Influencing Public Policy

1. Influencing Public Policy A Case Study… Presenter: Matt Zavadsky, MHA EMS Director, Volusia County Florida Adjunct Faculty, University of Central Florida College of Health and Public Affairs

2. Politics - Defined

3. Politics - Defined

4. Political vs.Regulatory Influence • “Mission” is different • Enabling Legislation • “Enables” rule making process • Statute vs. Administrative Law • “(4) The department shall adopt and enforce rules to carry out this section, including rules for permitting, equipping, and staffing transport ambulances and that govern the medical direction under which interfacility transfers take place.” • Master served • The people vs. the electorate From 401.252 F.S.

5. In the Beginning... • Start from the HIGH ground • Patient focused • Logical • Reduced burden • Simplification

6. Stakeholders • Seek constituents early • Gain input into the process • Offer a voice into the changes • Remember the mission • Cannot serve all masters • Sometimes consensus cannot be reached

7. Expert Support • When developing your position… • Consult with experts • Use studies if possible • Other similar communities / issues • AHA, NAEMSP, NASEMSD, etc. • Positions Papers on the issues

8. Gaining Support • Constituents • Personal briefings • Community groups • Position papers • Media • Especially Editorial Boards • Log feedback • Dispels the ‘in-the-dark’ argument

9. Countering Attacks • Remember - HIGH road • Don’t get into a ‘tit-for-tat’ • Continually re-state your position from the high ground • Patient Focused • Answer all concerns • Use a logging system • Make changes when possible and prudent

10. Volusia County Case Study • Daytona Beach Area • 450,000 residents • 1 million visitors on average • Beaches • Major special events • Bike Week Black College Reunion • Daytona 500 Pepsi 400 • Spring Break Biketoberfest

11. Volusia County Case Study • 1,200 square miles • Urban, Suburban and Rural • 12 EMS provider agencies • 11 1st Response and a single county-wide ambulance provider • 7 member County Council • 5 districts and 2 “At-Large”

12. Volusia County Case Study

13. Volusia County Case Study • Florida Law 101 • County’s issue ‘Certificates of Public Convenience and Necessity’ (COPCN) to EMS providers • Any ALS or BLS Transport service needs a COPCN in order to get (or retain) a State license • County’s may adopt ‘reasonable’ ordinances setting standards to COPCNs

14. Volusia County Case Study • Many issues like other communities • Jurisdictional boundaries • FD’s want ambulance transport • Potential fractionalized system • No data collection - refused • Limited EMD

15. Background • Existing EMS Ordinance Adopted in 1984 • Ronald Reagan was President • Gasoline was $1.13/gallon • Tina Turner’s “What’s Love Got To Do With It” was #1 Song • Karate Kid was top box office draw • Volusia County had 300,615 residents • DeBary and Deltona were not incorporated

16. Major Provisions of Revision • Closest Unit Response “Closest Unit Response Plan” means an agreement between neighboring jurisdictions to dispatch the closest available emergency medical services response vehicle to the scene of a medical emergency, regardless of jurisdictional boundaries.” “Applications for a non-transport COPCN shall include: A notarized statement that the applicant agrees to participate in a Closest Unit Response Plan for the duration of the Certificate. This requirement applies to applications for new and renewal COPCNs to be issued after October 1, 2006”

17. Major Provisions • Emergency Medical Dispatch “Emergency Medical Dispatch” means the Medical Director approved system of emergency call taking designed to dispatch the appropriate level of services based on established criteria and provide pre-arrival emergency medical instructions to the caller until EMS arrives. Applications for a non-transport COPCN shall include proof that the applicant is currently providing Emergency Medical Dispatch (EMD), or a copy of an agreement signed by the applicant for the provision of EMD services for the duration of the Certificate.” • Countywide Medical Director “There shall be a Medical Director either employed or contracted by the County to promulgate clinical protocols, provide clinical supervision and provide appropriate quality assurance for daily operations and training pursuant to this ordinance and pursuant to Florida Statute Ch. 401.”

18. Major Provisions • Medical Advisory Board “The County Council shall create by resolution an advisory board to be known as the “Volusia County Medical Advisory Board” whose mission is to review and recommend standards of care for the EMS System.” • Data Collection / Reporting “All Providers authorized to provide emergency medical services within Volusia County shall comply with the collection and reporting of aminimum data set (MDS) as required by the EMS Division. The MDS shall consist of clinical and operational data necessary in order to maximize the performance of the EMS System, including, but not limited to; call volume, response times, and clinical skills proficiency.”

19. Major Provisions • Alternative Transport Providers • Wheel chair and stretcher vans “Alternative Transportation Services (ATS) are providers who routinely transport persons who are confined to wheelchairs or stretchers and whose condition is such that these persons do not need nor are likely to need, immediate medical attention during transport. A Certificate of Public Convenience and Necessity shall be obtained from the County before engaging in this level of transportation service. “Applications for an Alternative Transport Service COPCN shall include: A notarized statement that the applicant agrees to comply with the clinical guidelines for ATS services promulgated by the County Medical Director for the duration of the Certificate; A schedule of the applicant’s intended rates, if any, and the length of time they will remain in effect. Any changes to the rate structure will require prior approval by the County Council”

20. Community Education • 78 Stakeholder Briefings • Providers, Fire Chief’s, City Managers (3 x), Volusia Council of Governments Board, Health Department, Hospitals, Rotary Clubs, Chambers of Commerce, Medical Society, Council on Aging, Aging Services Network, Daytona Civic League, Transportation for Disadvantaged Board, Editorial Boards, Radio Shows, TV Interviews • You name it, we’ve been there…

22. City Managers

23. Feedback • Process and form for specific feedback

24. Feedback • 74 pages of written responses • Over 55 recommendations • City of Port Orange (3) • Port Orange Fire Department • Ponce Inlet Fire Department (2) • Aging Services Network • City of New Smyrna Beach (2) • New Smyrna Beach Fire Department • City of Edgewater • Volusia County Fire Chief’s Association • Communications Interlocal Agency (RCC) • City of DeLand • City of Holly Hill

25. Feedback • Numerous revisions based on community and municipal recommendations • Revised definitions • Delayed Closest Unit Response implementation by 2 years • Some stakeholders disagree with THAT… • Eliminated BLS COPCN requirement • Changed insurance requirements • Revised Medical Director responsibilities

26. Resources Consulted…

27. Feedback & Response • Statutory authority • F.S. 401.25  Licensure as a basic life support or an advanced life support service • “(6)  The governing body of each county may adopt ordinances that provide reasonable standards for certificates of public convenience and necessity for basic or advanced life support services and air ambulance services. • In developing standards for certificates of public convenience and necessity, the governing body of each county must consider state guidelines, recommendations of the local or regional trauma agency created under chapter 395, and the recommendations of municipalities within its jurisdiction.”

28. Responses to Feedback:Closest Unit Response • 12 month $125,000 participative study • Unanimously approved by VCOG Board on September 30, 2002 • The municipal jurisdictions and the county should enter into automatic aid agreements to ensure closest unit response throughout the county.” (p. 115)

29. Chain of Survival • Guidelines 2000: • “A sudden cardiac arrest (SCA) victim’s chances for survival drops 7 – 10% each minute that passes” • “Time from collapse to defibrillation is the single greatest determinant of survival.” American Heart Association Guidelines 2000 for CPR and Emergency Cardiac Care: International Consensus on Science, Part 3, p. 23

30. Responses to Feedback:Closest Unit Response • Two person engines are not an acceptable staffing level for closest unit responses to medical calls • AHA recommends four rescuers at the scene (two EMTs & two Medics) • Two on FD and two EVAC = 4 personnel • Several cities are currently using two person engines and/or rescues for medical calls • Ormond Beach has been staffing and accepting closest unit response with the county using two persons/engine for the past two years American Heart Association Guidelines 2000 for CPR and Emergency Cardiac Care: International Consensus on Science, Part 5, p. 363

31. Responses to Feedback:Closest Unit Response • Results in a lower level of service • Which is a lower level? • Two people in three minutes • Four people in six minutes • Remember AHA?? 10% per minute… • An un-funded mandate • VCOG sub-committee has approved costing methodology • Up to neighbors to negotiate rates/funding

32. Responses to Feedback:Closest Unit Response • Ordinance only applies to medical calls, but you cannot separate fire and medical responses • CAD systems do this now on every call • Different units recommended to a structure fire than a dumpster fire

33. Responses to Feedback:Closest Unit Response • It’s happening anyway, why mandate it? • If we were not, it would not be • “Emergency” Commission meetings to pass CUR agreements before ‘mandate’ • Requires centralized dispatch • Although helpful, this is not mandatory • CADs can suggest other stations if they are closer to the call • This is done now

34. Closest Unit is Volusia County E-37 Next Closest Unit is Seminole County Rescue Next Closest Unit is Volusia County E-36

35. Responses to Feedback:Closest Unit Response • Results in the cities subsidizing the county • Ormond Beach and County Fire have been doing CUR for 2 years • In 2002, County stations responded into the city of Ormond Beach for medical calls more than Ormond Beach stations responded into county areas for medical calls • 285 vs. 259 respectively

36. Responses to Feedback:Closest Unit Response • Requires the cities to hire more staff

37. Responses to Feedback:Closest Unit Response • “We agree with the concept, but don’t want to be told we have to do it.” • Need more time to negotiate • Already agreed to delay CUR implementation for more than two years

38. Emergency Medical Dispatch • TriData Study: • “EMS dispatch agencies should utilize an emergency medical dispatch system that has been developed in conjunction with and approved by the EMS Medical Director” (p. 58)

39. “The Emergency Medical Dispatcher is the principle link between the public in need of medical assistance and the EMS system…” • “Without these specially trained, talented, dedicated, and skilled professionals, the EMS system cannot function optimally.” Consensus Documents and Position Paper; Clawson, MD; Prehospital and Disaster Medicine, October-December, 1989

40. “EMS physicians should participate actively in the development, training, quality assurance, medical control and direction of EMDs and medical dispatch centers.” Consensus Documents and Position Paper; Clawson, MD; Prehospital and Disaster Medicine, October-December, 1989

41. Responses to Feedback:Emergency Medical Dispatch • Training and certification costs • True IF the agency chooses to go in-house • No requirement to do it in-house • Ordinance allows caller transfer agreements • The two agencies doing EMD now have agreed to do it free for any agency • One button transfer in all centers now

42. Countywide Medical Direction • “The system has one Medical Director and one set of protocols. This is an excellent way to ensure standardization and quality service across the county.” (p. 122) • “… establish a Medical Control Committee” (p. 123) • “Having a uniform set of guidelines to follow would help personnel to operate safely and effectively on emergency incidents” (p.132) September 2002, Volusia Council of Governments, Inc., Comprehensive System Assessment for the Volusia County Fire and EMS System; TriData Corporation, Arlington, VA

43. Responses to Feedback:Countywide Medical Direction • Providers desire more MD time • Agency “Medical Advisors” are permitted • Still have one set of protocols and quality assurance standards • Proposed EMS budget includes additional QA contractor • Selection of Medical Director • EMS Medical Director has been selected by representative committee (city/county/hospitals) for many years

44. Responses to Feedback:Data Collection • TriData Study: • “If a uniform format of reporting could be instituted for all jurisdictions, more accurate comparisons can be made…” (p. 144) • “One of the keys to understanding how emergency medical systems (EMS) and agencies are performing in your area is by collecting and analyzing EMS data.” September 2002, Volusia Council of Governments, Inc., Comprehensive System Assessment for the Volusia County Fire and EMS System; TriData Corporation, Arlington, VA National EMS-C Data Analysis Resource Center; July 2003 Position Paper

45. Responses to Feedback:Data Collection • “All EMS systems should assess their performance through ongoing data collection, evaluation, reporting and standardization…” Chain of Survival American Heart Association Guidelines 2000 for CPR and Emergency Cardiac Care: International Consensus on Science, Part 12, p. 363

46. Expanded County Role • “Given the often tense working relationship between the municipalities, Volusia County government, EVAC, ECS and the various volunteer associations, the potential for achieving voluntary compliance for level of service standards is a daunting task. • This effort will require strong leadership from several key community leaders. Volusia County government will have to step up its role in facilitating this process.” (p. 110) September 2002, Volusia Council of Governments, Inc., Comprehensive System Assessment for the Volusia County Fire and EMS System; TriData Corporation, Arlington, VA

47. Expanded County Role • “The most effective high performance EMS systems feature a system design in which local elected officials assign responsibility for the oversight function of pre-hospital care to an entity separate from the provider of service, including an independent medical control board.” Contracting Guide for Emergency Ambulance Services, A Guide for Effective System Design: American Ambulance Association; Sacramento, CA

48. ·“People die needlessly because some cities fail to make basic, often inexpensive changes in the way they deploy ambulances, paramedics and fire trucks. In other cities, where the changes have been made, people in virtually identical circumstances are saved.” ·“Los Angeles is one of many cities that routinely lie to themselves about their true response times to medical emergencies. The result is needless deaths.” ·“Most other U.S. cities don't know their response times, refuse to disclose them or use imprecise measures that are meaningless in determining whether emergency crews reach victims in time to save them. This situation persists even though research clearly has shown that precise measuring improves performance and saves lives. “ o        “Many cities lack the strong leadership needed to improve emergency medical services. Leadership — by the mayor, the city council and community health officials — can make a dramatic difference. Boston, for example, more than doubled its survival rate over 10 years under the direction of a strong mayor who demanded change and enlisted city officials, businesses and many residents in the drive to save lives. “ ·“Of the 28 medical directors who answered USA TODAY's question about what forces in their systems affect performance and patient outcomes, 16 cited fire department culture or unions as key.” ·“Among the reasons for the Seattle system's effectiveness: oA strict policy of meticulously measuring the performance of the system, chiefly by monitoring sudden cardiac arrest survival, one of the truest measures of an emergency medical system's success. oStrong leadership from the start. o"The fire department itself is like most fire departments. It's not used to dealing with medical quality issues," he says. "If you left them alone, I don't think they would push this very far. I think most fire departments don't." Seattle's respected system could easily collapse without constant effort and close scrutiny of care. o"It's a fragile system," Cobb (Seattle’s Medical Director) says. "The quality of care is overseen by a handful of people. It wouldn't take much to disrupt that." "In government, we always find an excuse for why we don't do it. Very few people in government want to find out how we can do it. I'd rather figure out how we can do it and say, 'Why don't we have that program here?’” “Six Minutes to Live or Die”; USA Today investigative report; July 28 – 30, 2003

49. PRIVATE FIRM TO DISPATCH DAYTONA FIRE AND EMSJohn Bozzo, Staff Writer - December 11, 1999; Page 01C Imagine a fire or emergency medical unit from another city responding to your call because they were the nearest to provide help, regardless of government jurisdiction. "To the customer, it would be seamless," Daytona Beach Fire Chief Paul Skinner said. "No matter where you called 911 from, you would get the closest aid." Readers Write February 28, 2002; Page 05AFire/rescue admirable; needs county's participation I congratulate the leaders of Edgewater, New Smyrna Beach and Port Orange for having the foresight to combine their respective fire-rescue dispatching. The need for a closest unit response is undeniable. Officials: Responders should have no boundaries Lyda Longa, Staff Writer - March 25, 2003; Page 03C Should the nearest fire truck respond to emergency calls regardless of city boundaries? That's a question officials from Volusia County's 16 cities will ponder in coming weeks, after a meeting Monday of the Volusia Council of Governments. Council of Governments members -- including representatives from the County Council and each of the cities -- agreed that a so-called "closest unit" response system was the best way to serve residents.

50. 'Closest unit' steams chiefs Lyda Longa, Staff Writer - April 21, 2003; Page 01C City limit signs shouldn't stop a paramedic or firefighter from saving a life. But a proposed county ordinance ordering lifesaving workers to ignore those boundaries is running into roadblocks from area fire chiefs and city officials. Cities may sign off on response plan Lyda Longa, Staff Writer - April 29, 2003; Page 03C Elected city officials from around the county said Monday they would conditionally support a proposal compelling their firefighters to respond to medical emergencies regardless of city boundaries. That plan, known as closest unit response, could be the standard in Volusia County once the wrinkles that exist between the cities and county government are ironed out, County Councilman Dwight Lewis said at a Volusia Council of Governments meeting. City OKs county plan John Wisniewski, Staff Writer - May 20, 2003; Page 01S A proposed seven-city nearest-station response effort for fire and emergency medical services has been unanimously endorsed by the City Council. "It's a good beginning,"City Manager Joe Yarbrough said as the council last week approved a "Memo of Understanding" on the effort encompassing seven of the 10 municipalities in East Volusia County.