research shows that paramedic-level care is beneficial in a handful of critical instances.7 However, the Institutes of Medicine have called for more study to bet- ter understand how EMS can most effectively improve patient outcomes.8
Description Advantages Disadvantages
Private for-profit Service is provided using an exclusive or non-exclusive franchise or contract with the local government. It may or may not include rights to provide non-emergency services. Contracts may be level-of- effort or performance-based. Clinical performance, assets, capitalization, and day-to-day operations are managed wholly in the private sector.
• Limited day-to-day involvement for the local government, including public labor unions or public employees
• Performance contracts generally define services provided
• Labor cost structures are generally lower than nearly all public sector providers
• A local government’s system design and ongoing oversight costs may be recovered through franchise or user fees.
• Accountability and transparency issues associated with private firms
• Little financial oversight; financial oversight must be built into agreements, otherwise it is limited
• Agreements must be carefully developed to optimize competition and eliminate “free for all” unregulated competition
• Fewer career development opportunities, so personnel turnover may be higher
• Sudden service withdrawal could create crisis.
Community-based or volunteer nonprofit agency Service is provided by volunteers, paid personnel, or a combination of the two. Organizational governance comes from within the organization. Service may be supported by donations, user fees, or government subsidies. Assets, while often donated by the community, are typically under the control of the agency board.
• Lower cost structure
• Little day-to-day involvement by local government
• Service demands generally determine staffing model (use of paid personnel in addition to volunteer workforce).
• Difficulty recruiting volunteers
• Resistance to accountability and transparency issues
• Leadership, clinical competencies, and tenure vary widely based on individual member commitment
• Frequently undercapitalized and require additional public funding to stay solvent.
Hospital-based service
Service is provided by a local hospital or stand-alone entity owned or controlled by a hospital. Contracts may be level-of-effort or performance based. These services are frequently nonprofit and draw on the hospital’s clinical and administrative resources.
• Public confidence in the health care institution providing service
• Robust opportunities for clinical enhancements and positive career paths
• Capital usually provided by the hospital
• Limited day-to-day involvement by local government.
• Can be a low priority within the hospital’s financial and operational structures
• EMS revenue recovery overshadowed by hospital revenue recovery efforts
• May require some local tax funding.
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In the meantime, is it sound public policy for fire agencies to provide a lights-and- sirens response to every 911 request for service, or for personnel on every apparatus to be paramedics? With the previously discussed data in mind and for safety purposes, many communities limit the fire department’s first response to only those requests prioritized as life-threatening emergencies, in accordance with strict medical dispatch protocols.9
Fire departments facing budget constraints are exploring alternative strategies for meeting demand. Several have successfully implemented approaches to accomplish that goal. For example, in suburban Portland, Ore., Tualatin Valley Fire and Rescue deploys peak-demand engine companies or rescue response vehicles to match demand. During times of peak requests for service, response times can be maintained to the benefit of patients in need. To reduce the service-level impacts associated with shutting down fire companies, the San Jose Fire Department is using an innovative resource management strategy they devised called dynamic deployment. It requires an additional investment in resource-management software tools, communication center personnel, and ongoing data gathering and analysis, but it is anticipated to reduce service-level impacts to the most critical calls.10
Several communities—including Louisville, Ken.; Richmond, Va.; and Cleveland, Ohio—are experimenting with protocol-based triaging of non-emergency calls at the 911 dispatch level, providing callers with alternatives such as a nurse-assist line or an appointment and transportation to a clinic. This approach reduces responses to non-life- threatening calls, lowering costs and enabling scarce resources to remain ready for prior- ity calls.11
The role of fire departments and private ambulance services
The fire service and the private ambulance industry are the two largest providers of emergency ambulance service in the United States,12 but they view EMS delivery from contrasting perspectives. The fire service views its role as an “all hazards” department, with EMS as an extension of its public safety mission. Its involvement in EMS stems from many sources. In some communities, the fire service adopted EMS when a private pro- vider proved unreliable or abandoned the market. In other cases, many departments saw EMS (beyond first response) as a natural growth opportunity. For others, EMS was an opportunity for the fire service to increase revenue and maintain jobs as fire calls dimin- ished. This wasn’t always the case in every department, but today’s fire service is almost universally passionate and committed to being involved in EMS delivery. An example of this interest was recently evident when fire service stakeholder groups aligned to create the Fire-Based EMS Advocates Group and developed an informational campaign to pro- mote the fire service as the ideal provider for EMS.13
In contrast, the private sector views its own role as a health care and medical trans- portation provider delivering services in a public safety environment. Private providers often have a close connection with the communities in which they operate, but unlike fire departments, are typically contractual in nature. Ambulance contracts vary widely, from level-of-effort agreements (e.g., a company will base an agreed-on number of ambu- lances in a community 24 hours a day, 7 days a week) to comprehensive, performance- based contracts clearly delineating requirements and expectations. Private services are frequently focused on medical response and transport alone and typically do not expand into services unrelated to the core mission. The American Ambulance Association, a pri- vate sector advocacy group, has published a reference guide for community leaders con- sidering procuring emergency ambulance services.14
Fire departments and private ambulance companies both lobby local officials for the right to deliver emergency ambulance service. While each group promotes its model as
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the better option, no published research supports one model over another in terms of patient outcomes or efficiencies, and there is no indication that the diversity of providers will cease in the future. Local governments may benefit from adopting procurement prin- ciples, regardless of their current service delivery model—and whether or not they intend to conduct formal ambulance procurement.
Current fire/EMS reimbursement issues, future trends, and health care reform
The fire service has traditionally relied on tax revenue for funding. During the past decade, many fire agencies have added user fees to supplement this source. If a fire department provides emergency ambulance service, it is also possible for the agency to be partially reimbursed a fee-for-service through the billing of individual patients and insurance carriers. Rarely does the fee charged cover the full cost of providing the response and transportation service, and fire agencies commonly charge less than non- governmental providers and are not typically required to recoup the full cost of services because they receive community tax support.
Confusion often results when comparing transport-fee collection statistics among communities and entities. In our experience, nonprofits, government-based entities, and private companies use differing methods to calculate collection percentages. This makes benchmarking difficult and can result in one entity quoting higher collection performance than another, when the real difference lies in how the collection rates are calculated and how each entity accounts for contractual allowances (the amount that must be written off from Medicare and Medicaid charges due to federal requirements) and bad debt. The most reliable indicator of collection percentages is calculated by using the actual cash collected compared to the total amount billed.
Regardless of delivery model, EMS providers—like other health care providers—serve patients covered by a variety of insurance plans, as well as those who are underinsured or who have no health coverage. Because agencies do not receive full reimbursement for the services delivered, they must build unreimbursed services into their rate structure, thereby shifting the burden to private insurers (i.e., cost of service + unreimbursed ser- vices = retail cost). This may change with introduction of health care reform, but the impact on EMS reimbursements is not yet clear. Almost half of EMS patients are Medi- care and Medicaid patients. If states begin to cover the uninsured and better support the underinsured, increased revenue from fees could result. It’s not clear whether this will change the payment levels of other insurance payers.
Health care is moving away from level-of-effort reimbursement (i.e., payment for delivering a service regardless of if it was appropriate or delivered without error) to paying for only evidence-based care that is delivered safely. Today, EMS is funded for transports only (i.e., agencies typically receive reimbursement only when a patient is transported, as opposed to, say, when a patient is treated at the scene but refuses trans- port). This is true regardless of whether the care was appropriate or correctly delivered. As the reimbursement model evolves, EMS may be reimbursed for the care delivered, but at the same time could be required to focus on patient safety and to deliver the right evidence-based care. In our experience, most EMS provider organizations are not pre- pared for such a change, due to a lack of performance measurement and reliable process design. EMS providers of every variety need to begin now to develop reliable patient care systems, based on current evidence-based guidelines. EMS systems need to incorporate a series of outcome, process, and balancing measures that can be viewed over time to aid in process improvement and reduction in variability.
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Compounding issues
Fire and EMS agencies have become a social safety net for many people: Calling 911 brings a response, no matter the caller’s ability to pay, immigration status, or station in life. But when uninsured patients use 911 and the emergency department as a way to get primary health care, the cost to the system is far more expensive than if they had accessed care at a clinic or a doctor’s office.
In addition, the fire service faces several compounding issues, including: • Expanded fire service missions • Fewer fire calls • Post-9/11 assignments and disaster readiness • Decline in volunteers and expansion of career personnel • Response time issues • Public expectations • Brownouts and similar cost-reducing tactics • Effect on mutual aid.
The following sections discuss each of these issues.
Figure 1 Distribution of U.S. fire service call volume, 1986–2009
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Expanded fire service missions
Similar to the role it plays as a social safety net, the fire service’s embrace of an all-haz- ards mission has led to mission creep and added expense, as departments take on spe- cialized tasks such as swift-water rescue, confined space rescue, and hazardous materials response. These expanded roles require new skills, specialized equipment, and ongoing training. At the time, the decision to add additional responsibilities was based on good intentions—but now, many departments are struggling to maintain the staffing and skill levels required to safely provide these high-risk services.
Fewer fire calls
A critical development in the past twenty years is the dramatic reduction in fire-related responses, structure fires, and fire-related deaths. Between 1986 and 2008, the number of actual fire responses decreased by more than one-third.15 During that same period, total fire department call volume more than doubled, to more than 25 million requests for service in 2008.16 Much of that increase has come from additional calls for medical assis- tance. Figure 1 shows the distribution and growth of fire service calls.
Although residential fires still account for 84 percent of all structure fires in the United States, between 1986 and 2008, responses to residential fires declined more than 30 percent. In the same period, deaths in residential fires declined 42 percent.17 Fire prevention, improved building codes—including requirements for automatic sprinkler systems—early detection systems, and new firefighting technologies have resulted in this stunning reduction.
Post-9/11 assignments and disaster readiness
In the post-9/11 era, most fire departments have increasingly been tasked with addi- tional assignments, such as preparing for events related to weapons of mass destruction, formalizing incident command, conducting urban search and rescue, and addressing pandemic flu and active-shooter scenarios. The true cost of readiness is frequently mis- understood. Constant readiness for infrequent events—or events that may never happen but would have catastrophic consequences for an unprepared community—is expensive. The cost of readiness shows up in training, disaster drills, special equipment, and reserve forces.
Decline in volunteers and expansion of career personnel
Volunteers have always played an important role in America’s fire service, but volun- teerism is waning. Individuals now work in distant communities and have less free time, even as training requirements increase and liability concerns grow. While the number of volunteer firefighters has decreased since 1983, career firefighters increased by nearly 34 percent during the same period.18
Community officials often want to know if their fire service staffing levels are on par with those in other places. One informal yardstick sometimes used is the number of fire- fighters per thousand population, used to compare one community to another to bolster support for increased staff. But communities are so variable—and departments’ missions, risk profiles and scope can be so different—that these comparisons must be taken with a grain of salt. We know of no reliable evidence that supports an optimal number of fire- fighters per thousand population.
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Response time issues
With budget cuts, longer response times have attracted the attention of the press in a variety of communities. Fire companies have been shuttered without changing the deployment strategy, resulting in units that are farther away being the first to arrive at the scene of fires or medical emergencies. This delayed response allows additional time for fires to become larger in size and complexity, and in true medical emergencies, such as choking or sudden cardiac arrest, it may make a difference between life and death.
According to the 2000 U.S. Census data, 79 percent of the U.S. population lives in an urban area.19 In a recent survey of the emergency services in the 200 largest U.S. cities, only 63 percent of first responders reported measuring response times in accordance with National Fire Protection Association (NFPA) Standard 1710, which requires the crew to arrive at the scene of an emergency within six minutes.20,21 NFPA Standard 1710 allows for 60 seconds of dispatch time, 60 seconds of crew mobilization time, and 240 seconds of drive time (6 total minutes). Although the evidence supporting the time standard is limited and often contested, it remains the only nationally accepted standard communi- ties can use to benchmark performance.
More troubling in the survey is the fact that only 28 percent of the departments using the NFPA standard report being in compliance. Currently no national study or reporting requirement is in place to measure all communities throughout the country. Meanwhile, objective response time measurements are sporadic to nonexistent in most places, in our experience.
During tough economic times, many communities experience an increased demand for EMS, as residents have fewer health care options. Job losses and resulting losses of insurance benefits affect access to family physicians. Calling 911 and going to an emer- gency department (ED) become substitutes for primary care. This sets up a daunting challenge: As the demand for both ED and ambulance services expands, wait times in the ED increase, causing both service delays and reduced productivity for ambulance crews. With many EMS systems already coping with previous cutbacks, the result is even greater difficulty in providing timely services—or even maintaining critical services.
As noted, tax revenues are not likely to improve in the near term. We believe that many communities will face fundamental changes in the provision of fire and EMS. The key question for them is: Will your community safely and systematically plan for change, or will it be reactive and subject to the whim of special interests?
Public expectations
Most taxpayers are not aware of the actual cost to operate their fire services and EMS. Most also do not know if their fire department provides effective service or represents good value when compared to other similar agencies. Sensationalized media coverage and dramatic portrayals of emergency services often distort public and elected officials’ understanding of fire and EMS departments and the actual work they do. Furthermore, smaller communities can be strongly invested in having their own hometown fire depart- ments. While consolidating a variety of small agencies into one can make real economic sense, it can be hard for a community to give up the perceived control and community identity they have become used to. Regions facing true hardship may find consolidation as the only alternative.
Many fire and EMS agencies facing cutbacks are ill-equipped to make sound decisions regarding station closures or reduction and elimination of programs. This is mostly due to the lack of meaningful data. The fire service collects run-volume statistics, but data is not typically outcome oriented. In other words, it’s difficult to show a direct correlation between cost-reduction strategies and patient outcomes or structure fire losses.
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Brownouts and similar cost-reducing tactics
The news media are filled with regular reports of communities “browning out” fire sta- tions on a rotating basis. Brownouts occur when staff is reduced on each engine or truck company, often on a rolling basis, as an alternative to closing specific stations or taking certain pieces of equipment out of service. But, in truth, such practices do little but give the impression that the agency is acting to address the underlying problem. Without clearly measuring the pre- and post-reduction results, the department cannot know the real effect on the safety of citizens or employees.
Dramatic changes in resources should never be executed without a detailed under- standing of the likely outcomes and risks involved—including strategies to mitigate those risks. Without this understanding, a fire agency is rolling the dice with the public’s health and welfare. For example, say a community with six fire stations has decided to rotate the closure of one station per day. Each station, depending on its location, has dif- ferent risks associated with its specific response area, and it responds to a different num- ber of calls each day. Some stations are very busy; some are not. Some serve high-risk, industrial areas or densely populated areas, while others may serve neighborhoods with relatively low fire risk. If the downtown station runs an average of ten calls per day and a slower station only runs an average of one call per day, the risk to an individual living downtown for delayed care or fire response is exponentially greater when that station is closed for the day.
Policymakers must understand the consequences of station closures before making changes. Better data and information provide greater ability to minimize the risk. Further- more, any failure to quantify the impact and mitigate potential risks will only fuel critics when there is a significant degradation in the response to a major event, such as a fatal house fire or serious vehicle crash.
Reducing expenses associated with transporting EMS patients is another strategy being considered. Several large cities are exploring the pros and cons of privatizing their systems’ EMS transport component. The stated goal is a reduction in full-time fire depart- ment employees and resulting cuts in personnel costs. However, the “soft” or down- stream effects must also be taken into consideration for an honest comparison. Before privatizing, community leaders should consider the impact on the effective fire force and the collection of third-party revenues.
Effect on mutual aid
Reducing the number of firefighters may also mean increasing dependence on mutual aid from surrounding areas. Communities that were once self-sufficient for basic fire response now routinely find themselves needing support from other fire agencies. In fact, mutual-aid requests increased more than 400 percent from 1986 to 2008, with more than half of the fire agencies in the United States routinely relying on mutual aid for first alarm (initial) assignments.22,23 As communities further reduce costs and response capac- ity, mutual-aid requests will likely increase. Stretched to the breaking point, some fire agencies are questioning their ability to provide surrounding communities with mutual aid if they can’t provide reliable service to their own citizens. How would the commu- nity react if a response to a critical event were delayed or insufficient because units were deployed elsewhere?
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20 questions to discuss with your fire chief
1. How does the performance and cost of our program objectively benchmark against others with similar volumes and demographics, and where can we get the data to answer questions?
2. Are stations in the right locations to optimize our response capabilities and resources?
3. How many response resources is the “right” amount for fire calls? For medical calls? What tells us that this is correct?
4. What is an acceptable productivity level to expect from EMS personnel?
5. What is an evidence-based and legally defensible response-time goal for our community, and how often do we reach critical response levels (i.e., too few units)?
6. Many communities use a 90th-percentile response time as a standard for first arriving units. What is our response time standard?
7. Do we need to send a fire apparatus to calls, including all medical requests from 911?
8. Do units need to respond with lights and sirens to all 911 calls, despite the nature of the complaint?
9. How much down time do our fire and EMS personnel have while waiting for calls? How do we evaluate the “right” number and schedules for staffing?
10. How does our department treat the standards that are published by the National Fire Protection Association (NFPA) and the Insurance Services Office (ISO)—as requirements or as guidelines?
11. Fire-related responses are declining significantly. When are the numbers low enough to consider consolidating or contracting with another community? Are there other alternatives to having our own fire department?
12. Some communities are selectively closing stations (i.e., enacting rolling brownouts) to reduce costs. What are the benefits and risks of this strategy?
13. In addition to providing medical first response service, should our fire department get into or out of the business of transporting patients?
14. Should we consider getting into the business of non-emergency transports (interfacility and scheduled transports) and the extra revenue that might bring?
15. Regardless of what others are doing, is our fire department better positioned to provide EMS transportation in our community than other organizations? What factors should be considered?
16. Besides privatization, what strategies could be used to improve efficiency of our service?
17. Can service levels be enhanced without changing the governance structure or making significant additional investments?
18. How can we be assured that the processes, procedures, and protocols utilized in managing our emergency service agencies reflect current best practice? Where are we getting our information?
19. Fire and EMS are dangerous occupations and generate significant internal and external litigation. How should our fire and EMS system evaluate and mitigate both safety and legal risks associated with providing these services?
20. Emergency services represent a large percentage of our community’s budget. How do we show the taxpayers we are getting the best value for the dollars we spend?
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Tough choices in fire and EMS
Fire service leaders face difficult decisions, many on an unprecedented scale. Strate- gies that worked in the past may not be effective today. Traditionally, reducing expenses meant reducing training and travel, eliminating civilian positions, cutting back on the quality and quantity of office supplies and other nonessential materials, or delaying a new cadet academy or new stations. What happens now, when those tactics don’t come close to closing the budget gap? How do fire service and civic leaders make the right choices not just to meet this year’s budget, but for the long-term health and benefit of their department and the community? For a list of tough questions that city and county managers should be ready to ask their fire chief, see the “20 questions” sidebar.
Define the core mission
The process for making decisions may not be as complicated as it seems. First, depart- ments must refocus on core services. A detailed understanding of what fire departments are called on to do by their constituents will aid in clarifying their core mission. As Fig- ure 1 shows, in the vast majority of departments, response to medical emergencies is the number-one activity based on need, followed by motor vehicle collisions and fire-related calls—but each department needs to establish its own set of priorities based on commu- nity needs and values.
Focus on priority services
Once core priorities are established, the department can focus on ensuring that those pri- orities get proper attention. Establishing core priorities enables critical decision making about where to invest time, cut costs, or consider service elimination. For example, imag- ine a budget meeting where a decision needs to be made between buying new automated external defibrillators (AED), which could save dozens of lives each year, and purchas- ing new wetsuits for the dive rescue team to recover the remains of drowned swimmers. Historically, this could be a tough decision, decided by passionate debate between the responsible chiefs as to why one should receive funding priority. However, when the leadership team starts the discussion by clarifying its core mission, identifies the fre- quency of specific calls, and conducts a risk assessment, the decision becomes much easier. In this example, medical emergencies make up the majority of the call volume, and AEDs have been proven to save lives. They become the priority for purchase.
Use data to drive decisions
In addition to making key decisions based on the core mission, departments need to embrace data to drive decisions and focus on what results they are striving to achieve. For example, fire departments, like other public safety organizations, need to consider two foundational elements when matching resources to service needs: (1) provide geo- graphical coverage so that appropriate resources may respond in an evidence-based time frame for medical and fire calls and (2) supply those resources in adequate numbers to meet fluctuations in call demand.24
Police and EMS agencies have been experimenting with these concepts, but the fire service has limited experience with them. The key is to focus on what you’re trying to achieve. For example, research shows that the ideal number of firefighters to safely enable entry into a house is four.25 To achieve that goal, fire departments have focused on putting four personnel on every apparatus versus creatively looking at achieving the result of four personnel at the scene. The difference may be subtle, but it could mean that two pieces of apparatus cover a wider area with two or three people, so that the
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system is designed for the ideal number to arrive on the scene together. Focusing on the outcome or the result helps you to define the “what” and hopefully not get anchored by the “who” or “how.”
The key in these examples is obtaining clarity on the goal and using data and infor- mation to drive the decision. With a clear aim and good data, it’s not only easier to make sound decisions but also easier to communicate those decisions to staff and the public in a way that is clear, factual, logical, and free of the traditional selling that comes with decisions that are not made methodically. The process can still be difficult, but when stakeholders and decision makers are able to see the data and understand the reasoning, change initiatives can be implemented more quickly and with less resistance.
Use technology in decision making
Most departments have a wealth of data at their disposal. Valuable information about calls (including when, where, and type of call) is first recorded in 911 call centers. Agen- cies use computer-aided dispatch, geographic information systems, and record manage- ment systems to capture, profile, and analyze data. Unfortunately, without understanding the underlying processes that need to be managed, many departments have purchased either systems that provide only a single non-integrated solution or a “one size fits all” computer system that promises to do many things, but does none well. Effective data systems, once considered novel, are now among survival attributes for agencies. Addi- tional attention is required to capture data that will inform key process and management decisions.
Specific information about calls is also available though patient care reports that are increasingly done electronically. New federal health initiatives are encouraging inte- grated pre-hospital and hospital record systems that will allow study and improvement of patient outcomes. A variety of software programs assist in the analysis of data, providing guidance in the deployment of resources and monitoring of operational performance indi- cators, such as response time and time units spend idle at emergency departments. We’ve seen an increasing number of communities employing technology to help them better understand where to build new fire stations—and which ones to close.
A process for making tough decisions
Decisions to close stations; reduce staffing; and change schedules, work rules, and other mechanisms to control costs are often complex and always controversial. Making a dif- ficult decision in such an emotionally charged environment requires special attention to the process of making the decision in a disciplined manner and then implementing the decision with positive action.
The balanced decision process developed by the City of Cedar Rapids, Iowa, is a solid guide that other communities can adapt. This process has three distinct phases and seven steps recommended for making difficult public safety decisions, as illustrated in Figure 2.
Process, policy, and decision discussions are clearly separated in this approach. In a “real world” example, a suburban community has invested heavily in infrastructure and has limited reserves. It is grappling with an explosive housing boom that has suddenly stopped. Multiple poor decisions were previously made, now creating a severe revenue shortfall that is expected to continue for a number of budget cycles. Cuts are being made across the community, and it’s been suggested that two of nine fire stations be closed.
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Figure 2 Balanced decision process
Process discussion In the first phase (process discussion), the decision elements and informational elements are identified, timelines are developed, and the entire process is agreed on. Questions at this stage may include:
• What are the appropriate decision points?
• What questions need to be answered?
• What information and data are needed to answer those questions?
Courtesy of the City of Cedar Rapids, Iowa.
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These question help ensure that the process is intentional and that council members’ needs are anticipated early, rather than allowing the process to evolve haphazardly. Using the station-closing example, key elements in this phase are the determination of (1) what statistics and fiscal and operational analysis may be needed, (2) what those will cost, (3) what committees will address specific components of the issue, and (4) how the public will be engaged in the process.
Policy discussion
In the second phase (policy discussion), information is developed, reviewed, analyzed, and discussed to ensure that a thorough understanding of specific advantages and dis- advantages and the public policy implications for each option are clear. In our station- closing example, an independent analysis was commissioned during process discussion to review risks, identify potential mitigation strategies, and identify multiple future-state options for the fire department. In the policy discussion phase, information is presented, various stakeholder groups’ views and public input are considered, and council policy discussions focus on vigorous debate of the advantages and disadvantages of various options—not on support of particular positions.
Decision discussion
In the third phase (decision discussion), a final decision is reached after vigorous but principled debate occurs. Focus is placed on the discussion of positions and the rationale for those positions so con- sensus can be reached.
This approach recognizes that public health and safety issues are often emo- tionally laden. Transparency and the open disclosure of the advantages and disadvantages of each option being con- sidered enhance the public confidence in the ultimate decision reached.
Communicating with stakeholders
Once a decision is made, how you com- municate it is one of the most important elements of the change process. Laying groundwork with important stakeholder groups is essential, along with developing a communications plan that addresses the informational needs of key constituents. Your communication plan articulates your key messages and takes into account all of the ways you want to express those messages—through traditional and alternative media, your own website, town hall meetings, and every other way people in your community will get information and develop perceptions.
Your key constituents include the agency’s staff, public employees and union leader- ship, neighborhood groups, local business and chamber of commerce groups, and the media. For each of these groups, the following four questions must be answered.
Questions to be prepared to answer when seeking change
• What are we trying to accomplish?
• What’s wrong with the old way of doing things?
• What specifically will change?
• How does this affect me? (resident, visitor, employee)
• When and how will this be implemented?
• What can I do about it?
• How will this impact performance or outcomes?
• How will I know a change is an improvement?
• What is leadership doing about this?
Source: Adapted from Daryl R. Conner,
Managing at the Speed of Change, Villard
Books/Random House, 1992.
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• How will each group be affected by the change? Changes will not have the same effect on every group, and in the case of bargaining units, impact bargaining must be part of the process. It is important to know what evidence supports the assessment impact to be able to move from voicing opinions to sharing objective data. One of the tasks is to determine how to effectively target the message to different groups.
• What are the groups’ most likely points of resistance? Answers to this question flow directly from the first question. You must ask them to identify concerns and help them articulate the “iceberg” issues that may be looming large beneath the surface. Anticipate that not all members or groups can fully articulate their concerns, and try to harvest the dissent to be able to respond thoughtfully.
• Who are the champions? Champions are important out in the trenches, where change takes place. Influence is not distributed equally. Often the viability of the change process rests with the reactions of key opinion leaders. Identifying the cham- pions in each group and developing tactics to influence these individuals should not be overlooked. It’s just as important to understand that some groups will not be influ- enced and will remain in opposition to change.
• How will the information be communicated? A variety of channels should be uti- lized to communicate about the impending change. Remember the “rule of seven”: Communication experts cite research that shows that leaders must repeat the mes- sage at least seven times before most people will understand it. Repetition is not only okay; it’s a must. Make sure the leadership team has solid information early so that the communications can be consistently cascaded throughout the organization and community.
In addition to the fundamental legal and human resource requirements of imple- menting changes that may impact the future livelihood or employment status of staff members, the messaging needs to be focused on the organization’s mission and how the decision and the implementation process move the organization toward accomplishing its larger mission.
Summary
Even as the U.S. economy slowly recovers from recession, communities are expected to face tight budgets for years to come—and in some cases, unprecedented cuts will have to occur. While across-the-board reductions may seem fair, public safety agencies, and in particular fire and EMS, have special considerations to take into account. The core mission of fire departments has changed dramatically in the past fifty years, as medical- related calls have far outstripped fire suppression, yet fire suppression requires more personnel on scene. Some communities have used the budget crisis to fundamentally rethink their approach to fire and EMS. To do so effectively requires access to data and a systematic approach to engaging key stakeholders with a frank discussion of implementa- tion options and policy choices.
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1. Speech by Kevin Cochran, then director of U.S. Fire Administration, April 27, 2009, at the Fire and Rescue International Conference, Dallas, Tex.
2. Michael Blood, “LA mayor calls for layoffs, service cuts,” Associated Press, April 20, 2010. ABC News, abcnews.go.com/Business/ wireStory?id=10431697 (accessed December 5, 2010).
3. Division of Medical Sciences, Committee on Trauma and Committee on Shock, Accidental death and disability: The neglected disease of modern society. Washington, D.C.: National Academy of Sciences, National Research Council, September 1966.
4. Mickey Eisenberg, “Life in the balance: Emergency medicine and the quest to reverse sudden death,” New England Journal of Medicine 337 (July 17, 1997): 206–20.
5. Ibid.
6. Ian G. Stiell, Ontario Pre-hospital Advanced Life Support (OPALS) Study, Ottawa, Ontario: Canadian Health Services Research Foundation, February 25, 2005.
7. National EMS Advisory Council, “EMS makes a difference: Improved clinical outcomes and downstream healthcare savings” [position paper], ems.gov/pdf/nemsac-dec2009.pdf (accessed December 5, 2010).
8. Institutes of Medicine, “Emergency medical services at the crossroads” [white paper], June 13, 2006.
9. Kate Boyd Clawson and Jeff J. Dernocoeur, Principles of Emergency Medical Dispatch. Salt Lake City, UT: The National Academies of Emergency Dispatch, 2005.
10. Jenifer Goodwin, “An alternative to brownouts?” Best Practices in Emergency Services 13 (10): 1.
11. Jenifer Goodwin, “Precious resources,” Best Practices in Emergency Services 13 (7): 1, 10–11.
12. David Williams and Mike Ragone, “200-City Survey,” Journal of Emergency Medical Services February 2010: 38–42.
13. Fire Service-Based EMS Advocates, “Prehospital 9-1-1: The role of the fire service in EMS” [white paper], fireserviceems.com/download.php (accessed December 5, 2010).
14. American Ambulance Service, “Emergency services structured for quality” [special report], 2008.
15. Michael J. Karter Jr., “Fire service loss in the United States 2008,” and previous reports in the series, updated December 2009. National Fire Protection Association.
16. Ibid.
17. Ibid.
18. Ibid.
19. U.S. Department of Transportation, Federal Highway Administration, “Census 2000 population statistics: U.S. population living in urban vs. rural areas,” updated February 9, 2004. www.fhwa.dot.gov/planning/census/cps2k.htm (accessed December 5, 2010).
20. Williams and Ragone, “200-City Survey.”
21. National Fire Protection Agency Standard 1710, “Standards for the organization and deployment of fire suppression operations, emergency medical operations, and special operations to the public by career fire departments” updated 2010.
22. Ibid.
23. Ibid.
24. Ibid.
25. Ibid.
Notes
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Additional resources
• American Ambulance Association. EMS structured for quality: Best practices in design- ing, managing, and contracting for emergency ambulance service. McLean, Va.: Ameri- can Ambulance Association, 2008. fitchassoc.com/icma.
• Fire Service-Based EMS Advocates. “Prehospital 9-1-1 emergency medical response: The role of the United States fire service in delivery and coordination” [white paper], 2007. fireserviceems.com/download.php.
• Fitch, Jay, and Keith Griffiths. “EMS in critical condition: Meeting the challenge.” IQ Report 37 (5). Washington, D.C.: International City/County Management Association, 2005. bookstore.icma.org.
• Institute of Medicine. Emergency medical services: At the crossroads. Washington, D.C.: National Academies of Science, 2006.
• National Highway Traffic Safety Administration. Emergency medical services agenda for the future. Washington, D.C.: U.S. Department of Transportation, 1996.
• ———. EMS workforce agenda for the future. Washington, D.C.: U.S. Department of Transportation, 2008.
• ———. National EMS research agenda. Washington, D.C.: National Highway Traffic Safety Administration, 2001.
• U.S. General Accounting Office. Ambulance providers: Costs and expected mar- gins vary greatly. Washington, D.C.: U.S. General Accounting Office, May 2007. GAO-07-383.
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VOLUME 42/NUMBER 5, ITEM NO. E-43636
Recent Reports No. 4, 2010 Strengthen Your Local Economy through Economic Gardening
No. 3, 2010 The 5 Qualities of Collaborative Leaders—and How Communities Benefit
No. 2, 2010 Build a Successful Volunteer Program to Drive Growth and Recovery
No. 1, 2010 Promote Economic Development with Public-Private Partnerships
No. 6, 2009 Operations Planning for Improved Performance in a Tough Economy
No. 5, 2009 Creating a Multidimensional Talent Strategy to Avert Brain Drain and
Other Future Disasters
No. 4, 2009 Community Building: How to Do It, Why It Matters
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