Ambulance study produces findings, recommendations
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The 100-hour analysis was performed by Bart Regan, owner of Ambulance Service Consultants of Tennessee, for $2,500 at a rate of $25 an hour. He has issued a report that was presented at the Nov. 10 regular monthly meeting of the Fayette County Health and Welfare Committee.
The Ambulance Service, in conjunction with the county Fire Department and the various municipal departments, provides emergency medical services to a population of 35,471 within a 704.5-square-mile area.Deployment questions and delayed response times, along with rising costs, recently led the Fayette County Commission to focus on the Service.
Regan's report stated that, since its inception as a public utility, the Service has struggled with a "myriad of problems" that include vehicle deployment, "political manipulation, insufficient revenue capture and lack of planning."
The report acknowledged that the introduction of a private ambulance service in Oakland has taken some pressure off the county's Service. But it also said that has "diluted the revenue stream available" to it, as well as having the potential to "compromise the coordinated delivery" of emergency medical services in the county.
The report noted that a "lack of sufficient information" has prevented the commission from finding appropriate solutions. So, the analysis was designed to give it all the pertinent information and appropriate recommendations to enable the commission to find a solution that provides "well-balanced and cost-sensitive" emergency medical services to the county, based on the Public Utility Model.
The analysis included an in-depth study of the structure of the Ambulance Service, the quality of service it provides, the management methods employed, its ability to maximize revenue capture and conservation and to appropriately meet the needs of the community it serves now and in the future.
Noting that the Service is operated as a third public safety agency separate from the county Sheriff's Office and Fire Department, the report called that a model that has proved effective in many municipalities and counties throughout the nation. It is funded through income from services provided, as well as supplemental funding when necessary from the county's General Fund.
The report stated that "serious lack of convenient access" to data regarding ambulance runs required "extensive research and cross comparisons" of reports from several agencies in order to develop appropriate deployment requirements. Consequently, deployment information was developed based on three years of statistics that have an estimated accuracy of plus or minus 10 percent.
Evaluation of all the factors involved resulted in a list of findings, as well as recommendations to address them. They are:
(1) Because no long-range coordinated plan currently exists, one should be developed.
(2) Because there is no convenient access to the data required to effectively respond to the needs of the Service or to plan for future growth, a comprehensive electronic database should be established.
(3) Because the role of each member of the Service is not clearly defined, the organizational structure should be documented.
(4) Because the Service is not monitored by a separate committee and held accountable to its documented standards, such a committee should be designated that will document a system of accountability.
(5) Because the administrative staff is not presently structured to meet the needs of the Service, it should be restructured.
(6) Because there are currently no documented standard operating procedures, they should be established and documented.
(7) Because the majority of in-service training currently consists of self-study video modules, a comprehensive training program should be implemented for field personnel.
(8) Because the Tennessee Occupational Safety and Health Act's requirements for documentation of mandated plans are not being met, they should be revised, updated and implemented.
(9) Because there is no evidence that a risk assessment has ever been completed, one that complies with the Health Information Privacy Act should be completed and implemented.
(10) Because there is no logical system for control of inventory, one should be established for all supplies and equipment.
(11) Because there is no documented plan providing for the maintenance of durable medical equipment, a comprehensive program should be established.
(12) Because a computer-aided dispatch system, along with EMD-trained dispatchers, would enhance the Service's performance, dispatch procedures should be enhanced to provide for more efficient use of resources.
(13) Although rates allowed by Medicare and TennCare are capped, an adjustment of the current fee schedule could provide enhanced revenues from other sources. So, the fees that are currently charged should be reviewed in order to ensure maximum revenue capture.
(14) Because the Service is currently collecting 50 percent or less than the amount it is billing, an effective billing and collection program should be implemented to maximize the capture of revenue.
(15) Because the ambulances are not presently deployed in a manner that is most effective in providing appropriate response times to all areas of the county, a deployment plan that accomplishes this should be established.
The report noted that the recommendation for deployment of four ambulances in the county's Service is based on the primary criteria of appropriate response times.
"Obviously, consideration has to be given to the cost factor and a balance must be found," it stated. "The recommendation seeks to find that balance, without creating an undue financial burden on the county."
The report also stated that the unit contracted to the town of Oakland can only be considered an "ancillary" one for "mutual aid" as needed and when available. Because the Service currently owns five ambulances, the report noted that the deployment of a fourth one would not require the purchase of an additional ambulance.
"Consideration needs to be given by the repair facility to prioritizing repairs to any unit to reduce down time to a minimum," it stated. "Any agreement with a repair facility must include that contingency."
The report concluded that, because of a core of dedicated personnel, the Service is doing "an admirable job" of providing emergency medical services to the community, despite the many problems with which it is faced. Noting that the Service is constrained only by the "limitations of the organization," the report said each of these limitations can be easily addressed.
It said a development program must be instituted to give the administrative staff the tools to bring about the changes necessary to elevate the Service to the "level of excellence required." It also said decision-making that affects the Service must be "purged of political manipulation."
"A strategic error was made in failing to deploy a unit to the Oakland Fire Department when it was requested," the report stated. "This decision has the potential to fracture the coordinated provision of emergency medical services within the county. In addition, it has diluted the revenue stream available to the Service by approximately $350,000 in fiscal year 2007-2008 alone."
The report noted that reversal of this decision is possible. However, it also acknowledged that doing so now will "complicate other decisions" that need to be made regarding deployment of ambulances throughout the county.
"Establishing a base point from which to develop a long-range plan is critical," the report concluded. "Monitoring and maintaining the plan will provide the county a Service that could well become the model that other counties and municipalities strive to match."
