valley emergency medical services final version2-disasterbydesign 8-2004

7/30/2019 Valley Emergency Medical Services Final VERSION2-DisasterbyDesign 8-2004

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Evaluation of VEMS for the Council of Governments

DISASTER By DESIGN LLC. 1 203 673-4847Strategies for the Unexpected [email protected]

Valley Emergency

Medical ServicesSystem Evaluation

Jonathan BestDisaster By Design LLC.

Strategies for the Unexpected


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TABLE OF CONTENTS

Topic Pages

Purpose of Study 3Time Frame for Study 3Consultant Focus Group 3

Methodology 4Interviews 4Data Review 4Document Review 5Maps 5Financials 5Meeting minutes and Correspondence 6Bylaws 6Findings 7The Communities VEMS Serves 7Common Ground 7

Issues Affecting VEMS ` 8Analysis of the current VEMS 9 - 10Points of Departure for Paramedics 11EMD Impact 11Suggested Departure Point (Present) 12Suggested Departure Point (Future) 13Options for Paramedic Service 13 - 16Operating Efficiency and Value 17Cost of Present System 17Financial Oversight 17

Bundle Billing 18 - 20Governance Model and Structure 20Administrative Staff Structure 21Overview of Options 22Review of Past Recommendations 22 - 24Recommendations for Medical Control 25Quality Control and Improvement 25Expansion of Paramedic Services 26Recommendations 27PowerPoint Presentation slides 28 - 40


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PURPOSE OF THE STUDY

DISASTER By DESIGN LLC was retained by the Council of Governments to evaluateand review the Valley Emergency Medical Service, a 501(c)(3) corporation established in1983 to:

1. Foster the delivery of prompt and effective emergency medical services in the

Towns of Ansonia, Derby, Oxford, Seymour and Shelton and the surroundingarea.

2. Educate the pubic concerning the need for and provision of emergencymedical services.

3. Provide training to medical personnel and the public for rendering ofemergency medical assistance.

4. Facilitate the coordination of the provision of emergency medical services inthe Valley and to that end work with other organizations involved in thedelivery of emergency medical services, including local ambulancecompanies.

5. Provide volunteer emergency medical services to the Valley.

The 1995 consultants report stated goals are not being met. Interviews with individualswho participated in the development of VEMS describe confusion as to of the role ofVEMS. Some of those interviewed describe that the paramedic program overwhelmedthe other aspects of the VEMS program. The ambulance chiefs meeting to discuss issuesbecame operational discussions regarding Paramedics. Presently there appears to be nocommon agreement on the direction VEMS should take. An example of this conflict isdescribed by one of the participating organizations:

The purpose of VEMS originally was to allow the chiefs of the local volunteerambulance corps to meet with hospital representatives to solve problems and

work together to better serve the citizens of the area.

Unfortunately, the paramedic service has consumed the focus and mission ofVEMS and derailed the vision of its founding members into a dysfunctional bodythat has become incapable of properly carrying out the mission of the non profit.

This report will attempt to address the issues and questions identified in the Request forProposal. Further we intend to make recommendations for improvements in the VEMSprogram.

Time Frame for Study

The contract for services was executed on July 6, 2004 with a preliminary work productreport and PowerPoint presentation on CD was delivered on August 1, 2004. Questionswere generated by the Council of Governments VEMS Task Force. A response to thequestions was submitted back to the VEMS Task Force on August 16, 2004. A copy ofthe questions and responses is attached in Appendix 1. There were no meetings with theTask Force although they had been requested by the consultants to discuss the workproduct document. A final report is being delivered on August 26, 2004.


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Consultant Group

The consultant group consisted of Jonathan Best, Martin Stillman, Doug Berkowitz, JeffLaReau and Joanne Orlando. Throughout the contract time ongoing discussions relativeto this project were done via Email, phone and in person. Documents were distributed tothe members for their review. On July 27

th,2004 the consultant group conducted a focus

group in Stamford, Ct. reviewing the documents and data that had been collected. Themeeting developed this report and outlined a work plan for the future. In addition severalmeetings were held to analyze the data that had been collected by Disaster by Designfrom the South Central CMED Center.

Methodology

The methodology of review consisted of interviews, data review, document review, aconsultant focus meeting and system comparisons.

Interviews

We conducted interviews with the following participants:

Dr. H Boris, Griffin HospitalJohn Gustafson, South Central CMEDJerry Schwab, Oxford EMS, President of the VEMS BoardJason Perillo, Shelton EMS, Treasurer of the VEMS BoardFrank Marcucio, Seymour EMSTom Lenart, Derby EMSMark Kiesling, Past President of the VEMS Board (via telephone)Barbara Martin, Regional EMS CoordinatorMarge Deegan, VP, Griffin HospitalWilliam Powanda, VP Griffin HospitalRoy Tidmarsh, Ansonia Rescue Services

Bob Holdsworth, Holdsworth Associates, Inc. (via telephone)

In addition we spoke with paramedics who have either worked or presently work in theVEMS system.

Document Review

In this process we reviewed maps, financials, meeting minutes, correspondence andBylaws. The documents were provided to us by individuals during interviews and at ourrequest. We purchased and reviewed maps of the Lower Naugatuck Valley area. Inaddition we drove through each of the communities to understand the response issues forparamedic fly cars.

Data Review

The collection point for response data is the South Central CMED located in New Haven.We contacted John Gustafson the Director of South Central CMED. He provided to usraw dispatch data for the VEMS units. The format was provided was Microsoft Access97 in read only files. Call data consists of incident locations, unit identifiers andbenchmarks in the response system. We initially reviewed 1592 responses, 17 responses


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had incomplete information. Upon completion of that data there was a concern that thenumbers were not consistent with our experience. After a telephone conversation withCMED the problem was resolved. A subsequent review of 6909 calls was conducted.See Appendix 2. A total of 1747 calls had incomplete information.Our response time analysis is based upon our review of 5162 calls that had the requiredinformation. The process of data analysis was extremely unwieldy. In order to identifyresponse time the process had to be verified manually. This issue was identified in

interviews with most of the system participants in that securing EMS response datarequired significant time commitment. While on an individual call you could identify theinformation quickly, if you chose to do a monthly analysis it was a time intensiveprocess. This makes the process of quality assurance on response difficult on a regularbasis. Therefore it is difficult to determine system performance. In our analysis we didsome sampling of the data and verified what providers were telling us relative to responseor non response of VEMS units. We were told that there is no uniform system in placefor providers to receive monthly response data exclusive to EMS units presently. Weappreciated the South Central CMED staff taking time to meet with us and for providingthe data. Our findings are as follows:

Activation time represents the time from a call being received to a vehicle acknowledgingthey are en-route to an emergency.

Response time represents the time a call is received (including activation time)to a vehicle being on the scene of an incident.

Average Activation Time 2.39 minutesAverage Response Time 10.91 minutes

Call Activity Level VEMS 2003

Seymour, 1157,

17%

Oxford, 391, 6%

Derby, 1199, 17%

Shelton, 2570,

37%

Ansonia, 1592,

23%

VEMSCalls

MissingData

CallsReviewed

ActivationTime

ResponseTime

Ansonia 1592 308 1284 2.57 8.03Derby 1199 288 911 1.38 7.46Oxford 391 134 257 2.24 15.57Seymour 1157 415 742 3.21 12.25Shelton 2570 602 1968 2.59 11.28Totals 6909 1747 5162


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Financials

Review of financials involved budget documents and projections done by the Treasurerof VEMS who is a CPA. We requested a Profit & Loss statement and were told it hadnot been developed yet but was in process. We reviewed the 2004 financials withprojections and the 2005 anticipated budget. Other budget figures were not available tous. We also received a copy of the financial report that was submitted by an independent

firm. There opinion was that the financials were in order. During our interviews withvarious service heads there was much discussion of a $93,000.00 liability to AMR forpayroll. This item was not reflected on the financials. It was explained that this oldliability was the result of failure to make 3 months of payments for staffing. This numberhad been carried over for a period of time. At present it was under negotiation withAMR.

Our analysis of the numbers presented indicates that VEMS is functioning, but any eventthat would impact the revenue stream would be catastrophic. We also received ananalysis of Paramedic implementation in an existing service which indicates that it wouldrequire a service having over 2000 calls in order to be solvent. We reviewed this figures

and believe them to be sound. We appreciate the Treasurers assistance with thiscomponent. A copy of the financial documents is attached in Appendix 3.

Paramedic AnalysisREVENUE

Ambulance calls 1200 1400 1600 1800 2000 3000

ALS Percentage 40% 40% 40% 40% 40% 40%

Paramedic Transports 480 560 640 720 800 1200

ALS Transport Rate $ 638.00 $ 638.00 $ 638.00 $ 638.00 $ 638.00 $ 638.00

BLS Transport Rate $ 346.00 $ 346.00 $ 346.00 $ 346.00 $ 346.00 $ 346.00

Differential to ALS $ 292.00 $ 292.00 $ 292.00 $ 292.00 $ 292.00 $ 292.00

Collection Rate 70% 70% 70% 70% 70% 70%

Billing Fee Rate 10.5% 10.5% 10.5% 10.5% 10.5% 10.5%

Revenue $ 87,810.24 $ 102,445.28 $ 117,080.32 $ 131,715.36 $ 146,350.40 $ 219,525.60

EXPENSE

(Incremental hourly cost) $ 4.00 $ 4.00 $ 4.00 $ 4.00 $ 4.00 $ 4.00(Cost of a paramedic,total) $ 24.00 $ 24.00 $ 24.00 $ 24.00 $ 24.00 $ 24.00

Weekdays

Days $ 48.00 $ 48.00 $ 48.00 $ 48.00 $ 48.00 $ 48.00

Nights $ 288.00 $ 288.00 $ 288.00 $ 288.00 $ 288.00 $ 288.00

One day $ 336.00 $ 336.00 $ 336.00 $ 336.00 $ 336.00 $ 336.00

One week $ 1,680.00 $ 1,680.00 $ 1,680.00 $ 1,680.00 $ 1,680.00 $ 1,680.00

Weekends

Full weekend $ 1,152.00 $ 1,152.00 $ 1,152.00 $ 1,152.00 $ 1,152.00 $ 1,152.00

Total weekly cost $ 2,832.00 $ 2,832.00 $ 2,832.00 $ 2,832.00 $ 2,832.00 $ 2,832.00

Total Annual Cost $ 147,264.00 $ 147,264.00 $ 147,264.00 $ 147,264.00 $ 147,264.00 $ 147,264.00

(Expense) / Revenue (59,453.76) (44,818.72) (30,183.68) (15,548.64) (913.60) 72,261.60Provided by VEMS, reviewed by Jonathan Best


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The table on page 6 demonstrates the dollars required to convert one paid EMT to a onepaid Paramedic. The dollar figure represents the difference in salary. It was thencalculated to give daily and weekly cost estimates. There was also a calculation for nightdifferential coverage and weekend costs. These figures only represent the salarydifferential. Other operational costs were not included. The table clearly indicates that aservice with less than 2000 calls per year would have no ability to afford the paramedicsalone without adding any additional operational expenses. The call volume required

moves higher when you add any other operational costs. There are fixed personnel coststo operate a paramedic system. While initially it seems that with existing staff andinfrastructure an independent paramedic program could get off the ground, there is a longterm financial liability. The cost of providing paramedic service on each communitywould be significant. In addition the intent is to develop a paramedic response systemthat will last long term. If the system designed is dependent on specific individuals thepotential for failure exists. This has been the issue in many other paramedic programs.The most effective way for this area to provide paramedic level service is through aregional system that shares the costs.

Meeting minutes and correspondence

The meeting minutes and correspondence reviewed were specific to an issue that wasraised relative to the ability of one community to withdraw from the VEMS program andrecover the PSA for paramedic coverage. In the 1995 consultation performed byHoldsworth and Associates the issue of having five separate PSAs was brought up. Thisissuance created a regulatory problem for VEMS. That consulting group correctlyidentified this issue and suggested a solution. The VEMS board met on December 28th,1995. A motion was made to authorize Holdsworth and Associates to write a letter onbehalf of VEMS to OEMS requesting a change in PSA from five (5) PSAs to one (1)PSA, however if any of the ambulance corps decide to upgrade to paramedic level, theywould be allowed to assume the PSA for the city or town they cover provided they are

certified to the paramedic level pending state approval. The motion was passed.Holdsworth and Associates drafted a letter that was signed by the President of the Board.This letter stated By vote of the Board of Directors of Valley Emergency MedicalServices Inc. duly made seconded and approved at our meeting held this date, we herebyrequest clarification of our PSA assignment. In 1989 we were assigned five individualPSAs for the municipalities of Ansonia, Derby, Seymour, Shelton and Oxford. Thisassignment appears to have been an oversight. We hereby formally request that thecurrent service area be immediately clarified and consolidated into one single PSA, as webelieve it should have been in 1989. There was no mention of the individual townsability to request separate PSAs as the original motion indicated. The Office ofEmergency Medical Services responded stating Please accept this letter as approval of

your request to clarify your PSA assignment. It was not our intent to assign five differentPSAs even though the documentation would indicate that position. I will be forwardingto you the formal and unusual paperwork, but please use this as a clarification ofassignment until receipt of the normal documentation. Valley EMSs PSA assignmentfor paramedic intercept is as follows:

The geographic area that includes the boundaries of the municipalities of

Ansonia, Derby, Seymour, Shelton and Oxford.


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It is clear that a single PSA was issued to VEMS. It is also clear that there are noservices presently certified at the paramedic level. Should a service become certified atthe paramedic level the issue of breaking up the regional system and PSA would rest withOffice of Emergency Medical Services.

Other sets of minutes were reviewed to understand the interactions of Board of VEMS ingeneral. We were presented with several letters questioning an outstanding debt to

American Medical Response. This correspondence is followed by FOI request that is notdated. Other items of correspondence were reviewed as they were presented duringinterviews. All the correspondence indicates a dynamic among Board members thatmakes the operation of VEMS difficult.

Bylaws

In our examination we viewed the Bylaws as incomplete and contradictory. There areseveral areas of confusion. There is no mention of the position of President in thedocuments we were given. The page numbering indicates this section may not be in theBylaws presently. We are sure the absence of a role for President in the Bylaws is an

oversight but it needs to be corrected. The Bylaws also call for 3 to 13 directorships.That number should be more specific. In another section the Bylaws identify 16 Boardpositions. There are conflicts page to page in these documents.

There is a description of paramedic service provider on the Board of Directors. TheBylaws need to clarify as to who this individual is. The intent we learned throughdiscussion was to have the representative of the commercial provider serving as back upto VEMS sit as an ex-officio member. This individual representing a contractor shouldsit at the meetings as a requirement of the contract. By making them an ex-officiomember their position is raised to a level that is not required.

The Bylaws provide for municipal participation for municipalities that provide subsidiesto VEMS. Several years ago the VEMS Board decided to eliminate the municipalsubsidies. At the present time no municipalities subsidize VEMS. The change was neverreflected in the Bylaws. This places these municipal Board positions in question.

In Section 10 the Bylaws state there is no requirement for notice of the annualorganizational meeting. This may be a violation of the Freedom of Information Act.Several sections later the Bylaws discuss the Secretary giving notice of meetings. Thiscontradicts Section 10.

Finally there is a section that creates a paramedic service board. This group is supposed

to be responsible for VEMS operations and has sole authority over funds provided bymunicipalities. The presence of this paramedic service board undermines the authority ofthe Board of Directors.

The issues stated represent several areas of the Bylaws that need attention. There areothers. We have the ability to provide sample Bylaws or assist with development but donot believe a complete rewrite is within the scope of this study.


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FINDINGS

The Communities VEMS Serves

During the course of our review DISASTER By DESIGN found the participants in theVEMS system possess tremendous experience, significant intelligence and talent in theEMS services. The volunteer organizations serve their communities very well and are

committed to providing quality emergency medical services. There are significantresources and infrastructure in each community for the provision of EMS.Each volunteer ambulance corps appears to have solid funding for their programs.There is no question that each of the participating communities is served well by theirrespective EMS organizations. Each of the municipalities exhibits great concern for thehealth and safety of their citizens.

A concern identified by several of those interviewed was that there had been severalstudies of the system done before and most of the recommendations had never beenimplemented. This has resulted in a feeling of frustration. Examples given:

1. VEMS Board drafts work plan at 1990 retreat(Most of the recommendations were not implemented)2. Consultant study was performed and recommendations were developed in 1995.

(Most of the recommendations were not implemented)

3. Consultant was asked to return and review progress in 1999 or 2000(Most of the recommendations were not implemented)

The question was asked of us Why this analysis is going to be any different than othersthat have been performed?

We appreciate their participation in the study in spite of their concerns.

Common Ground

In conducting conversations with the services and participants of the VEMS system wefound significant common ground. Each of the service heads mentioned these items asgoals for EMS:

Need for Paramedic ServiceQuality Patient CareCost Effective ServiceServe Their CommunitiesSupport the Volunteer Ambulance Services

These common ground items represent a good platform to implement improvements tothe VEMS program. These items are also the basic goals identified originally whenVEMS was created.


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Issues Affecting VEMS

During the interviews we found individuals with significant concerns. The concernsfocused on not satisfactorily fulfilled expectations and failures to maintain agreements.These perceptions have created conflict eroding support for the regional concept ofparamedic delivery. The lack of trust between participants has created an ineffective

Board of Directors. The VEMS system has a solid core but the discord between boardmembers makes progress difficult. There is a basic lack of clear mission statement. Thishas resulted in a lack of commitment to VEMS by some of the participants. Specificallycomments we received were:

1. VEMS has passed its time and there is a need to develop individual services.2. VEMS survival is closely tied to the survival of the volunteer ambulance services.3. Concern over clinical quality of EMS if the system were to be dismantled.4. The support for volunteer programs has not lived up to expectations.

The motto of VEMS on its patch is UNITED TO SERVE. The system was designed to

serve the communities, patients and volunteers. There is perception of some is thatVEMS is failing to do that resulting in services attempting to find other solutions. Ourreview of response time and operational issues indicate that VEMS is providing the levelof service intended with the present available resources. With changing communities itmay be necessary to enhance the resources to address the issues and concerns statedabove.

Analysis of the current VEMS

The basic day to day operations of VEMS function. We addressed the financial fragilityof VEMS in an earlier paragraph. The average response time by our calculation from the

data given to us by CMED is 10.91. Last year the VEMS system responded to 6909calls. The community paramedic program that has been discussed is a good idea and canwork if structured properly. We do have a method of structuring it but believe that wouldbe a distraction in light of the larger issues that VEMS faces. The larger issue is that thesevere level of discord that exists between the participants in the program. Mitigatingthis discord should take priority over all other future projects. Our recommendation isthat VEMS resolve the board dynamics that presently exist. This is possible.

Out of frustration with VEMS some communities have developed plans for separateparamedic programs. We believe this is a mistake. If the decision is to dissolve VEMSthe communities will need to develop solutions that best suit their needs. We would not

presume to provide recommendations in the context of this report of how individualcommunities should address the paramedic service issue. Further we believe VEMSwould need outside assistance to create new programs in the future. If VEMS isdissolved we stand ready to assist any community with their development of paramedicprograms.


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The figures presented in the diagram are from the South Central CMED budget for July1, 2004 to June 30, 2005. The call volume numbers represent the 2003 activity that thenew budget was based on. This is total EMS calls for communities not just VEMSparamedic calls. The census figures were provided by Council of Governments.TheOxford number presented is not from CMED it is the result of a conversation with theDirector of Oxford EMS (600 calls). Oxford uses the CMED center in NorthwestConnecticut and not South Central.

1884

1592

13141199

600

391

1300

1157

3282

2570

0

500

1000

1500

2000

2500

3000

3500

Ansonia Derby Oxford Seymour Shelton

Comparison of Paramedic Use by Town / 2003

Total CMED Calls

Total VEMS Calls

The VEMS paramedic system covers 91.7 square miles. Base on the numbers collectedthe Valley volunteer ambulance services responded to 8380 total calls in 2003. VEMS

paramedics responded to 6909 calls in 2003.

During interviews we were told that the process of evaluating response data was difficult.The need for a comprehensive data collection system of EMS activity is essential for bothquality assurance and operational planning.

Service PopulationServed

SquareMiles

Call Volume(C-med)

Comments

Ansonia 18,554 6.0 1,884

Derby 12,391 5.4 1,314

Seymour 15,454 15.0 1,300

Shelton 38,101 31.9 3,282

Oxford 9,821 33.4 600 Estimate fromOxford EMS Director /Dispatched by NWCMED


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Some of the participating volunteer ambulance services reported failures of VEMS toprovide paramedic response. It was acknowledged that in most cases the VEMS unitsare on other calls. There is 100% response to the first paramedic calls in the PSA, whichis required by regulation. Other participating volunteer ambulance services stated theresponse has been adequate. We found it difficult to verify the response performance thathad been reported regarding availability. One service provided data that demonstrated inone month 31 calls were passed to non-VEMS paramedic units. We have no data to

contradict that. We reviewed 6909 calls to evaluate if some of the discussions we hadwith service heads were accurate. This was all the VEMS responses for the year 2003.The data was given to us by the South Central CMED. We found the response time to beadequate for paramedic response. Response time represents an excellent performancemeasure of an EMS system.

Regarding lack of availability, issues that contribute are geography, unit placement; turnaround time at the hospitals and mileage. Back up paramedic coverage is presentlyprovided by American Medical Response (AMR) under a contractual arrangement. Thebackup paramedic service (AMR) sends vehicles from Bridgeport to respond to 911 callswhen an available VEMS unit is not available. There also appears to be utilization of

units assigned to Griffin Hospital as transfer units. When the closer units are notavailable this long distance response could contribute to the perception of paramedicunavailability. Options to address this issue have not been addressed. For instance, aneighboring town has a paramedic service that has not been utilized even with itsgeographic location between the Valley and Bridgeport. Other commercial ambulanceproviders may also provide some relief to this issue.

Oxford presently has a paramedic response time of 15.57 minutes. This is the longest ofany of the communities that VEMS serves. It is clear that geography plays into this time.Oxford is not in the South Central Region. Oxford is presently dispatched by theNorthwest Region Communications Center. Oxford stated that there is a greater level of

comfort in North West CMED. In speaking with the Oxford EMS Director and theDirector of South Central CMED it was felt that no delay in response occurs with thisdispatch structure. We do feel that relocating a unit closer would reduce their presentparamedic response times to Seymour and Oxford. The goal would be to achieve an 8minute average response time across the regional area served by VEMS.

VEMSCalls

ResponseTime

Ansonia 1592 8.03Derby 1199 7.46Oxford 391 15.57

Seymour 1157 12.25Shelton 2570 11.28


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Points of Departure for Paramedics

At the present time the VEMS paramedics are located in Shelton and Derby. On severalsite visits we found the unit together at Griffin Hospital. This shows a lack ofsupervision and impacts on response time.

This map represents the present response situation. While we did not attach responsetimes to it we believe the circle represent the response in the Valley presently. Thelowest circle represents an excellent response, the middle circle an adequate response andthe top circle an area in need of improvement in response. An excellent response would

be a paramedic response with an 8 minute average. An adequate response is a paramedicresponse with a 10 -12 minute average. An area in need of improvement is a responsetime in excess of 15 minutes on average. We recognize that response time variances exist,but based on our review we believe this is the present situation.

Impact of Emergency Medical Dispatch on VEMS

On July 1, 2004 all Public Safety Answering Points were required to implementemergency medical dispatch. Each EMS response agency would be required to developprocedures to meet this challenge. Calls previously dispatched as paramedic call betriaged to a lesser level of response because of the increased information gathered by the

call taker. The result could be a reduction in overall response numbers for VEMS. Theother result may be an improvement in paramedic availability and response time. Inspeaking with John Gustafson from South Central CMED, he believed that there thatwould have little impact. During these next few months it will be imperative to evaluatethe impact of EMD on the VEMS program. During interviews some services commentedabout improvements in paramedic responses of late. There are many variables that maybe responsible for this, including this study, but it is more than likely that theimplementation of emergency medical dispatch has helped.


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Suggested Departure Points for Paramedics (Present)

As an immediate resolution to some to the concerns that we heard, we believe that oneVEMS paramedic unit should be moved to the Seymour/Oxford Border (along Rt. 8).This would still provide for response in the areas that have the highest volume and lowerthe response time to outlying areas. The intent would be to more evenly distributeresponses through geographic relocation. Paramedic units should be relocated as calls

occur making the system much more dynamic than it presently is. This would be amodified system status management program performed by the on duty paramedics notthe dispatch center. The areas of overlap would be the recommended staging pointswhen one unit is responding to a call. We believe this would insure a higher likelihood ofparamedic response as displayed on the map below.


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Suggested Departure Points for Paramedics (Enhanced Recommendation)

An option that was discussed was the addition of a third paramedic unit during peakactivity times. A more significant study would be needed to determine the peak times butclearly this would address the issue of a unit not being available for the second or thirdcalls. We also believe that the financial impact would be minimal, but would recommendthat it be reviewed as the unit starts working to insure there is no financial loss. The

present volume of calls would allow for a part time third unit during peak periods. Thisopinion is based on the information we collected. If some aspect of the information isflawed we would recommend that this not be implemented until actual numbers could bedeveloped. In this presentation you will notice that the areas of highest call volume haveoverlapping response times to maintain the high level of service as it relates to paramedicresponse.

Options for Paramedic Service

There are three options relative to VEMS. Each of the options has advantages anddisadvantages. After much review, we felt we should present these options along with

the advantages and disadvantages. The options are as follows:

1. Keep the Current VEMS Program Unchanged

2. Eliminate the Current VEMS Program

3. Enhance the Current VEMS Program


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This program has not been adequately supported in its present state. It occurred when theVEMS Board decided to eliminate municipal funding. The elimination of municipalfunding limited the municipal oversight over the VEMS program. It also created animpression that the municipalities had limited interest in the paramedic program whichwe know to be untrue. Based on the action of the VEMS Board the municipalitiesstopped providing subsidies for service. This elimination of municipal subsidy not onlyhad long term financial impact but may have jeopardized the position of the Board

members who represent the municipalities based on the Bylaws.

VEMS lacks leadership. This is defined as participation of the hospitals, municipalitiesand internally. There is a need for an identifiable single person responsible for VEMS.This person must have the full support of the hospital and municipalities.

The present paramedic system is very linear in function and has failed to grow to addressthe varied health care needs in the community.

If VEMS continues to operate in its present state and the Board dynamics continue,VEMS will not experience success over the long term.

Option 1 Keep the Current VEMS Program Unchanged

Advantages

Keeping the existing program is always an option. The VEMS program exists in itspresent state. The present VEMS has customer/community acceptance. The programpromotes regionalization. The program is very cost effective. VEMS exists presentlywith no municipal subsidy. The communities receive paramedic service with no impacton tax base. Citizens are billed directly for service. This participation makes VEMSeligible for grant funding along with the participating communities. The issue of

regionalization is high on the priority list for grants presently specifically HomelandSecurity grants. The present paramedic program provides single organization for medicalcontrol. VEMS provides paramedic service to communities which might not be able tosupport such services individually, either financially or clinically.

Option 2 Eliminate the Current VEMS Program

Disadvantages

The present VEMS program has some customer/community acceptance as a result theremay be some fallout from discontinuing service. VEMS promotes regionalization of

very expensive health care services; some might be concerned about the cost of serviceswithout regional sharing of cost. This program has been very cost effective and receivesno municipal subsidy. The foundation has been laid for community involvement on aregional basis. Eliminating VEMS could result in a poor public image in communitiesthat have supported the project and concept since its inception in 1983.


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The financial liabilities of VEMS while discussed are truly unknown, eliminating theprogram might have a significant financial liability and therefore closing may cost morethan remaining open. There are also grants that have been received and may require thatsome monies be returned because of projections stated in original grant applications.There are potential grant liabilities.

If the VEMS program disappeared each of the communities would have the responsibility

to provide service at a paramedic level. While many options for this exist it would stillbe significantly more expensive to each community. Some communities have expressedconcern that this might compromise their existing volunteer services. Elimination ofVEMS would require paramedic medical control to five individual programs. It wouldimpact on the clinical quality of the program because all of the communities with theexception of one lack sufficient call volume to support individual paramedic programs.Volume is not the only parameter, it is also call acuity. Alternative educationalexperiences can substitute for doing some paramedic skills in the field. The issue ofavailability of this type of education is a concern. If each of the five services requiredalternative educational experiences the demand would be excessive. Alternativeeducational experiences only really apply to technical skills such as intubation and

intravenous therapy. It does not really assist paramedics in the skill of seeing patients.There is no replacement for patient contact in a field environment. While many servicessay they use alternative educational experiences to bolster their level of confidence everytime we have looked carefully we find many programs not fulfilling their obligations. Asa result the quality of the advanced life support programs are poor. If paramedics arerotated from urban or suburban areas to low volume services there is a better chance ofsuccess. We do not believe the opportunities for alternative educational experiencesexist in sufficient number to support this type of a program for five ambulance services inthe valley. We do believe that the five communities combined provide a good case mixand call volume to support a paramedic program.

Eliminating this program ignores considerable opportunity to serve the Valley with aneffective, high quality paramedic response program. Eliminating VEMS disregardsrecognized need for a regional system. At the time VEMS was created the communitiesin the Valley had created a cutting edge program providing paramedics. There is asignificant amount of sweat equity invested in this project.

Option 2 Eliminate the Current VEMS Program

Advantages

The elimination of VEMS would allow interested communities to develop independent

paramedic programs. Potentially it might increase the number of available paramedicunits from two to five. Eliminating the regional program would require existinginfrastructure in the towns to provide paramedic service. It would eliminate staffliabilities. Existing financial liabilities may be eliminated with the closure of VEMS.This would transfer the risk liability from VEMS to the communities for paramedicservices.


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Option 3 Enhance the Current VEMS Program

Disadvantages

Enhancing the VEMS program would require consistent and sustained municipal andcorporate financial commitment. There would be an increase in cost because of thecapital and human resources needs. There is always a potential for failure of VEMS.

Option 3 Enhance the Current VEMS Program

Advantages

VEMS has some customer/community acceptance. The program promotesregionalization. There is a broad-based appeal to use a regional system. The program iscost effective and clinically sound. The communities receive paramedic service andcitizens are billed directly for service. The existing community EMS services participatein VEMS operations. This participation makes VEMS eligible for grant funding. Theissue of regionalization is high on the priority list for grants, specifically HomelandSecurity grants. VEMS provides paramedic service to communities which might not be

able to support them individually. VEMS creates a single point of contact for MedicalControl and quality assurance. The present paramedic program provides singleorganization for medical control. The limited market competition allows VEMS toexpand services and become more financially sound. Many opportunities exist forpotential expansion of market to support the VEMS program. This option represents themost reasonable option for the provision of a clinically sound, financially secureorganization.

Paramedic Program Cost Examples

There is no set rule of thumb regarding the cost of a paramedic system. There is no

argument that paramedic systems are expensive. An incremental cost analysis wasprovided on page 6 of this report. That cost analysis would be the personnel expenseonly of converting an EMT to a paramedic. It did not account for operations costs. Onthe next page we have included examples of operational costs for paramedic fly cars.There are average costs recognizing that each area has differences such as cost of living,availability of workforce and competition all impact on the final cost figure. Aparamedic system does not replace a basic EMS system. While some economies of scaleexist the example is all operational costs required. This does not include personnel costs.There is an identified shortage of paramedics, volunteers and EMTs. Five separateparamedic programs would have difficulty in securing sufficient staff to cover all shifts.Having the managers of the system run on calls creates weaknesses in the organizations.

Cost of Present VEMS System Paramedic Cost Example

$542,809.81* (2004 operating expenses) $431,000.00** For Two Vehicles$1487.15 Daily operating cost $576,700.00** For Three Vehicles

*Includes personnel costs

**Does not include personnel costs / operating expenses only


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Fly Car Operations

Expense Models

One Vehicle TwoVehicles

Present VEMS $ ThreeVehicles

FourVehicles

Payroll $376,085.89

Professional LiabilityInsurance (1)

$20,000.00 $40,000.00 Third party contract $60,000.00 $80,000.00

Auto Insurance (1) $45,000.00 $90,000.00 $21,368.00 $135,000.00 $180,000.00Marketing & Advertising $2,000.00 $4,000.00 not done $4,000.00 $4,000.00

Accounting/Tax Services $15,000.00 $30,000.00 in house $30,000.00 $30,000.00

Office Supplies $1,000.00 $2,000.00 in house $2,500.00 $3,000.00

Rent $25,000.00 $25,000.00 None $30,000.00 $35,000.00

Maintenance & Repairs $40,000.00 $60,000.00 $14,898.00 $80,000.00 $100,000.00

Telephone $17,000.00 $17,000.00 Unknown $20,000.00 $20,000.00

Medical Supplies $40,000.00 $50,000.00 $8,346.31 $60,000.00 $70,000.00

Payroll Processing $8,000.00 $9,000.00 Third party contract $10,000.00 $10,000.00

Clothing $8,000.00 $16,000.00 Third party contract $24,000.00 $32,000.00

Gas $25,000.00 $50,000.00 $18,330.00 $75,000.00 $100,000.00

Vehicle Supplies/Parts $4,600.00 $9,200.00 $10,000.00 $12,000.00

Food/Meals $1,000.00 $2,000.00 $3,000.00 $4,000.00

Employee Medical Exams $2,500.00 $5,000.00 Third party contract $7,500.00 $10,000.00

Employee Recruitment $2,500.00 $4,000.00 Third party contract $4,000.00 $4,000.00

Education/Training $1,900.00 $3,800.00 Third party contract $5,700.00 $7,600.00

Biomedical Services $10,000.00 $10,000.00 Unknown $12,000.00 $12,000.00

Miscellaneous Expenses $2,000.00 $4,000.00 $21,741.00 $4,000.00 $4,000.00

Totals $270,500.00 $431,000.00 $542,809.81** $576,700.00 $717,600.00

**This includes payroll and third party contract costs

Operating Efficiency and Value

A review of the financials was performed by meeting with the Treasurer. In Appendix 3we have attached the documents we were given. The costs listed on the next page werebroken down just to provide an overview. We subsequently reviewed the financials wewere given in detail. We were told that the financial picture has improved. We have noreason to doubt that. We saw a financial report that had been completed by an outsideparty. Their cover letter indicates no significant issues. We reviewed the 2004 budgetalong with the 2005 budget projections. In order to forecast the actual financial situationwe would need several prior years. There is an expressed concern by several of thoseinterviewed regarding a $93,000.00 liability to American Medical Response. It was

acknowledged that a debt of this type existed. There was no documentation of this debton the financial documents we were shown. It was explained that this debt was a 120 daylate cost for 3 months of personnel expenses and has continued to be carried through thesystem. Combining an accrual system and a cash system makes interpreting the financialpicture difficult. Based on the information we were given the financials appeared to be inorder. We have made some recommendations for financial oversight.


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Cost of Present System

$542,809.81 (2004 operating expenses)$1487.15 Daily operating cost$216.07 Cost per call$429.00 OEMS approved rate for VEMS

Financial Oversight

Some members of the Board of VEMS expressed concerns regarding the finances.VEMS is fortunate at the present time to have a CPA as its Treasurer. This may notalways be the case. There are steps that should be taken to maintain a higher level ofcommunication on financial issues and establish further financial controls for the future.In this process it was acknowledged that financial reviews are done annually by anoutside party. For an organization like VEMS, which is 21 years old and receives grants,it would not be too aggressive to have a formal audit. That would accomplish three

things; provide a level of comfort for Board members who have verbalized concerns;provide for comprehensive communications and establish a starting financial point duringa recommended restructure of VEMS. Lastly, should VEMS ever receive subsidy fromthe communities it serves, an audit may be required because of the use of public funds.That same argument may hold true because VEMS receives Medicare dollars. Afterspending some time with the financial documents we would like to make the followingrecommendations:

1. Engage an outside accounting organization to perform a formal audit.(This should be done every five years with an annual financial review)

2. Improve communications to the Towns through an Annual Report on Activity and

Financial Condition3. Produce an annual and monthly P&L to be submitted to the Board of Directors4. Produce an annual and monthly Billing Summary to be submitted to the Board of

Directors5. Establish request for proposal system for major purchases in excess of $2500.006. Institute a Purchase Order system for all purchases

Bundle Billing

One consistent issue we discussed with individuals we interviewed was bundle billing.There is a great deal of concern about citizens specifically seniors receiving two bills for

one ambulance trip. Our analysis indicates the while the issue of seniors being sentsecond bills for ambulance service would disappear with bundle billing. However, thereis an issue of changing Medicare regulations. At the present time only one service in theVEMS area conducts bundle billing. In the present process a single bill is sent, apayment is received the ambulance service takes their complete share and what ever isleft goes to VEMS. This is the product of the current bundle billing arrangement that wasnegotiated. We can find no rule that dictates this is how it should work. If bundlebilling was implemented with this present negotiated process, the pending changes to theMedicare reimbursement would dramatically change the financial picture for VEMS.


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If there are no changes to the current bundle billing situation VEMS would receivearound $78.00 per intercept call from all services with the exception of Oxford. As a ruralcommunity Oxford has potential to bill at a full intercept rate. The issue of bundle billingwould overall be a loss for VEMS since the system requires around $216.07 per call withthe present budget. We have no expectation this figure will go down in fact we believe itwill increase as VEMS grows. So on each Medicare call there would be a $138.07shortfall per call. With the help of the VEMS Treasurer a review of numbers and

projected subsidy that might be required under the present system.

SUBSIDY REQUIRED

FY '03 FY '04 FY '05 FY '06 FY '07

Ansonia (3,879.53) 13,599.55 33,804.95 50,610.46 51,622.67

Derby 7,574.52 16,404.60 25,976.22 33,741.95 34,416.79

Oxford 3,787.26 8,202.30 12,988.11 16,870.98 17,208.40

Seymour 9,468.15 20,505.75 32,470.28 42,177.44 43,020.99

Shelton 16,095.86 34,859.78 55,199.47 71,701.65 73,135.68

33,046.26 93,571.99 160,439.03 215,102.47 219,404.52

FY '08 FY '09 FY '10 FY '11 FY '12

Ansonia 52,655.12 53,708.22 54,782.39 55,878.04 56,995.60

Derby 35,105.13 35,807.23 36,523.37 37,253.84 37,998.92

Oxford 17,552.56 17,903.61 18,261.69 18,626.92 18,999.46

Seymour 43,881.41 44,759.04 45,654.22 46,567.30 47,498.65

Shelton 74,598.39 76,090.36 77,612.17 79,164.41 80,747.70

223,792.61 228,268.46 232,833.83 237,490.51 242,240.32

To create these numbers we used call volume and projected out. We recognize thesenumbers create concern because of their size. It is important to state that this would bethe situation only under the present bundle billing arrangement.

Oxfords situation may be unique in that it has been described as a rural community. Ifthis is the case the VEMS would be eligible for a full intercept fee from Medicare. Theonly service that can charge for paramedic intercept directly is a rural community. Whatdefines a rural community is population and land mass. If Oxford is recognized as a ruralcommunity this could result in improved financial returns.

At the present time two different billing services are used by the ambulance services.This process may be more efficient with a sole source provider. A relationship throughthe hospitals should be developed to verify insurance coverage and improvereimbursement. Contractual arrangements can be developed to accomplish this process.An area for potential savings to both VEMS and the ambulance services is to bill as a


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group using its own staff. The elimination of outsourcing the billing process maygenerate enough money to, pay for the process and reduce a liability to fund VEMS.Traditional billing firms charge between 8% and 10% in administrative fees. If youproject out against 6909 calls at the blended rate of $250.00 per call and use an averageof 9% the savings of fees would be $155,452.00. The down side of this proposal is thatVEMS would have to develop billing expertise. Once developed, based on the currentcall volume this would require 1 FTE. Other options are for the hospital or the COG to

assist with this process.

To resolve the issue of bundle billing, a method of splitting the money recovered needs tobe renegotiated. One proposal is to adapt a flat fee system. The expense of a call doneby VEMS is $220.00. The flat fee would be $220.00 per call billed to the ambulanceservices each month. No bill would be generated to seniors, which is a major concern ofall communities. Part of this proposal would require that the payment be net 30 days,because the cash flow condition of VEMS does not allow a position to carry these costsfor any period of time. If we assume that VEMS does 2600 calls a year, at a flat fee of$220.00 the income from operations would be $572,000.00 per year. The paymentwould be based on town call volume. This figure also provides some dollars for future

development. It is a very tight dollar figure. Using the percentages of utilization, we areable to project out potential cost to the communities on a monthly basis as follows:

Shelton $18,590.00Ansonia $10,486.00Seymour $ 7,626.00Derby $ 7,626.00Oxford $ 3,336.00

If the services bundle bill at an ALS rate, because of the relationship with VEMS anddeduct their BLS cost, the remaining dollars would offset this above stated expense.

Then the remaining dollars or difference in dollars would be billed directly to thecommunities. Obviously this plan has some roadblocks but none are insurmountable.There may be a compliance issue relative to the billing methodology described and thecommunities would have to agree to make up the variance in expenses. This is anexample of a billing model that might work, but some details would need negotiation anddiscussion.

Flat Rate Calculation for VEMS

Anticipated Call Volume 2,625

ALS 1 Emergency Rate $ 638.00

BLS Rate $ 346.00

Additional ALS revenue $ 292.00

Collection Rate 75%

with applied collection rate $ 219.00

Billing fee rate 10.50%

with applied billing fees $ 196.01

Per call loss to BLS service $ 15.42

with funded depreciation $ 30.66

Annualized subsidy required $ 40,486.88

This projection provided by VEMS Treasurer


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Projected contributions of communities with this bundle billing model

Towns Projected SubsidyAnnual

Contribution Calls

Ansonia $8,907.12 578

Derby $6,477.90 420

Seymour $6,477.90 420

Shelton $15,789.88 1024

Oxford $2,834.08 183

Totals $40,486.88 2625

This projection provided by VEMS Treasurer

The billing process and regulatory compliance represent areas in need of attentionrelative to financial performance. While billing companies have experience it is difficultto place the full responsibility of billing and regulatory compliance on them. In fact theMedicare compliance rules state that even if you outsource the responsibility still restswith the generating organization. VEMS needs to have a compliance officer in place toprotect its interests.

Our review of these financials involved the experience of the consulting team in the areaof financial management for an EMS service.

Governance Model and Structure

In reviewing the organization of VEMS, several issues came to our attention. BasicallyVEMS functions but does not meet its full potential. The financial situation allowsVEMS to operate but from our view the dynamics of the Board of Directors interfereswith their ability to meet their mission. The Bylaws do not reflect currently what ishappening. Even with a review of those Bylaws nothing will change unless the Board

dynamics change. Many good organizations have failed because of an inability on thepart of their Boards to work together. The original organization known as VEMSrepresented a cutting edge system for delivery of paramedics in Connecticut. As timeprogressed several events occurred that brought VEMS to where it is today. Onesignificant event was eliminating the municipal subsidy by the VEMS Board. This gavethe VEMS Board independence, but also eliminated municipal input. The ambulanceservices are separate incorporated organizations and not part of the municipality with theexception of Ansonia. Some ambulance service representatives would argue theyrepresent their municipalities on the Board.

The VEMS non profit Board should be made up of individuals who represent the

community and VEMS without the additional mantle of responsibility for individualambulance services. The Bylaws address this with a Paramedic Operations committee.This is probably where the service heads should be members and operational decisionsshould be made. The Board should develop goals, plans and policy. The operationcommittee should decide how to enact these. If a decision is made to hire an OperationsManager then the Paramedic Operations committee should assume the original mission ofVEMS by providing a forum for open discussion among service heads. The OperationsManager would handle day to day operations of the paramedic program. We agree that


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paramedic operations have taken most of VEMS Boards time however since this has thegreatest financial impact it is understandable.

The lack of a business, marketing and strategic plan also prevents VEMS fromadvancing forward. This is clearly the responsibility of the Board, however because theydeal with day to day issues and the dynamic is so poor it is impossible to look at thisproblem.

Our recommendation is that Disaster by Design be contracted to conduct a managementretreat with VEMS Board Members only. We have a vision of how this program can beenhanced and provide for good working relationships between the various parties. Fromthe management retreat the goals for VEMS can be prioritized and completed. To bringan executive into this program at this time would be non productive. The dynamics needto be worked on by a third party that has no interest aside from developing the system tosecure success. Once the issues have been addressed regarding dynamics and the systemmoves forward an executive can be retained. Any person that would take the position ofexecutive now should be advised it is a temporary position. Stability of the organizationmust be achieved first. This is not a quick process with one management retreat. This

process could take a year to a year and a half.

For the future it is essential that this work plan be developed and followed:

1. Organize and conduct a management retreat to work on group dynamics.2. Review and rewrite Bylaws3. Restructure Board of Directors4. Designate municipal representatives5. Develop immediate short term goals for VEMS6. Re-evaluate Paramedic Operating Group and change focus7. Take vendor off as ex-officio member and require attendance by contract

8. After reorganization hire appropriate staff (Operations Manager)9. Develop an on going business plan10.Develop 2 year strategic plan11.Develop 5 year long range plan

Administrative Staff Structure

At the present time VEMS has no administrative staff. It has operated through theHerculean efforts of the Board members. It is clear that an organization of this size andfinancial complexity needs administrative support. This is our suggestion of how

relationships should be viewed and tasks performed. The administrative staff of VEMSshould consist of a Medical Director (part time), Operations Manager, part time assistantand Paramedics supported by a full time EMS Coordinator at Griffin Hospital. The EMSCoordinator would not be an employee of VEMS but would participate in thedevelopment of VEMS for the position of insuring quality in performance.. TheOperations Manager would be staff to the Board of Directors, liaison to volunteerambulance services, manage the budget, supervise staff, make public appearances, attendrelevant meetings and manage all other related responsibilities. The part time assistantwould support the operations of VEMS; maintain records, purchase orders, files and other


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related office duties. The diagram below shows how the relationships for the OperationsManager should exist. This unusual diagram further shows the need for VEMS to workcooperatively with many groups and not threaten the existence of any group. Thespecific development of the administrative staff structure would be a role for the Board ofDirectors.

Overview of Options

In looking at VEMS, we believe the communities have the potential for superior regionalparamedic services with an intact system. While some communities believe it would bein their interest to separate, it is apparent that clinical quality would suffer and costs ofservice over the long term would not create savings but in fact would cost thecommunities more. Over the short term it looks attractive, however the volume of callsin any one town does not exist to support the level of service that VEMS has the potentialof providing.

VEMS / 3 or 4 Towns

There has been much discussion regarding one or two of the communities pulling out ofthe VEMS system. Any community leaving the VEMS system would have a potentialdomino effect on other communities affecting the level of paramedic service in the entireValley. The cost of providing the two VEMS vehicles would remain the same so on theexpense side of the budget there would be no appreciable change. We also believe thatoverall there would be a significant loss of call volume that would impact the VEMSsystem financially. There would be an increase in volume from participatingcommunities; however the overall loss of volume would appear to be greater. There wasno data available to us to give a comprehensive evaluation. The unknown number is thecalls that are being passed to back up services. We do not believe the small increase involume would make up for the loss of two communities. We believe that VEMS couldcontinue to function with 3 or 4 towns participating. Very tight cost control would berequired or perhaps even a reduction of service. This would be a very financially fragilesystem. We do not believe that VEMS would be either effective or solvent with only oneor two towns.

VolunteerAmbulance

Corps

ParamedicBack upContractor

VEMS

Paramedics

EMSCoordinator

Griffin

Hospital

VEMS

BOARD OFDIRECTORS

VEMSOperationsManager


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VEMS / 5 Towns

It is our belief that by changing the Board dynamics VEMS is the best choice for allconcerned. The contiguous geography makes the Valley region ideal for a regionalsystem. There is a great deal of work to this proposal. In terms of cost, clinicalefficiency, paramedic coverage and response enhancing the VEMS program represents

the best option for the Valley. This is our recommendation.

Review of Past Recommendations

DISASTER By DESIGN reviewed the Holdsworth Associates Inc. 1995recommendations at length. We also spoke with Bob Holdsworth regarding his previousstudy. Many of the suggestions for changes in 1995 were very accurate. The changingenvironment however has created some different situations. The proposed changes thatwere submitted in the 1995 are in need of being updated. It was clearly disappointingthat many of the suggested changes made in 1995 were not implemented. This was thestated concern of many of the people we interviewed. It is our hope this will not be the

case with this consultant study. Our review of the changes has the followingrecommendations:

1. Restructure the Corporation This represents the single greatest challenge forVEMS and its participants. The corporation needs attention, restructure and

context change to remain viable.Incorporating the municipalities is of significantimportance.

2. Continuation of Service We agree that to continue the VEMS program isappropriate. It is our feeling that the data collection system has not materially

changed and is still in need of significant work to assist the Board in decisionmaking with very timely and accurate data.

3. PSA Consolidation - The merging of the PSA which was a recommendation wasdone. As previously noted however, the motion of the Board was not transmitted

to the OEMS and therefore the issue of towns securing the R5 for their community

and taking it from VEMS is not clear cut.

4. Dispatch Criteria While at the time this was a very appropriaterecommendation the present change in the law requiring Emergency Medical

Dispatch changes the recommendation. It is already being addressed on the

dispatch side. VEMS should develop policies to better interact with the CMEDEMD program. VEMS should demand better data from CMED on EMS. A

comprehensive quality assurance program regarding dispatch should be

implemented. It should not just be an occurrence based program.


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5. Unit Positioning We spent some time driving over the roads to evaluatemileages and safe operating speeds. The previous response diagrams were

developed based on calculating the information from the service heads, our

driving through the communities and experience with a system of this type. This

recommendation to relocate a vehicle is not something that is absolutely

quantifiable but it would clearly improve the response to areas presentlycomplaining about poor response. The VEMS units should be relocated to insure

better response and service. Based on the information provided that moving a

vehicle north and in the vicinity of Route 8 would serve the system best. It would

reduce response time to outlying areas and still be available to communities with

higher volume. The net effect would be a stabilization of response time across the

area and higher customer satisfaction.

Decisions on mutual aid and call activity need further review. There is also a

greater need for comprehensive EMS only data on the system. Integrating any

aspect of VEMS with AMR when you have a competent dispatch center already

would not be a recommendation. There is a need for VEMS to maintain a level ofindependence that would be reduced with a any partnership for dispatch and data

collection. If a partnership is the chosen course of action a very tight contract

would need to be drawn up to protect VEMS interest.

6. Reimbursement Management Our report speaks to this issue. We do agreethat while there have been improvements billing and collection practices need to

be formalized.

7. Paid Administrator - We agree that VEMS needs leadership from a paidprofessional, however the present dynamic that exists would require that much

work be done prior to placing anyone in that position. Our belief is that if anindividual was hired now it would be setting them up for failure and as a result

the program may fail. The issues facing the Board require serious work and a

structure needs to put into place that would allow the administrator the ability to

function effectively. The breakdowns in communication and process create a

situation that would require a person of extraordinary experience and expense or

an individual who recognizes that the first administrator of VEMS is a temporary

position. In this temporary position, the charge would be to get as much done as

possible in a limited amount of time. DISASTER By DESIGNwould suggest

outsourcing the original management role for VEMS to develop stability in its

processes. Subsequent to that the Board could hire a full time administrator to

assume the post. VEMS should not get involved with commercial ambulancecontractors or management service organizations providing staff for EMS for this

level of assistance. Finally it is imperative that a national search be conducted

for the administrator. The use of a vendor to assist with the process would be

most helpful. Due to the dynamic that exists regardless of the talent level the

administrator should not come from any of the participating communities or live

in them until after appointment. A high level of competence is required along with

significant interpersonal skills and Board management skills.


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8. Bylaws The issue of problems with the Bylaws have been stated earlier. Someof the areas we identified are different than originally identified in the 1995 study.

The situation is still that a Bylaws change is one of the first steps required.

9. Budget Options - We reviewed the financial documents. VEMS is fortunate tohave a CPA as Treasurer. This will not always be the case. It is imperative that

person consider our recommendations and put together financial policy and

practice including budget methodology. Further we would restate ourrecommendation regarding an audit. While everything appears in order the

recommendation is for the future when the Treasurer might not have the same

level of experience as the present one. We do not believe the micro management

of the budget process is of the highest priority because the service functions well

on a financial level.

Recommendations for Medical Control

The role of Griffin Hospital in VEMS is important. EMS is a medical system. The goalis to provide comprehensive pre hospital care to patients before they arrive at the

hospital. From all parties involved there is great concern that pre-hospital care be of thehighest quality. To have rigid separation of operations and quality assurance is not in thebest interest of an EMS system. The hospital should not have operational authority forVEMS. It is clear that Griffin Hospital and the Volunteer Ambulance services workeddiligently and effectively to create VEMS. It is also clear that the patient was the focus.Frequently the patient is forgotten. This is not the case in the Valley. There is a blendingof operations and quality assurance that must take place. How an organization functionsimpacts on quality of care. There is effective care which is skills and affective carewhich is customer service. Both of these affect patient outcomes. As times changed andrelationships developed there appears to be a need for greater oversight. Recognizing thisGriffin Hospital stepped up and created the position of full time EMS coordinator which

will be filled in the next few weeks. This EMS Coordinator will improve hospitaloversight on the pre-hospital care system. The following steps should be implemented toassist in making the system more effective:

1. Negotiate Medical Control contracts with all services providing ALS and BLS2. Establish formal written policies for EMS3. Extend hospital outreach to services by providing training and guidance4. Participate in strategic planning of EMS in Valley5. Investigate cooperative ventures with VEMS and Volunteer Ambulance Services6. Establish a Transfer unit? (Medic to VEMS when needed)

The hospital working in partnerships with the EMS providers can only further improvethe pre-hospital care system.


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Quality Control and Quality Improvement Activities

EMS systems while having a public safety role provide health care. The practice ofdelivering health care requires comprehensive quality control and improvement. There isa definite need to develop measures such as acceptable response time to measure theperformance of the VEMS operation. Each EMS system requires a medical control

authority. This authority can be a designated medical director through a sponsor hospital.The medical control authority should present to the Board a list of performance measuresthat will be evaluated. They should center on patient outcomes and skill performancecriteria. The Board has the ability to add items to the list such as customer service,driving practice and documentation. These measures establish benchmarks forperformance so what ever is chosen is continually measured. We would suggest usingsome nationally accepted measures but this is a local decision as to how you measureperformance. It is important to realize that the Medical Director and Griffin Hospitalshould be the focus of quality control and improvement. Some states actually have QArequirements in their EMS regulations. Other aspects of quality control and improvementrelate to operations and customer service. All of these should be part of the process.

There should be no line between operations and medical care because each impacts theother. As stated before, there is effective care which is skills and affective care which iscustomer service. Both of these affect patient outcomes. Ultimately the MedicalDirector and the hospital have significant responsibility. Quality control andimprovement requires a high level of respect and trust. It represents teamwork of diffuseorganizations with the same goal that of caring for these communities and their patients.Without this trust and teamwork an EMS system would not be successful.

Expansion of Paramedic Services to other Contiguous Municipalities

Most of these identified communities are supported to some level by commercial

services. There are many opportunities for VEMS to expand its market. If some of theseopportunities are realized the program should become much more stable. Before any ofthese opportunities are pursued the need for VEMS to improve its public image andoperations. This remains as the single greatest challenge. In its present situation nocommunity would consider VEMS because of the level of poor press that has beengenerated. Some of the recommendations are not complete expansion of a regionalparamedic system into these communities. Partial expansion into communities thatrequire paramedic intercept is a potential. If VEMS were to offer a superior product atless cost to the neighboring communities we believe they would look at it. Any one whoreads the paper today or in the last several months would say no to VEMS. If theimprovements are made the paradigm can be shifted to make VEMS the most desirable

EMS Paramedic program around. It would once again become the leader in how EMS isprovided to communities. This is a real opportunity. It does require vision to see it. Webelieve it exists.

We have identified some communities that might consider using VEMS in the future if acomprehensive marketing plan is developed and the improvements are made.This would be an extremely competitive environment.


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There have been no discussions with these communities however they are logical choicesbecause they are contiguous to the VEMS service area. They are:

1. Orange2. Woodbridge3. Beacon Falls4. Monroe

5. Stratford6. Trumbull

Recommendations

1. Enhance the VEMS current programContinue to provide paramedic service to all five communitiesRelocate one paramedic unit to the Seymour/Oxford border (along Rt. 8)Evenly distribute response times through geographic relocation

2. Conduct management retreat with present Board membersRestructure Board of DirectorsReevaluate Paramedic Operating GroupDesignate municipal representativesTake paramedic vendor off as ex officio member

Require attendance of paramedic vendor by contractAfter reorganization hire appropriate staff (Operations Manager)VEMS needs to improve its public image/operations

3. Perform complete Bylaw review4. Develop immediate recovery plan for VEMS with immediate short term goal5. Make the Medical Director the focus of quality control and improvement6. Improve Data on Response7. Develop on going business plan8. Develop 2 year strategic plan9. Develop 5 year long range plan10. Encourage the Service Chiefs and Hospitals to meet to discuss EMS11. Produce to the Towns an annual report on activity and financial condition

12. Create a system for a formal audit every five years or as required by anoutside accounting firm.

13. Continue annual financial reviews14. Annual and monthly production of P&L submitted to Board of Directors15. Annual and monthly production of Billing Summary submitted to Board of

Directors16. Request for proposal system for major purchases over $2,500.0017. Institute a purchase order system18. Negotiate medical control contracts19. Establish formal written policies for EMS20. Investigate cooperative ventures with VEMS and Volunteers

21. Measure the performance of the VEMS operationImprove data reportingDevelop performance measures and establish benchmarks22. Develop a comprehensive marketing plan

Research partial expansion vs. complete expansionVEMS needs to clear up its public image/operations