BY ALLEN J. RICHARDS
Fire-based emergency medical service (EMS) departments in the United States continue to face annual increases in medical calls that exceed the capability of strategic plans developed five to seven years ago. Constant change and updates to the national healthcare system require fire-based EMS departments to seek innovative methods for improving delivery. The all-hazards post-9/11 approach to emergency management makes a fire department, with its well-equipped and highly trained personnel, the ideal agency to provide professional EMS within the community. However, decreased operating budgets, increased costs of equipment, the traditional fire service culture, and continual requests to do more with less are issues preventing fire departments from fully embracing or adopting EMS in their jurisdictions. Development of a Strengths, Weaknesses, Opportunities, and Threats (SWOT) analysis that solicits input from internal and external stakeholders can create buy-in to foster ownership where EMS operations can be researched, implemented, and improved.
The terrorist events of 9/11 forever changed the landscape and scope of first-response agencies. Police, fire, and EMS, which already provide coverage with limited resources, are now mandated by the federal government to perform additional duties in an effort to protect citizens from more complicated threats and hazards. Additionally, an aging population continues to use prehospital care for chronic illnesses, forcing fire-based EMS systems to examine methods of recovering costs associated with providing this service when tax dollars fall short. The recent downturn in the U.S. economy forced many public safety agencies to determine new methods to fund critical resources; budget items; and, more importantly, personnel. Federal, state, and local governments have made difficult decisions about how to continually provide equipment and services to keep pace with the rising demand for emergency health care in the prehospital setting.
Large populations of uninsured citizens routinely use the 911 system as a primary care avenue for chronic healthcare needs. Fire departments that have EMS incur significant expense because of rising healthcare costs and lower reimbursements from insurance companies. Strategic planners and fire service leadership must continually seek innovative ways to provide services by sustaining professional customer service within financial constraints set by a limited budget. The most recent threat to fire departments with EMS delivery is the process where local governments decide which agency will provide service. Using private ambulance companies in lieu of fire department assets has become a highly contested topic across the United States during budget negotiations with fire service leaders. The increased use of emergency medical resources, along with the rising costs of health care and technology, lead many municipalities to consider eliminating EMS from fire departments and to seek out competitive bids for service from private ambulance companies. However, citizens have come to trust and rely on the fire department for its ability to manage all emergency incidents despite the rapid changes in health care and the increased cost of EMS delivery.
HISTORY OF EMS
In the 1970s, the television show EMERGENCY! highlighted the heroism and medical prowess of Los Angeles County Squad 51 paramedics and firefighters. This was the public’s first real exposure to prehospital trauma care and how it could become a life-saving process. The show was based on a 1966 conceptual model for modern EMS described in a comprehensive 37-page report by the National Academy of Sciences’ National Research Council entitled Accidental Death and Disability: the Neglected Diseases of Modern Society, commonly referred to as the “White Paper.”1 Strategic planners at the time of this publication could not have predicted the rapid increase in EMS requests once the nation realized the professional and efficient manner in which fire department personnel could deliver medical care in the prehospital setting. Subsequently, the popularity and availability of cellular phones contributed to the number of calls dispatch receives on each emergency situation.
In 1971, 16 percent of all fire department calls were medical in nature. By 1973, that number had jumped to 54 percent, pushing fire department officials to plan for increased medical training of their personnel and start strategically planning for a fire-based EMS system.2 In conjunction with the increase in cardiac arrests, many fire departments realized they could have a positive effect on the outcome if their personnel were trained in advanced life support (ALS). Most departments recognized the potential increase in medical calls and started training their firefighters at a basic life support (BLS) level.
A testament to effective strategic planning and the desire to become a model for professionalism in the EMS field, the Phoenix (AZ) Fire Department (PFD) began by training fire personnel to the BLS level; by 1974, every firefighter in the PFD was a certified emergency medical technician (EMT). Meanwhile, the Arizona government developed legislation to permit paramedics to operate under established medical control. In true strategic planning fashion, nine PFD firefighters began their paramedic training through a local hospital. When Arizona’s paramedic act achieved final approval, the PFD paramedics had already finished their training and were ready to test for state certification.3 This type of forward thinking led several other fire departments to examine their existing structure to consider EMS as part of their operations and long-term strategic plans.
With the publication of the White Paper and increased media exposure, fire departments started reviewing and implementing EMS as an operational entity tied to traditional fire operations. At the inception of the program, after the honeymoon wore off, departments were left with the responsibility but an obvious lack of funding options. Financial problems plagued fire-based EMS systems from the start.4 When provisions of the 1976 EMS Systems Act were amended, EMS organizations across the nation had to start planning their own financial futures. This meant that EMS programs were required to seek financial commitments from local governments or nonprofit agencies to maintain their operations. Because of the lack of prudent strategic planning on the part of leadership, large amounts of money would have to be secured over a span of just four years, as federal assistance was scheduled to end in the 1980s. (4)
In any successful business model, customer satisfaction is the key to longevity. Strategic planning should include measures that provide customer feedback, which allows a fire-based EMS organization to establish metrics for improvement. Strategic quality planning in EMS focuses on the customers (patients) and their needs from the entire healthcare system and how to achieve successful integration. A working strategic planning model can increase awareness at all levels of the department on how each phase is integrated into the overall process (Figure 1). The main focus of any customer service metric is to provide a support structure for the core values that directly relate to response time, quality care, and improved customer relations from patients who receive medical care provided by the fire department.
|Source: Richards, 2012.|
Since most of the patients within the community pay taxes for fire service, leaders should become aware of how attitudes of firefighters and paramedics impact the department image. This allows fire service leaders an opportunity to provide guidance and mentoring to further establish constant improvement in customer relations. Complaints from civic leaders to city government officials are a detriment to EMS operations that could lead to scrutiny of the entire program.
Research concludes that firefighters who are cross-trained as paramedics have the ability to respond to extreme medical conditions with the same efficiency as a full-alarm fire assignment. It is well known that both career and volunteer fire departments stand ready 24 hours a day, 365 days a year to answer emergency calls in extreme conditions. The number of emergency medical calls rises each year, which allows interaction with members of the community, giving fire/EMS personnel unique and frequent opportunities to improve customer relations that result in trust and support. This is a crucial element to the survival of EMS within the fire service. How many instances can you remember when you were told by the patient when you responded to a medical call with a fire engine, “I didn’t call the fire department; I requested an ambulance”? This comment and others similar to it illustrate that we as a profession do not provide enough information to citizens about the integrated role of fire and EMS.
Fire-based EMS systems that create an environment-positive change by developing a flexible and integrated SWOT analysis greatly improve the ability to project operational needs to city leaders and citizens of the community. Eliminating a static document and replacing it with a newly developed working document will help create the continuity that will enable the department to adapt to each new challenge the department encounters. There are four distinct criteria for a successful strategic plan5:
1 Mitigate external forces such as strong competition, shrinking revenues, or changing market demands that are seen as a threat to the organization. (5)
2 Stay informed about rapid changes such as technological developments or changes in professional practice introduced in the field. (5)
3 Eliminate traditional ways of doing things that have become less effective; heightened expectations for improved performance are where the focus needs to be. (5)
4 Seek out new methods to solve current and anticipated problems; existing structures and practices do not resolve problems, resulting in a constant “churning” of old issues. (5)
Fire service leaders must look at the historical aspect of EMS and combine it with anticipated changes to develop flexibility and continuity in the plan with input from key stakeholders. Failure to anticipate future growth and the changing needs of the community can cause a fire-based EMS system to become irrelevant and targeted for a third-party ambulance takeover of service.
Strategic planners within the EMS division of any fire department must devise relevant but complementary goals for improving EMS service delivery that also support fire operations. Each firefighter/paramedic should have ample opportunity to voice concerns and opinions that contribute to the vision of the department and support the fire and EMS mission statement.
Traditional leadership attitudes and the long-standing culture are barriers to integrating EMS into the fire service. Many current fire service leaders contend that they do not have the time or patience to deal with new EMS concepts and ideas. This puts a great deal of stress on firefighters who are learning and performing the EMS function on a daily basis. A significant part of the strategic plan for the inclusion of EMS should outline a specific plan on how chief and company officers can improve their attitudes, abilities, and skills to produce a positive image toward EMS in the department. Nothing will destroy morale faster than leaders who do not support the members of the department working hard to improve EMS delivery and customer satisfaction.6
SWOT FOR FIRE-BASED EMS
Before you can conduct and understand what an effective SWOT analysis is, you should know what strategic planning does not do. Strategic planning is not any of the following7:
- It does not predict the future or make decisions that can’t be changed. If an unexpected shift occurs, major strategic decisions may have to be revisited sooner than they would in a typical three- to five-year planning cycle.
- It is not a substitute for the judgment of leadership. The data analysis and decision-making tools of strategic planning do not make the organization function; they can only support the intuition, reasoning skills, and judgment that people bring to the work of their organization.
- Strategic planning is not always a smooth, predictable, and linear process. No one should be surprised if the process feels less like a trip on a train and more like a ride on a roller coaster. But roller coaster cars will arrive at their destination as long as they stay on track!
To further strengthen the argument of having an integrated strategic plan, EMS leaders should adopt fire suppression tactics as a means of achieving equality in this fashion8:
1 Conduct preincident planning. Knowing about specific target addresses such as nursing homes, assisted-living facilities, and correctional institutions in your area will help you identify problems associated with particular populations with special needs.
2 Perform a size-up. When you compare the fire command sequence to the EMS approach of patient assessment, diagnosis, and treatment plan; BLS and ALS interventions; and continuous patient monitoring, you will find that they are analogous and that the use of the command sequence is appropriate for EMS incidents as well.
3 Determine strategy and tactics. Once an EMS officer/paramedic has the necessary information to make informed decisions, the next responsibility is to put together an action plan to correct the identified problems.
4 Decide and implement. Determine the individual actions necessary to carry out the plan that will produce the desired results.
5 Continually reevaluate strategy. Patients need to be continually monitored for changing vital signs, changes in level of pain and mental status, and other physiologic indicators that show if the chosen course of treatment is improving the patient’s condition.
Using input from several sources and understanding trends within the fire service, health care, and the community, a SWOT analysis will give leaders an opportunity to devise and revise a flexible working plan that will be relevant for current and future operations.
Acquiring a fire-based EMS system has many distinct advantages over private ambulance services. Members of a fire department are adept at handling multifaceted emergencies with greater skill and preparation. Firefighter/paramedics have more than sufficient training to manage unexpected problems, complex rescues, and hazardous environments. Continual training in unpredictable environments under less than ideal conditions allows fire-based EMS departments the opportunity to serve the needs of the public quickly and efficiently.
EMS delivery by the fire service has a deficiency that largely goes unattended: Department members often do not view patient care as engaging or an opportunity to increase public trust. Many firefighters disdain “riding the box” but still provide excellent patient care in spite of these feelings. EMS organizations that employ strict business models typically do well with the bottom line but fall short with trust and positive image. Fire departments that merely tolerate EMS are lacking in innovation for improving service and do not deliver optimal patient care. Significant personal and organizational efforts are needed to meet the established goals. EMS has traditionally, with few exceptions, employed a “shoot from the hip” approach with regard to strategic planning. Because of the nature of our business, we usually operate in a reactive, rather than a proactive, manner. (7)
Fire service leaders and firefighters realize the lopsided percentages (fire vs. EMS calls) prevalent in modern fire-based EMS departments. Strategic planning should include situational awareness that supports the principle of sensitivity to operations and sees it as a blueprint for future success. This includes an aggressive customer service development culture so that each interaction with citizens is a positive one. Understanding the constant change in the fire service as the balance shifts from fewer fire responses to more EMS calls will provide opportunities within the department for medical process improvements. For example, consider the premise that EMS has potential to provide a revenue source from delivery of high-quality service and increased patient satisfaction. Fire-based EMS systems have one or more response surveys in place that provide critical feedback from patients for evaluating service provided that can be used for future improvements.
Lack of customer engagement and complacency can become threats to fire-based EMS and potentially tarnish public trust. Continuing education programs do not provide enough focus on external threats and assessment for improving EMS delivery where professional standards are the focus. Each fire department must hold paramedics and EMTs to high medical standards as they would any other profession that serves the public. Citizens place specific trust in fire department personnel, and those charged with that responsibility must be known for their ability to use their fire and medical knowledge in novel ways to solve complex problems in addition to providing superior service every time a citizen requests assistance.
Medical protocols and technology surrounding EMS are constantly changing. Firefighter/paramedics are responsible for staying informed and proficient as their task list becomes longer in each aspect of the profession. The all-hazards approach requires the firefighter/paramedic to act as a multifaceted response force when it pertains to public safety and emergencies. Strategic planning is a critical part of fire-based EMS organization survival as resources are reduced and mission requirements are increased. Traditional fire service leaders must continue to refine their thought process tactics; this includes viewing the inclusion of EMS as a means of organizational survival. With improved methods of fire prevention and public education, the number of active fires will continue to decrease while requests for routine health care and emergency medical response will continue to rise.
Budget development and planning are now the cornerstone activities for executive fire officers in the current economics-sensitive environment. Improving methods for educating incumbent politicians and newly elected officials should be a top priority for fire service leaders to ensure the strategic plan for fire-based EMS is funded and supported. Evidence-based predictions and continual assessment can make fire service leadership more confident that the strategic plan can survive in peak economic stability and, more importantly, when difficult times lie ahead.
1. Erich, J. (2007). White Paper States Case for Fire-Based EMS. EMS Magazine 36(10), 40.
2. O’Brien, RJ. (2003). The Future of Fire-Based EMS: Paramedic Programs and Internships. Fire Engineering 15(6,) 36-42.
3. Simpson, J. (2008). Developing a Fire-Based EMS System: One Department’s Strategic Plan. Fire Engineering 161(6), 28-31.
4. Sayre, MR, White, LJ, Brown, LH, & McHenry, SD. (2005). The National EMS Research Strategic Plan. Prehospital Emergency Care 9(3), 255.
5. Snead, GC, & Porter, R. (1996). Restructuring fire and emergency medical services. Public Management 78(2), 8.
6. Weick & Sutcliffe. (2007). Managing the Unexpected. San Francisco, CA: John Wiley & Sons Inc., Jossey – Bass Publishing.
7. Barishansky, R. (2008). Strategic Planning for EMS Agencies, EMS World, July 8, retrieved from www.emsworld.com.
8. Holliday, SC. (2011). Using Fire Suppression Strategy and Tactics for EMS. Fire Engineering 164(5), 26-29.
ALLEN J. RICHARDS is a firefighter/paramedic and field trainer for the Grapevine (TX) Fire Department. He is a 25-year veteran of U.S. Army Aviation, serving as an operations/training officer and UH-60L Blackhawk pilot. He has a bachelor of science degree in aviation technology and a master’s degree in public safety/emergency management. He is an adjunct instructor for the EMS and Fire School at Tarrant County College and a National Fire Academy instructor in EMS special operations.