The Myth of the Perfect Model

What defines a quality EMS system is rooted in local experience. Who provides the services and how they do so may vary from place to place, but each of us has our opinion of the ideal model, shaped by our own experiences and exposures. Truth be told, there is no one "ideal" system model, but rather a whole host of local factors that determine the right delivery method for a community. Understanding the good and bad of each model is important to appreciating what makes sense for your community.

     What follows are broad descriptions of several system models and the advantages and disadvantages of each. Students of EMS systems are all too aware of the limited published literature available about each model, and much of what you'll read here is drawn from the experiences of system review and design practitioners who have decades of background with EMS systems. At the conclusion, basic benchmarks are highlighted to help readers look at their own systems.

     For purposes of this discussion, six common system types are described: fire service, private for-profit, third service, not-for-profit, public-utility and hospital-based. Obviously, many subtypes exist.

The Fire Service Model
     In addition to its dedicated commitment to fire suppression, the fire service has a long history of providing emergency ambulance service. Many communities have known no other model of delivery. Over the last decade, several localities have transitioned their emergency ambulance services from other models to their fire departments. Reasons have included performance, finances and sustainability. Last year, fire-based EMS represented the largest provider of emergency ambulance service in large cities.1

     Within fire-based EMS services, it's important to distinguish between two submodels: dual- and single-role. In dual-role systems, personnel are trained as both firefighters and EMTs or paramedics. Single-role systems have an EMS division or section, but their personnel, and often their management, are kept separate from fire suppression.

     One other distinction of fire-based EMS is its focus on 9-1-1 patient populations, and not those requiring interfacility, critical-care or nonemergent medical transportation.

     Advantages-Firehouses have long been part of local neighborhoods. Citizens respect firefighters and perceive them as heroic. This provides a high degree of comfort to citizens and can often reduce public concern for the sustainability of emergency ambulance service.

     Fire-based service can be a benefit to public officials responsible for ensuring continued quality care. As part of local government, fire department management is directly responsible to city or county managers and elected officials. This allows oversight of the department's ability to accomplish key performance goals.

     Adding EMS into the fire department organizational structure may also provide advantages in the day-to-day management of both services. With fire suppression and prehospital emergency care operations under one roof, the need for parallel or separate management and administration is eliminated.

     Finally, training personnel as both EMS providers and firefighters enhances the versatility of the workforce, offers people variety in their duties and provides flexibility for management. Cross-trained personnel have the lowest attrition rate in the industry.2

     Disadvantages-While fire-based EMS offers many advantages, it is not without disadvantages. It is important to note that many of these are rooted more in tradition than any inherent limitation of the model. They can often be overcome.

     Fire-based EMS systems tend to be measured on their level of effort (LOE) rather than the results of their performance. When a system's performance is viewed solely in the context of LOE or successfully completing a process, it captures only a piece of the puzzle. Having performance expectations that are outcome-focused emphasizes achievement of results.