Valley Emergency Medical Services Final VERSION2-DisasterbyDesign 8-2004

Evaluation of VEMS for the Council of Governments
Valley Emergency Medical Services System Evaluation
Jonathan Best
Disaster By Design LLC.
Strategies for the Unexpected
DISASTER By DESIGN LLC.

203 673-4847 BESTEMS@aol.com

TABLE OF CONTENTS Topic Purpose of Study Time Frame for Study Consultant Focus Group Methodology Interviews Data Review Document Review Maps Financials Meeting minutes and Correspondence Bylaws Findings The Communities VEMS Serves Common Ground Issues Affecting VEMS ` Analysis of the current VEMS Points of Departure for Paramedics EMD Impact Suggested Departure Point (Present) Suggested Departure Point (Future) Options for Paramedic Service Operating Efficiency and Value Cost of Present System Financial Oversight Bundle Billing Governance Model and Structure Administrative Staff Structure Overview of Options Review of Past Recommendations Recommendations for Medical Control Quality Control and Improvement Expansion of Paramedic Services Recommendations PowerPoint Presentation slides Pages 3 3 3 4 4 4 5 5 5 6 6 7 7 7 8 9 - 10 11 11 12 13 13 - 16 17 17 17 18 - 20 20 21 22 22 - 24 25 25 26 27 28 - 40


PURPOSE OF THE STUDY DISASTER By DESIGN LLC was retained by the Council of Governments to evaluate and review the Valley Emergency Medical Service, a 501(c)(3) corporation established in 1983 to: 1. Foster the delivery of prompt and effective emergency medical services in the Towns of Ansonia, Derby, Oxford, Seymour and Shelton and the surrounding area. 2. Educate the pubic concerning the need for and provision of emergency medical services. 3. Provide training to medical personnel and the public for rendering of emergency medical assistance. 4. Facilitate the coordination of the provision of emergency medical services in the Valley and to that end work with other organizations involved in the delivery of emergency medical services, including local ambulance companies. 5. Provide volunteer emergency medical services to the Valley. The 1995 consultants report stated goals are not being met. Interviews with individuals who participated in the development of VEMS describe confusion as to of the role of VEMS. Some of those interviewed describe that the paramedic program overwhelmed the other aspects of the VEMS program. The ambulance chiefs meeting to discuss issues became operational discussions regarding Paramedics. Presently there appears to be no common agreement on the direction VEMS should take. An example of this conflict is described by one of the participating organizations: The purpose of VEMS originally was to allow the chiefs of the local volunteer ambulance 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 of VEMS and derailed the vision of its founding members into a dysfunctional body that 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 for Proposal. Further we intend to make recommendations for improvements in the VEMS program. Time Frame for Study The contract for services was executed on July 6, 2004 with a preliminary work product report and PowerPoint presentation on CD was delivered on August 1, 2004. Questions were generated by the Council of Governments VEMS Task Force. A response to the questions was submitted back to the VEMS Task Force on August 16, 2004. A copy of the questions and responses is attached in Appendix 1. There were no meetings with the Task Force although they had been requested by the consultants to discuss the work product document. A final report is being delivered on August 26, 2004. DISASTER By DESIGN LLC.

Consultant Group The consultant group consisted of Jonathan Best, Martin Stillman, Doug Berkowitz, Jeff LaReau and Joanne Orlando. Throughout the contract time ongoing discussions relative to this project were done via Email, phone and in person. Documents were distributed to the members for their review. On July 27th, 2004 the consultant group conducted a focus group in Stamford, Ct. reviewing the documents and data that had been collected. The meeting developed this report and outlined a work plan for the future. In addition several meetings were held to analyze the data that had been collected by Disaster by Design from the South Central CMED Center. Methodology The methodology of review consisted of interviews, data review, document review, a consultant focus meeting and system comparisons. Interviews We conducted interviews with the following participants:
Dr. H Boris, Griffin Hospital John Gustafson, South Central CMED Jerry Schwab, Oxford EMS, President of the VEMS Board Jason Perillo, Shelton EMS, Treasurer of the VEMS Board Frank Marcucio, Seymour EMS Tom Lenart, Derby EMS Mark Kiesling, Past President of the VEMS Board (via telephone) Barbara Martin, Regional EMS Coordinator Marge Deegan, VP, Griffin Hospital William Powanda, VP Griffin Hospital Roy 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 the VEMS system. Document Review In this process we reviewed maps, financials, meeting minutes, correspondence and Bylaws. The documents were provided to us by individuals during interviews and at our request. We purchased and reviewed maps of the Lower Naugatuck Valley area. In addition we drove through each of the communities to understand the response issues for paramedic 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 us raw dispatch data for the VEMS units. The format was provided was Microsoft Access 97 in read only files. Call data consists of incident locations, unit identifiers and benchmarks in the response system. We initially reviewed 1592 responses, 17 responses DISASTER By DESIGN LLC.

had incomplete information. Upon completion of that data there was a concern that the numbers were not consistent with our experience. After a telephone conversation with CMED 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 required information. The process of data analysis was extremely unwieldy. In order to identify response 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 data required significant time commitment. While on an individual call you could identify the information quickly, if you chose to do a monthly analysis it was a time intensive process. This makes the process of quality assurance on response difficult on a regular basis. Therefore it is difficult to determine system performance. In our analysis we did some sampling of the data and verified what providers were telling us relative to response or non response of VEMS units. We were told that there is no uniform system in place for providers to receive monthly response data exclusive to EMS units presently. We appreciated the South Central CMED staff taking time to meet with us and for providing the data. Our findings are as follows: VEMS Calls Ansonia 1592 Derby 1199 Oxford 391 Seymour 1157 Shelton 2570 Totals 6909 Missing Data 308 288 134 415 602 1747 Calls Reviewed 1284 911 257 742 1968 5162 Activation Time 2.57 1.38 2.24 3.21 2.59 Response Time 8.03 7.46 15.57 12.25 11.28
Activation time represents the time from a call being received to a vehicle acknowledging they 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 minutes Average Response Time 10.91 minutes
Call Activity Level VEMS 2003

Ansonia, 1592, 23% Shelton, 2570, 37%
Derby, 1199, 17%
Seymour, 1157, 17%
Oxford, 391, 6%


Financials Review of financials involved budget documents and projections done by the Treasurer of VEMS who is a CPA. We requested a Profit & Loss statement and were told it had not been developed yet but was in process. We reviewed the 2004 financials with projections and the 2005 anticipated budget. Other budget figures were not available to us. 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 with various service heads there was much discussion of a $93,000.00 liability to AMR for payroll. This item was not reflected on the financials. It was explained that this old liability was the result of failure to make 3 months of payments for staffing. This number had been carried over for a period of time. At present it was under negotiation with AMR. Our analysis of the numbers presented indicates that VEMS is functioning, but any event that would impact the revenue stream would be catastrophic. We also received an analysis of Paramedic implementation in an existing service which indicates that it would require 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 this component. A copy of the financial documents is attached in Appendix 3. Paramedic Analysis
REVENUE Ambulance calls ALS Percentage Paramedic Transports ALS Transport Rate BLS Transport Rate Differential to ALS Collection Rate Billing Fee Rate Revenue EXPENSE (Incremental hourly cost) (Cost of a paramedic, total) Weekdays Days Nights One day One week Weekends Full weekend Total weekly cost Total Annual Cost $ $ 1,152.00 2,832.00 $ $ 1,152.00 2,832.00 $ $ 1,152.00 2,832.00 $ $ $ 1,152.00 2,832.00 147,264.00 (15,548.64) $ $ $ 1,152.00 2,832.00 147,264.00 (913.60) $ $ $ 1,152.00 2,832.00 147,264.00 72,261.60 $ $ $ $ 48.00 288.00 336.00 1,680.00 $ $ $ $ 48.00 288.00 336.00 1,680.00 $ $ $ $ 48.00 288.00 336.00 1,680.00 $ $ $ $ 48.00 288.00 336.00 1,680.00 $ $ $ $ 48.00 288.00 336.00 1,680.00 $ $ $ $ 48.00 288.00 336.00 1,680.00 $ $ 4.00 24.00 $ $ 4.00 24.00 $ $ 4.00 24.00 $ $ 4.00 24.00 $ $ 4.00 24.00 $ $ 4.00 24.00 $ $ $ $ 1200 40% 480 638.00 346.00 292.00 70% 10.5% 87,810.24 $ $ $ 1400 40% 560 638.00 346.00 292.00 70% 10.5% $ 102,445.28 $ $ $ 1600 40% 640 638.00 346.00 292.00 70% 10.5% $ 117,080.32 $ $ $ $ 1800 40% 720 638.00 346.00 292.00 70% 10.5% 131,715.36 $ $ $ $ 2000 40% 800 638.00 346.00 292.00 70% 10.5% 146,350.40 $ $ $ $ 3000 40% 1200 638.00 346.00 292.00 70% 10.5% 219,525.60
$ 147,264.00
$ 147,264.00
$ 147,264.00 (30,183.68)
(Expense) / Revenue (59,453.76) (44,818.72) Provided by VEMS, reviewed by Jonathan Best


The table on page 6 demonstrates the dollars required to convert one paid EMT to a one paid Paramedic. The dollar figure represents the difference in salary. It was then calculated to give daily and weekly cost estimates. There was also a calculation for night differential coverage and weekend costs. These figures only represent the salary differential. Other operational costs were not included. The table clearly indicates that a service with less than 2000 calls per year would have no ability to afford the paramedics alone without adding any additional operational expenses. The call volume required moves higher when you add any other operational costs. There are fixed personnel costs to operate a paramedic system. While initially it seems that with existing staff and infrastructure an independent paramedic program could get off the ground, there is a long term financial liability. The cost of providing paramedic service on each community would be significant. In addition the intent is to develop a paramedic response system that will last long term. If the system designed is dependent on specific individuals the potential 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 a regional system that shares the costs. Meeting minutes and correspondence The meeting minutes and correspondence reviewed were specific to an issue that was raised relative to the ability of one community to withdraw from the VEMS program and recover the PSA for paramedic coverage. In the 1995 consultation performed by Holdsworth and Associates the issue of having five separate PSAs was brought up. This issuance created a regulatory problem for VEMS. That consulting group correctly identified 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 on behalf 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, they would 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 Medical Services Inc. duly made seconded and approved at our meeting held this date, we hereby request clarification of our PSA assignment. In 1989 we were assigned five individual PSAs for the municipalities of Ansonia, Derby, Seymour, Shelton and Oxford. This assignment appears to have been an oversight. We hereby formally request that the current service area be immediately clarified and consolidated into one single PSA, as we believe it should have been in 1989. There was no mention of the individual towns ability to request separate PSAs as the original motion indicated. The Office of Emergency 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 different PSAs even though the documentation would indicate that position. I will be forwarding to you the formal and unusual paperwork, but please use this as a clarification of assignment until receipt of the normal documentation. Valley EMSs PSA assignment for paramedic intercept is as follows: The geographic area that includes the boundaries of the municipalities of Ansonia, Derby, Seymour, Shelton and Oxford.


It is clear that a single PSA was issued to VEMS. It is also clear that there are no services presently certified at the paramedic level. Should a service become certified at the paramedic level the issue of breaking up the regional system and PSA would rest with Office of Emergency Medical Services. Other sets of minutes were reviewed to understand the interactions of Board of VEMS in general. We were presented with several letters questioning an outstanding debt to American Medical Response. This correspondence is followed by FOI request that is not dated. Other items of correspondence were reviewed as they were presented during interviews. All the correspondence indicates a dynamic among Board members that makes the operation of VEMS difficult. Bylaws In our examination we viewed the Bylaws as incomplete and contradictory. There are several areas of confusion. There is no mention of the position of President in the documents we were given. The page numbering indicates this section may not be in the Bylaws 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 Board positions. There are conflicts page to page in these documents. There is a description of paramedic service provider on the Board of Directors. The Bylaws need to clarify as to who this individual is. The intent we learned through discussion was to have the representative of the commercial provider serving as back up to VEMS sit as an ex-officio member. This individual representing a contractor should sit at the meetings as a requirement of the contract. By making them an ex-officio member their position is raised to a level that is not required. The Bylaws provide for municipal participation for municipalities that provide subsidies to VEMS. Several years ago the VEMS Board decided to eliminate the municipal subsidies. At the present time no municipalities subsidize VEMS. The change was never reflected 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 annual organizational meeting. This may be a violation of the Freedom of Information Act. Several sections later the Bylaws discuss the Secretary giving notice of meetings. This contradicts 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 by municipalities. The presence of this paramedic service board undermines the authority of the Board of Directors. The issues stated represent several areas of the Bylaws that need attention. There are others. We have the ability to provide sample Bylaws or assist with development but do not believe a complete rewrite is within the scope of this study.


FINDINGS The Communities VEMS Serves During the course of our review DISASTER By DESIGN found the participants in the VEMS system possess tremendous experience, significant intelligence and talent in the EMS services. The volunteer organizations serve their communities very well and are committed to providing quality emergency medical services. There are significant resources 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 their respective EMS organizations. Each of the municipalities exhibits great concern for the health and safety of their citizens. A concern identified by several of those interviewed was that there had been several studies of the system done before and most of the recommendations had never been implemented. 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) (Most of the recommendations were not implemented)
3. Consultant was asked to return and review progress in 1999 or 2000 The question was asked of us Why this analysis is going to be any different than others that 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 we found significant common ground. Each of the service heads mentioned these items as goals for EMS: Need for Paramedic Service Quality Patient Care Cost Effective Service Serve Their Communities Support the Volunteer Ambulance Services These common ground items represent a good platform to implement improvements to the VEMS program. These items are also the basic goals identified originally when VEMS was created.


Issues Affecting VEMS During the interviews we found individuals with significant concerns. The concerns focused on not satisfactorily fulfilled expectations and failures to maintain agreements. These perceptions have created conflict eroding support for the regional concept of paramedic 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 board members makes progress difficult. There is a basic lack of clear mission statement. This has resulted in a lack of commitment to VEMS by some of the participants. Specifically comments we received were: 1. 2. 3. 4. VEMS has passed its time and there is a need to develop individual services. VEMS survival is closely tied to the survival of the volunteer ambulance services. Concern over clinical quality of EMS if the system were to be dismantled. 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 that VEMS is failing to do that resulting in services attempting to find other solutions. Our review of response time and operational issues indicate that VEMS is providing the level of service intended with the present available resources. With changing communities it may be necessary to enhance the resources to address the issues and concerns stated above. Analysis of the current VEMS The basic day to day operations of VEMS function. We addressed the financial fragility of 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 6909 calls. The community paramedic program that has been discussed is a good idea and can work if structured properly. We do have a method of structuring it but believe that would be a distraction in light of the larger issues that VEMS faces. The larger issue is that the severe level of discord that exists between the participants in the program. Mitigating this discord should take priority over all other future projects. Our recommendation is that VEMS resolve the board dynamics that presently exist. This is possible. Out of frustration with VEMS some communities have developed plans for separate paramedic programs. We believe this is a mistake. If the decision is to dissolve VEMS the 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 individual communities should address the paramedic service issue. Further we believe VEMS would need outside assistance to create new programs in the future. If VEMS is dissolved we stand ready to assist any community with their development of paramedic programs.

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Service Ansonia Derby Seymour Shelton Oxford Population Served 18,554 12,391 15,454 38,101 9,821 Square Miles 6.0 5.4 15.0 31.9 33.4 Call Volume (C-med) 1,884 1,314 1,300 3,282 600 Comments
Estimate from Oxford EMS Director / Dispatched by NWCMED
The figures presented in the diagram are from the South Central CMED budget for July 1, 2004 to June 30, 2005. The call volume numbers represent the 2003 activity that the new budget was based on. This is total EMS calls for communities not just VEMS paramedic calls. The census figures were provided by Council of Governments. The Oxford number presented is not from CMED it is the result of a conversation with the Director of Oxford EMS (600 calls). Oxford uses the CMED center in Northwest Connecticut and not South Central.
Comparison of Paramedic Use by Town / 2003
3500 3282
3000 2570 2500
2000
1884 1592 Total CMED Calls Total VEMS Calls 1314 1199 1300 1157
1500
1000 600 391 500
0 Ansonia Derby Oxford Seymour Shelton
The VEMS paramedic system covers 91.7 square miles. Base on the numbers collected the 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 both quality assurance and operational planning.

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Some of the participating volunteer ambulance services reported failures of VEMS to provide paramedic response. It was acknowledged that in most cases the VEMS units are on other calls. There is 100% response to the first paramedic calls in the PSA, which is required by regulation. Other participating volunteer ambulance services stated the response has been adequate. We found it difficult to verify the response performance that had been reported regarding availability. One service provided data that demonstrated in one 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 had with 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 be adequate for paramedic response. Response time represents an excellent performance measure of an EMS system. Regarding lack of availability, issues that contribute are geography, unit placement; turn around time at the hospitals and mileage. Back up paramedic coverage is presently provided by American Medical Response (AMR) under a contractual arrangement. The backup paramedic service (AMR) sends vehicles from Bridgeport to respond to 911 calls when 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 not available this long distance response could contribute to the perception of paramedic unavailability. Options to address this issue have not been addressed. For instance, a neighboring town has a paramedic service that has not been utilized even with its geographic location between the Valley and Bridgeport. Other commercial ambulance providers may also provide some relief to this issue. Oxford presently has a paramedic response time of 15.57 minutes. This is the longest of any 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 the Northwest 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 the Director of South Central CMED it was felt that no delay in response occurs with this dispatch structure. We do feel that relocating a unit closer would reduce their present paramedic response times to Seymour and Oxford. The goal would be to achieve an 8 minute average response time across the regional area served by VEMS. VEMS Calls 1592 1199 391 1157 2570 Response Time 8.03 7.46 15.57 12.25 11.28
Ansonia Derby Oxford Seymour Shelton

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Points of Departure for Paramedics At the present time the VEMS paramedics are located in Shelton and Derby. On several site visits we found the unit together at Griffin Hospital. This shows a lack of supervision and impacts on response time.
This map represents the present response situation. While we did not attach response times to it we believe the circle represent the response in the Valley presently. The lowest circle represents an excellent response, the middle circle an adequate response and the 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 paramedic response with a 10 -12 minute average. An area in need of improvement is a response time 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 implement emergency medical dispatch. Each EMS response agency would be required to develop procedures to meet this challenge. Calls previously dispatched as paramedic call be triaged 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. The other result may be an improvement in paramedic availability and response time. In speaking with John Gustafson from South Central CMED, he believed that there that would have little impact. During these next few months it will be imperative to evaluate the impact of EMD on the VEMS program. During interviews some services commented about improvements in paramedic responses of late. There are many variables that may be responsible for this, including this study, but it is more than likely that the implementation of emergency medical dispatch has helped. DISASTER By DESIGN LLC.
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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 one VEMS 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 lower the response time to outlying areas. The intent would be to more evenly distribute responses through geographic relocation. Paramedic units should be relocated as calls occur making the system much more dynamic than it presently is. This would be a modified system status management program performed by the on duty paramedics not the dispatch center. The areas of overlap would be the recommended staging points when one unit is responding to a call. We believe this would insure a higher likelihood of paramedic 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 peak activity times. A more significant study would be needed to determine the peak times but clearly this would address the issue of a unit not being available for the second or third calls. We also believe that the financial impact would be minimal, but would recommend that 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. This opinion is based on the information we collected. If some aspect of the information is flawed we would recommend that this not be implemented until actual numbers could be developed. In this presentation you will notice that the areas of highest call volume have overlapping response times to maintain the high level of service as it relates to paramedic response.
Options for Paramedic Service There are three options relative to VEMS. Each of the options has advantages and disadvantages. 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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Option 1 Keep the Current VEMS Program Unchanged
Disadvantages All of the participants originally felt the VEMS system was the best way to provide paramedics, support volunteer services and provide community education on EMS. The greatest issue facing VEMS is the Board of Directors dynamics. Many organizations much larger than VEMS have failed because of the failure of their Board to work together even when the business made sense and was profitable. VEMS is dependant on cooperative working relationships between services. There is a basic lack of cooperative relationships required for a regional organization to be successful. The present competitive nature of the participating services continues to contribute to the shortcomings of the VEMS. While competition is a positive attribute for the services at this point it is not a positive attribute for the VEMS program. Each of the service heads brings tremendous expertise and experience to the Board of VEMS. This could be a great advantage. This expertise and experience is not being utilized to its fullest potential. The organization is losing emergency service support due to perceived failures in system performance. If this situation continues the future outlook for VEMS is not positive. VEMS lacks adequate supervision on a day to day basis. The practice of supervision is not what is done but how employees respond to it. On several visits we found the VEMS units huddled together at the hospital and not posted. I am sure when the supervisor checked everyone was where they were supposed to be. The practice of how paramedics conduct themselves when no one is watching speaks to the lack of supervision. The QA system it appears to be episodic. There is no comprehensive review of response time on a regular basis. Several of the service heads spoke to the fact they never heard from anyone until there was a problem. Our belief is that a comprehensive QA program should be developed in concert with the services. The hiring of an EMS coordinator by Griffin Hospital should help with this. That hiring is in process. At present the system lacks a comprehensive quality assurance system. The present VEMS program is very fragile. A disruption of revenue stream can create a financial hardship or catastrophe depending on how long the stream is disrupted. That financial disruption could come from changing Medicare rates, sudden increase in cost such as fuel, competition in the area, catastrophic accident or medical error. The profit margin of VEMS relative to expense is very small. We would have expected it to be larger after 21 years of service. There is no capitalization plan or financial reserve. There is no written business plan or marketing plan for this organization. The present billing system creates customer dissatisfaction which then impacts on participating towns because of two bills being generated. The concern is that citizens specifically seniors are receiving two bills for one ambulance trip. While bundle billing may appear attractive, the present Medicare rule changes will not serve VEMS well and in fact may hasten the financial shortfall. The need for a uniform billing process is apparent. The need to agree on a better distribution of revenue is essential. The lack of infrastructure while cost effective makes VEMS very nebulous to the customers.

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This program has not been adequately supported in its present state. It occurred when the VEMS Board decided to eliminate municipal funding. The elimination of municipal funding limited the municipal oversight over the VEMS program. It also created an impression that the municipalities had limited interest in the paramedic program which we know to be untrue. Based on the action of the VEMS Board the municipalities stopped providing subsidies for service. This elimination of municipal subsidy not only had 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, municipalities and 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 address the 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 its present state. The present VEMS has customer/community acceptance. The program promotes regionalization. The program is very cost effective. VEMS exists presently with no municipal subsidy. The communities receive paramedic service with no impact on tax base. Citizens are billed directly for service. This participation makes VEMS eligible for grant funding along with the participating communities. The issue of regionalization is high on the priority list for grants presently specifically Homeland Security grants. The present paramedic program provides single organization for medical control. VEMS provides paramedic service to communities which might not be able to support 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 there may be some fallout from discontinuing service. VEMS promotes regionalization of very expensive health care services; some might be concerned about the cost of services without regional sharing of cost. This program has been very cost effective and receives no municipal subsidy. The foundation has been laid for community involvement on a regional basis. Eliminating VEMS could result in a poor public image in communities that 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 the program might have a significant financial liability and therefore closing may cost more than remaining open. There are also grants that have been received and may require that some 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 still be significantly more expensive to each community. Some communities have expressed concern that this might compromise their existing volunteer services. Elimination of VEMS would require paramedic medical control to five individual programs. It would impact on the clinical quality of the program because all of the communities with the exception of one lack sufficient call volume to support individual paramedic programs. Volume is not the only parameter, it is also call acuity. Alternative educational experiences can substitute for doing some paramedic skills in the field. The issue of availability of this type of education is a concern. If each of the five services required alternative educational experiences the demand would be excessive. Alternative educational 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 services say they use alternative educational experiences to bolster their level of confidence every time we have looked carefully we find many programs not fulfilling their obligations. As a result the quality of the advanced life support programs are poor. If paramedics are rotated from urban or suburban areas to low volume services there is a better chance of success. We do not believe the opportunities for alternative educational experiences exist in sufficient number to support this type of a program for five ambulance services in the valley. We do believe that the five communities combined provide a good case mix and call volume to support a paramedic program. Eliminating this program ignores considerable opportunity to serve the Valley with an effective, high quality paramedic response program. Eliminating VEMS disregards recognized need for a regional system. At the time VEMS was created the communities in the Valley had created a cutting edge program providing paramedics. There is a significant 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 paramedic units from two to five. Eliminating the regional program would require existing infrastructure in the towns to provide paramedic service. It would eliminate staff liabilities. Existing financial liabilities may be eliminated with the closure of VEMS. This would transfer the risk liability from VEMS to the communities for paramedic services.

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Option 3 Enhance the Current VEMS Program
Disadvantages Enhancing the VEMS program would require consistent and sustained municipal and corporate financial commitment. There would be an increase in cost because of the capital 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 promotes regionalization. There is a broad-based appeal to use a regional system. The program is cost effective and clinically sound. The communities receive paramedic service and citizens are billed directly for service. The existing community EMS services participate in VEMS operations. This participation makes VEMS eligible for grant funding. The issue of regionalization is high on the priority list for grants, specifically Homeland Security grants. VEMS provides paramedic service to communities which might not be able to support them individually. VEMS creates a single point of contact for Medical Control and quality assurance. The present paramedic program provides single organization for medical control. The limited market competition allows VEMS to expand services and become more financially sound. Many opportunities exist for potential expansion of market to support the VEMS program. This option represents the most reasonable option for the provision of a clinically sound, financially secure organization. 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 was provided on page 6 of this report. That cost analysis would be the personnel expense only of converting an EMT to a paramedic. It did not account for operations costs. On the 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. A paramedic system does not replace a basic EMS system. While some economies of scale exist the example is all operational costs required. This does not include personnel costs. There is an identified shortage of paramedics, volunteers and EMTs. Five separate paramedic 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 $542,809.81* $1487.15 (2004 operating expenses) Daily operating cost Paramedic Cost Example $431,000.00** For Two Vehicles $576,700.00** For Three Vehicles
*Includes personnel costs **Does not include personnel costs / operating expenses only DISASTER By DESIGN LLC.
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Fly Car Operations Expense Models One Vehicle Payroll Professional Liability Insurance (1) Auto Insurance (1) Marketing & Advertising Accounting/Tax Services Office Supplies Rent Maintenance & Repairs Telephone Medical Supplies Payroll Processing Clothing Gas Vehicle Supplies/Parts Food/Meals Employee Medical Exams Employee Recruitment Education/Training Biomedical Services Miscellaneous Expenses Two Vehicles $40,000.00 $90,000.00 $4,000.00 $30,000.00 $2,000.00 $25,000.00 $60,000.00 $17,000.00 $50,000.00 $9,000.00 $16,000.00 $50,000.00 $9,200.00 $2,000.00 $5,000.00 $4,000.00 $3,800.00 $10,000.00 $4,000.00 Present VEMS $ $376,085.89 Third party contract $21,368.00 not done in house in house None $14,898.00 Unknown $8,346.31 Third party contract Third party contract $18,330.00 Three Vehicles $60,000.00 $135,000.00 $4,000.00 $30,000.00 $2,500.00 $30,000.00 $80,000.00 $20,000.00 $60,000.00 $10,000.00 $24,000.00 $75,000.00 $10,000.00 $3,000.00 $7,500.00 $4,000.00 $5,700.00 $12,000.00 $4,000.00 $576,700.00 Four Vehicles $80,000.00 $180,000.00 $4,000.00 $30,000.00 $3,000.00 $35,000.00 $100,000.00 $20,000.00 $70,000.00 $10,000.00 $32,000.00 $100,000.00 $12,000.00 $4,000.00 $10,000.00 $4,000.00 $7,600.00 $12,000.00 $4,000.00 $717,600.00
$20,000.00 $45,000.00 $2,000.00 $15,000.00 $1,000.00 $25,000.00 $40,000.00 $17,000.00 $40,000.00 $8,000.00 $8,000.00 $25,000.00 $4,600.00 $1,000.00 $2,500.00 $2,500.00 $1,900.00 $10,000.00 $2,000.00
Third party contract Third party contract Third party contract Unknown $21,741.00 $542,809.81**
Totals $270,500.00 $431,000.00 **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 3 we have attached the documents we were given. The costs listed on the next page were broken down just to provide an overview. We subsequently reviewed the financials we were given in detail. We were told that the financial picture has improved. We have no reason to doubt that. We saw a financial report that had been completed by an outside party. Their cover letter indicates no significant issues. We reviewed the 2004 budget along with the 2005 budget projections. In order to forecast the actual financial situation we would need several prior years. There is an expressed concern by several of those interviewed 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 debt on the financial documents we were shown. It was explained that this debt was a 120 day late cost for 3 months of personnel expenses and has continued to be carried through the system. Combining an accrual system and a cash system makes interpreting the financial picture difficult. Based on the information we were given the financials appeared to be in order. We have made some recommendations for financial oversight.

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Cost of Present System $542,809.81 $1487.15 $216.07 $429.00 (2004 operating expenses) Daily operating cost Cost per call 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 not always be the case. There are steps that should be taken to maintain a higher level of communication on financial issues and establish further financial controls for the future. In this process it was acknowledged that financial reviews are done annually by an outside 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 during a recommended restructure of VEMS. Lastly, should VEMS ever receive subsidy from the 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. After spending some time with the financial documents we would like to make the following recommendations: 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 Condition 3. Produce an annual and monthly P&L to be submitted to the Board of Directors 4. Produce an annual and monthly Billing Summary to be submitted to the Board of Directors 5. Establish request for proposal system for major purchases in excess of $2500.00 6. 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 sent second bills for ambulance service would disappear with bundle billing. However, there is an issue of changing Medicare regulations. At the present time only one service in the VEMS area conducts bundle billing. In the present process a single bill is sent, a payment is received the ambulance service takes their complete share and what ever is left goes to VEMS. This is the product of the current bundle billing arrangement that was negotiated. We can find no rule that dictates this is how it should work. If bundle billing was implemented with this present negotiated process, the pending changes to the Medicare reimbursement would dramatically change the financial picture for VEMS. DISASTER By DESIGN LLC.
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If there are no changes to the current bundle billing situation VEMS would receive around $78.00 per intercept call from all services with the exception of Oxford. As a rural community Oxford has potential to bill at a full intercept rate. The issue of bundle billing would overall be a loss for VEMS since the system requires around $216.07 per call with the present budget. We have no expectation this figure will go down in fact we believe it will increase as VEMS grows. So on each Medicare call there would be a $138.07 shortfall 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 Ansonia Derby Oxford Seymour Shelton (3,879.53) 7,574.52 3,787.26 9,468.15 16,095.86 33,046.26 FY '08 Ansonia Derby Oxford Seymour Shelton 52,655.12 35,105.13 17,552.56 43,881.41 74,598.39 223,792.61
FY '04 13,599.55 16,404.60 8,202.30 20,505.75 34,859.78 93,571.99 FY '09 53,708.22 35,807.23 17,903.61 44,759.04 76,090.36 228,268.46
FY '05 33,804.95 25,976.22 12,988.11 32,470.28 55,199.47 160,439.03 FY '10 54,782.39 36,523.37 18,261.69 45,654.22 77,612.17 232,833.83
FY '06 50,610.46 33,741.95 16,870.98 42,177.44 71,701.65 215,102.47 FY '11 55,878.04 37,253.84 18,626.92 46,567.30 79,164.41 237,490.51
FY '07 51,622.67 34,416.79 17,208.40 43,020.99 73,135.68 219,404.52 FY '12 56,995.60 37,998.92 18,999.46 47,498.65 80,747.70 242,240.32
To create these numbers we used call volume and projected out. We recognize these numbers create concern because of their size. It is important to state that this would be the situation only under the present bundle billing arrangement. Oxfords situation may be unique in that it has been described as a rural community. If this is the case the VEMS would be eligible for a full intercept fee from Medicare. The only service that can charge for paramedic intercept directly is a rural community. What defines a rural community is population and land mass. If Oxford is recognized as a rural community 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 through the hospitals should be developed to verify insurance coverage and improve reimbursement. 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 DISASTER By DESIGN LLC.
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group using its own staff. The elimination of outsourcing the billing process may generate 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 you project out against 6909 calls at the blended rate of $250.00 per call and use an average of 9% the savings of fees would be $155,452.00. The down side of this proposal is that VEMS would have to develop billing expertise. Once developed, based on the current call 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 to be renegotiated. One proposal is to adapt a flat fee system. The expense of a call done by VEMS is $220.00. The flat fee would be $220.00 per call billed to the ambulance services each month. No bill would be generated to seniors, which is a major concern of all 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 costs for 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 payment would 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 are able to project out potential cost to the communities on a monthly basis as follows: Shelton Ansonia Seymour Derby Oxford $18,590.00 $10,486.00 $ 7,626.00 $ 7,626.00 $ 3,336.00
If the services bundle bill at an ALS rate, because of the relationship with VEMS and deduct 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 the communities. Obviously this plan has some roadblocks but none are insurmountable. There may be a compliance issue relative to the billing methodology described and the communities would have to agree to make up the variance in expenses. This is an example of a billing model that might work, but some details would need negotiation and discussion.
Flat Rate Calculation for VEMS Anticipated Call Volume ALS 1 Emergency Rate BLS Rate Additional ALS revenue Collection Rate with applied collection rate Billing fee rate with applied billing fees Per call loss to BLS service with funded depreciation Annualized subsidy required
$ $ $ $ $ $ $ $
2,625 638.00 346.00 292.00 75% 219.00 10.50% 196.01 15.42 30.66 40,486.88
This projection provided by VEMS Treasurer

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Projected contributions of communities with this bundle billing model
Towns Projected Subsidy Ansonia Derby Seymour Shelton Oxford Totals Annual Contribution $8,907.12 $6,477.90 $6,477.90 $15,789.88 $2,834.08 $40,486.88 Calls 578 420 420 1024 183 2625
This projection provided by VEMS Treasurer
The billing process and regulatory compliance represent areas in need of attention relative to financial performance. While billing companies have experience it is difficult to place the full responsibility of billing and regulatory compliance on them. In fact the Medicare compliance rules state that even if you outsource the responsibility still rests with the generating organization. VEMS needs to have a compliance officer in place to protect its interests. Our review of these financials involved the experience of the consulting team in the area of financial management for an EMS service. Governance Model and Structure In reviewing the organization of VEMS, several issues came to our attention. Basically VEMS functions but does not meet its full potential. The financial situation allows VEMS to operate but from our view the dynamics of the Board of Directors interferes with their ability to meet their mission. The Bylaws do not reflect currently what is happening. 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 the part of their Boards to work together. The original organization known as VEMS represented a cutting edge system for delivery of paramedics in Connecticut. As time progressed several events occurred that brought VEMS to where it is today. One significant event was eliminating the municipal subsidy by the VEMS Board. This gave the VEMS Board independence, but also eliminated municipal input. The ambulance services are separate incorporated organizations and not part of the municipality with the exception of Ansonia. Some ambulance service representatives would argue they represent 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 individual ambulance services. The Bylaws address this with a Paramedic Operations committee. This is probably where the service heads should be members and operational decisions should be made. The Board should develop goals, plans and policy. The operation committee should decide how to enact these. If a decision is made to hire an Operations Manager then the Paramedic Operations committee should assume the original mission of VEMS by providing a forum for open discussion among service heads. The Operations Manager would handle day to day operations of the paramedic program. We agree that DISASTER By DESIGN LLC.
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paramedic operations have taken most of VEMS Boards time however since this has the greatest financial impact it is understandable. The lack of a business, marketing and strategic plan also prevents VEMS from advancing forward. This is clearly the responsibility of the Board, however because they deal with day to day issues and the dynamic is so poor it is impossible to look at this problem. Our recommendation is that Disaster by Design be contracted to conduct a management retreat with VEMS Board Members only. We have a vision of how this program can be enhanced and provide for good working relationships between the various parties. From the management retreat the goals for VEMS can be prioritized and completed. To bring an executive into this program at this time would be non productive. The dynamics need to be worked on by a third party that has no interest aside from developing the system to secure success. Once the issues have been addressed regarding dynamics and the system moves forward an executive can be retained. Any person that would take the position of executive now should be advised it is a temporary position. Stability of the organization must 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 Bylaws 3. Restructure Board of Directors 4. Designate municipal representatives 5. Develop immediate short term goals for VEMS 6. Re-evaluate Paramedic Operating Group and change focus 7. 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 plan 10. Develop 2 year strategic plan 11. Develop 5 year long range plan
Administrative Staff Structure At the present time VEMS has no administrative staff. It has operated through the Herculean efforts of the Board members. It is clear that an organization of this size and financial complexity needs administrative support. This is our suggestion of how relationships should be viewed and tasks performed. The administrative staff of VEMS should consist of a Medical Director (part time), Operations Manager, part time assistant and Paramedics supported by a full time EMS Coordinator at Griffin Hospital. The EMS Coordinator would not be an employee of VEMS but would participate in the development of VEMS for the position of insuring quality in performance.. The Operations Manager would be staff to the Board of Directors, liaison to volunteer ambulance services, manage the budget, supervise staff, make public appearances, attend relevant meetings and manage all other related responsibilities. The part time assistant would support the operations of VEMS; maintain records, purchase orders, files and other DISASTER By DESIGN LLC.
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related office duties. The diagram below shows how the relationships for the Operations Manager should exist. This unusual diagram further shows the need for VEMS to work cooperatively with many groups and not threaten the existence of any group. The specific development of the administrative staff structure would be a role for the Board of Directors.
VEMS BOARD OF DIRECTORS
Volunteer Ambulance Corps VEMS Operations Manager
EMS Coordinator Griffin Hospital
Paramedic Back up Contractor
VEMS Paramedics
Overview of Options In looking at VEMS, we believe the communities have the potential for superior regional paramedic services with an intact system. While some communities believe it would be in their interest to separate, it is apparent that clinical quality would suffer and costs of service over the long term would not create savings but in fact would cost the communities more. Over the short term it looks attractive, however the volume of calls in any one town does not exist to support the level of service that VEMS has the potential of providing. VEMS / 3 or 4 Towns There has been much discussion regarding one or two of the communities pulling out of the VEMS system. Any community leaving the VEMS system would have a potential domino effect on other communities affecting the level of paramedic service in the entire Valley. The cost of providing the two VEMS vehicles would remain the same so on the expense side of the budget there would be no appreciable change. We also believe that overall there would be a significant loss of call volume that would impact the VEMS system financially. There would be an increase in volume from participating communities; however the overall loss of volume would appear to be greater. There was no data available to us to give a comprehensive evaluation. The unknown number is the calls that are being passed to back up services. We do not believe the small increase in volume would make up for the loss of two communities. We believe that VEMS could continue to function with 3 or 4 towns participating. Very tight cost control would be required or perhaps even a reduction of service. This would be a very financially fragile system. We do not believe that VEMS would be either effective or solvent with only one or two towns. DISASTER By DESIGN LLC.
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VEMS / 5 Towns It is our belief that by changing the Board dynamics VEMS is the best choice for all concerned. The contiguous geography makes the Valley region ideal for a regional system. There is a great deal of work to this proposal. In terms of cost, clinical efficiency, 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. 1995 recommendations at length. We also spoke with Bob Holdsworth regarding his previous study. Many of the suggestions for changes in 1995 were very accurate. The changing environment however has created some different situations. The proposed changes that were submitted in the 1995 are in need of being updated. It was clearly disappointing that many of the suggested changes made in 1995 were not implemented. This was the stated 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 following recommendations:
1. Restructure the Corporation This represents the single greatest challenge for VEMS and its participants. The corporation needs attention, restructure and context change to remain viable. Incorporating the municipalities is of significant importance. 2. Continuation of Service We agree that to continue the VEMS program is appropriate. 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 decision making with very timely and accurate data. 3. PSA Consolidation - The merging of the PSA which was a recommendation was done. 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 appropriate recommendation 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 CMED EMD 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 evaluate mileages 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 presently complaining 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 of independence 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 agree that while there have been improvements billing and collection practices need to be formalized. 7. Paid Administrator - We agree that VEMS needs leadership from a paid professional, 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 an individual 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 DESIGN would 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 ambulance contractors 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. DISASTER By DESIGN LLC.
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8. Bylaws The issue of problems with the Bylaws have been stated earlier. Some of 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 to have 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 our recommendation 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 goal is 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 the highest quality. To have rigid separation of operations and quality assurance is not in the best interest of an EMS system. The hospital should not have operational authority for VEMS. It is clear that Griffin Hospital and the Volunteer Ambulance services worked diligently 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 blending of operations and quality assurance that must take place. How an organization functions impacts on quality of care. There is effective care which is skills and affective care which is customer service. Both of these affect patient outcomes. As times changed and relationships developed there appears to be a need for greater oversight. Recognizing this Griffin 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 hospital oversight on the pre-hospital care system. The following steps should be implemented to assist in making the system more effective: 1. 2. 3. 4. 5. 6. Negotiate Medical Control contracts with all services providing ALS and BLS Establish formal written policies for EMS Extend hospital outreach to services by providing training and guidance Participate in strategic planning of EMS in Valley Investigate cooperative ventures with VEMS and Volunteer Ambulance Services Establish a Transfer unit? (Medic to VEMS when needed)
The hospital working in partnerships with the EMS providers can only further improve the 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 of delivering health care requires comprehensive quality control and improvement. There is a definite need to develop measures such as acceptable response time to measure the performance 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 measures that will be evaluated. They should center on patient outcomes and skill performance criteria. The Board has the ability to add items to the list such as customer service, driving practice and documentation. These measures establish benchmarks for performance so what ever is chosen is continually measured. We would suggest using some nationally accepted measures but this is a local decision as to how you measure performance. It is important to realize that the Medical Director and Griffin Hospital should be the focus of quality control and improvement. Some states actually have QA requirements in their EMS regulations. Other aspects of quality control and improvement relate 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 the other. As stated before, there is effective care which is skills and affective care which is customer service. Both of these affect patient outcomes. Ultimately the Medical Director and the hospital have significant responsibility. Quality control and improvement requires a high level of respect and trust. It represents teamwork of diffuse organizations 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 these opportunities are realized the program should become much more stable. Before any of these opportunities are pursued the need for VEMS to improve its public image and operations. This remains as the single greatest challenge. In its present situation no community would consider VEMS because of the level of poor press that has been generated. Some of the recommendations are not complete expansion of a regional paramedic system into these communities. Partial expansion into communities that require paramedic intercept is a potential. If VEMS were to offer a superior product at less cost to the neighboring communities we believe they would look at it. Any one who reads the paper today or in the last several months would say no to VEMS. If the improvements 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 is provided to communities. This is a real opportunity. It does require vision to see it. We believe it exists. We have identified some communities that might consider using VEMS in the future if a comprehensive 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 choices because they are contiguous to the VEMS service area. They are: 1. 2. 3. 4. 5. 6. Recommendations 1. Enhance the VEMS current program
Continue to provide paramedic service to all five communities Relocate one paramedic unit to the Seymour/Oxford border (along Rt. 8) Evenly distribute response times through geographic relocation
Orange Woodbridge Beacon Falls Monroe Stratford Trumbull
2.
Conduct management retreat with present Board members

Restructure Board of Directors Reevaluate Paramedic Operating Group Designate municipal representatives Take paramedic vendor off as ex officio member Require attendance of paramedic vendor by contract After reorganization hire appropriate staff (Operations Manager) VEMS needs to improve its public image/operations
3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22.
Perform complete Bylaw review Develop immediate recovery plan for VEMS with immediate short term goal Make the Medical Director the focus of quality control and improvement Improve Data on Response Develop on going business plan Develop 2 year strategic plan Develop 5 year long range plan Encourage the Service Chiefs and Hospitals to meet to discuss EMS Produce to the Towns an annual report on activity and financial condition Create a system for a formal audit every five years or as required by an outside accounting firm. Continue annual financial reviews Annual and monthly production of P&L submitted to Board of Directors Annual and monthly production of Billing Summary submitted to Board of Directors Request for proposal system for major purchases over $2,500.00 Institute a purchase order system Negotiate medical control contracts Establish formal written policies for EMS Investigate cooperative ventures with VEMS and Volunteers Measure the performance of the VEMS operation
Improve data reporting Develop performance measures and establish benchmarks
Develop a comprehensive marketing plan

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

31

Valley Emergency Medical Services Final VERSION2-DisasterbyDesign 8-2004

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Evaluation of VEMS for the Council of Governments

Valley Emergency Medical Services System Evaluation

DISASTER By DESIGN LLC.

203 673-4847 BESTEMS@aol.com

Evaluation of VEMS for the Council of Governments

DISASTER By DESIGN LLC.

203 673-4847 BESTEMS@aol.com

Evaluation of VEMS for the Council of Governments

203 673-4847 BESTEMS@aol.com

Evaluation of VEMS for the Council of Governments

203 673-4847 BESTEMS@aol.com

Evaluation of VEMS for the Council of Governments

Call Activity Level VEMS 2003

Derby, 1199, 17%

Seymour, 1157, 17%

DISASTER By DESIGN LLC.

203 673-4847 BESTEMS@aol.com

Evaluation of VEMS for the Council of Governments

(Expense) / Revenue (59,453.76) (44,818.72) Provided by VEMS, reviewed by Jonathan Best

DISASTER By DESIGN LLC.

203 673-4847 BESTEMS@aol.com

Evaluation of VEMS for the Council of Governments

DISASTER By DESIGN LLC.

203 673-4847 BESTEMS@aol.com

Evaluation of VEMS for the Council of Governments

DISASTER By DESIGN LLC.

203 673-4847 BESTEMS@aol.com

Evaluation of VEMS for the Council of Governments

Consultant study was performed and recommendations were developed in 1995.

DISASTER By DESIGN LLC.

203 673-4847 BESTEMS@aol.com

Evaluation of VEMS for the Council of Governments

DISASTER By DESIGN LLC.

203 673-4847 BESTEMS@aol.com

Evaluation of VEMS for the Council of Governments

Estimate from Oxford EMS Director / Dispatched by NWCMED

3000 2570 2500

1000 600 391 500

0 Ansonia Derby Oxford Seymour Shelton

DISASTER By DESIGN LLC.

203 673-4847 BESTEMS@aol.com

Evaluation of VEMS for the Council of Governments

Ansonia Derby Oxford Seymour Shelton

DISASTER By DESIGN LLC.

203 673-4847 BESTEMS@aol.com

Evaluation of VEMS for the Council of Governments

203 673-4847 BESTEMS@aol.com

Evaluation of VEMS for the Council of Governments

DISASTER By DESIGN LLC.

203 673-4847 BESTEMS@aol.com

Evaluation of VEMS for the Council of Governments

203 673-4847 BESTEMS@aol.com

Evaluation of VEMS for the Council of Governments

DISASTER By DESIGN LLC.

203 673-4847 BESTEMS@aol.com

Evaluation of VEMS for the Council of Governments

Keep the Current VEMS Program Unchanged

Eliminate the Current VEMS Program

DISASTER By DESIGN LLC.

203 673-4847 BESTEMS@aol.com

Evaluation of VEMS for the Council of Governments

Eliminate the Current VEMS Program

DISASTER By DESIGN LLC.