EMS 315 test 4

medical malpractice

•Negligence -When an EMS worker has a duty to act -This is created within the jurisdiction the EMS agency responds to or is chartered to operate in -A breach of that duty occur when the worker does not observe a patient-care or operational standard, and that breach causes an injury •Negligence -To be considered negligence, that injury must have been linked to the actions or lack of actions by EMS workers •Malfeasance -When an EMS worker performs an act that violates a standard of care or a law •Nonfeasance -When an EMS worker fails to act, often called an act of omission •Contributory negligence -When the patient is said to have done something that contributed to his or her injury or death •Comparative negligence -Requires each agency, person, or participant that the claimant or plaintiff has filed on to pay for injuries or damages in the same proportion as his or her part in responsibility for the injury

patient parking

•Occurs when a patient is prevented from being transferred from the ambulance gurney to a hospital bed or gurney •Occurs when hospital personnel believe that they are not responsible for the patient •EMTLA states that a patient is presented to the hospital when the patient is on hospital property or within 250 feet of the hospital, including the parking lot •A hospital that does not provide an initial screening exam and stabilizing treatment is in violation of the EMTLA law

lawsuit progression

•Pre litigation phase -EMS manager makes initial contact with insurance companies or the agency's legal staff and risk-management department •Discovery phase -Requires bringing together all the information together, both good and bad -Requires EMS managers and the employees involved to assist the legal team -During discovery EMS personnel are usually questioned by the victim's attorney in a deposition or a written interrogative •In some states a medical malpractice case must first attempt to go through an alternative dispute-resolution system •If attempt at alternative dispute resolution fails, then the case usually goes to trial

preventative maintenance

•Preventive maintenance (PM) -Prevent a malfunction or failure, not just correct it after it occurs -Should also be a key component of managing vehicle recalls; vehicle warranties also help to prevent unnecessary costs to the EMS agency -Equipment and vehicle manufacturers normally provide routine maintenance and inspection recommendations for their products •Preventive maintenance (PM) -These recommendations should be used as the basis for developing the system's routine maintenance requirements and PM schedule -Individual team members should be accountable for performing and documenting routine inspections, cleaning, and maintenance, using standardized checklists as part of regular shift changes •Preventive maintenance (PM) -Using a standardized checklist makes the task easier and helps to avoid overlooking any requirements

discipline

•Progressive discipline -Involves an increasing level of severity for actions that violate the organization's rules, standard operating procedures, or standards of conduct -In most progressive discipline systems, the procedures are divided into formal and informal processes: §In the informal process, typically coaching and counseling occurs that is not placed in the formal system of discipline and the documentation is kept with the immediate supervisor §Coaching and counseling is applied in progressive discipline when it is a training or performance issues that is not serious but not in line with given work standards

history of quality management

•Quality improvement -Sum of all activities undertaken to continuously examine and improve products and services -Activities are prospective, concurrent, and retrospective, depending when they are conducted relative to an event -Tools include tests, databases, infield observations, chart review, customer service surveys, and checkout sheets •Scientific management - Fredrick Taylor §Author of The Principles of Scientific Management (1911) •A formal look at the motivations of work that would result in improved efficiency •Frank and Lillian Gilbreth -Improved upon scientific management by studying human motivations at work and the psychological aspects of work •Elton Mayo -Studied the efficiency of work and its relationship to working conditions -The Hawthorne studies §Focused more attention on understanding individuals, attitudes, and groups and less on organizational structure and efficiency of the work §Concluded that the knowledge of being observed causes alterations in behavior •W. Edwards Deming -Applied quality processes to modern manufacturing -Began working in Japan in 1950 and was instrumental in building the Japanese industry into an economic world power Problems in a production process are due to flaws in the design of the system, as opposed to being rooted in the motivation or professional commitment of the workforce •W. Edwards Deming -Quality is maintained and improved when leaders, managers, and the workforce understand and commit to constant customer satisfaction through continuous quality improvement •If Deming's principles were applied to the prehospital area, EMS would focus on quality patient care and appropriate use of resources •The EMS system would be focused on system quality and productivity, not revenue •Two other modern quality-improvement methods, supported by the Joint Accreditation Committee on Hospital Organizations, provide a background for EMS-related quality-improvement or quality-assurance activities -Philip Crosby §Organizations should redesign operations to encourage doing the job right the first time §Challenged organizations to think of how processes could be redesigned to reduce errors and to reach a goal of zero defects -Ernst and Young •DR. Joseph M. Juran -Revolutionized the Japanese philosophy on quality management -Juran's work incorporates the human aspect of quality management, which is referred to as total quality management (TQM) -Top management involvement -The need for widespread training in quality •QI program must reflect the strong interdependency among all of the operations within an organization's production processes •Juran advocated a quality trilogy that included quality planning, quality control, and quality improvement •Quality planning -The process of understanding what the customer needs -Designing all aspects of a system that is able to reliably meet those needs •Quality control -Is used to constantly monitor performance for compliance with the original design standards -If performance falls short of the standard, plans are put into action to deal quickly with the problem •Quality Improvement (QI) -Occurs when new, previously unobtainable levels of performance are achieved -Requires the continuous comparison of the system to itself using performance measures

ems interaction within the health care system

•Regulatory agencies tend to have many hats to wear and are often given marching orders by the political leadership of the day -Continual changes as political agendas and administrations change •For emergency-service organizations, this can appear to be inconsistency •Good relations with people will always produce better results

state emergency operation plan

•Stafford Act -States are encouraged to engage in emergency planning and are provided funding to augment the state's planning efforts -Each state has an EOP for the deployment of state resources and to guide coordination activities with the NRP -Many of these plans closely resemble the NRP in organizational concept and through the use of an emergency support function (ESF) structure -A properly developed plan also will have sufficient flexibility to allow it to be applied modularly to any emergency or disaster in which the state is called upon for assistance •The state accesses resources from the federal government through the request for activation of the NRP •In order to obtain federal activation, the state must demonstrate that the disaster or emergency exceeds its abilities to respond to the incident, even though the state EOP has been activated •This concept of demonstrating need also applies to the local jurisdiction's ability to access the state EOP •Once local fire and EMS officials have determined that the incident exceeds their capabilities to respond, those local agencies contact city or county officials to request activation of the local EOP by declaring a local state of emergency and, subsequently, by activation of the state's EOP

federal legislation and ems

•The EMS manager and leadership should be aware of current legal statutes that affect the delivery of EMS or affect the EMS system -Emergency Medical Treatment and Active Labor Act (EMTLA) §This section of federal law was taken from an amendment to the Consolidated Omnibus Budget Reconciliation Act (COBRA) -Emergency Medical Treatment and Active Labor Act (EMTLA) §Covers any emergency medical condition and is designed to prevent unequal treatment of patients in need of emergency care §Applies to every hospital and every patient §Requires that any individual who comes to a hospital be given a medical screening exam by qualified personnel, stabilized, and transferred to an appropriate facility if necessary §The hospital must maintain transfer records for up to five years

vehicle costs

•Vehicle costing starts with the initial cost of the vehicle -The purchase price, taxes, warranty, and delivery charges are the initial cost of the vehicle •The cost of maintenance, repairs, and non-warranted parts is recorded and feed into the cost for EMS vehicles •It is important that a job card be filled out for any repair or maintenance on the vehicle and it should include the vehicle number, odometer reading, hours and cost of labor, and any miscellaneous expenses around the event, for example, towing •Fuel cost for each vehicle needs to be tracked •Overhead cost such as support personnel, office, cell phone, and filing or computerized applications to operate the system should be included as a portion of the expenses

RFP Construction

•Vendors should be qualified by the committee or the EMS manager overseeing the process •A stable operational history, solid customer support, FDA approval, and up-to-date technology are important in a profile of a vendor •Most companies should support your product for its life cycle -Seven years for vehicles and eight years for medical equipment •An EMS manager should contact the vendor's most recent customers and at least three other customers who have used their product for several years

training and inservice

•When a new vehicle arrives, EMS personnel should receive appropriate education and training •This should also include how the vehicle is to be checked out and maintained according to manufacturer's specifications •EVOC and CEVO are two programs designed to help train EMS personnel to operate emergency vehicles •Crashes are a common cause of litigation and risk for an EMS agency •Emergency-vehicle collisions are often serious, and some court cases have resulted in criminal charges being levied against EMS workers involved in them

Baldridge criteria

•Malcolm Baldrige National Quality Award -A national award given to companies and businesses in recognition of their achievements in quality -The award is managed by the United States Department of Commerce's National Institute of Standards and Technology -Is given by the president of the United States

physician prerogative

•In situations that involve clinical performance and the delegated practice of a paramedic under the direction of the medical director, the physician may impose discipline that can result in a reduction in pay or a downgrade in or loss of certification •The physician has the right to eliminate, restrict, or suspend certifications or licensure under his or her delegated practice

Garrity rule

-An invocation that may be made by a public-safety employee being questioned regarding actions that may result in criminal prosecution -A public-safety worker is invoking his or her right against self-incrimination -Any statements made after invoking Garrity may be used only for department- investigation purposes and not for criminal- prosecution purposes

interstate resource response plans

•In the wake of some of the major disasters in recent years, a concept of interstate resource agreements has developed and was invaluable in Louisiana during hurricane Katrina (2005) •These agreements, which are placed into statute with the participating states, allow for the movement of resources from one state to another •Although the NRP may have been activated already, these plans provide for access to resources that may not be available from the federal government •The ready acquisition of like or in-kind ambulances, fire apparatus, and law-enforcement officers can be achieved through such plans •Emergency Management Assistance Compact (EMAC) •Southern Regional Emergency Management Compact (SREMAC)

vehicle maintenance

•It is important to establish a schedule for preventive maintenance •Preventive maintenance is a schedule of mechanical checks or changes designed to prevent critical failures in vital equipment •Preventive-maintenance schedules should be based on manufacturer recommendations, or schedules should be determined within the organization

hazardous materials response

•"Worker Protection Standards for Hazardous Waste Operations and Emergency Response" or the HAZWOPER standard, 1989 •Requires all emergency services to develop and implement a written incident plan to handle hazmat emergencies •The Department of Transportation has issued hazmat guidelines and recognition tools, OSHA has mandated training for emergency medical responders, FEMA is providing funds for training, and the EPA is providing hotline support •The crossover to hazmat response has also resulted in funding requirements for personal protective clothing and equipment •Must ensure adequate training to protect the health and safety of EMS members as well as provide the protocols and SOPs necessary to ensure the delivery of quality medical care

calculating unit hour cost

•A measure of the total cost of providing coverage during a given accounting period divided by the total number of unit hours of coverage provided during that same accounting period •This measurement can be used to identify whether or not unit-hour costs can help identify excessive cost compared to the quality of care being delivered

national credentialing system

•A nationwide system for credentialing has been established under the IMAS initiative •Currently, FEMA has established a nationwide system of credentialing by working with existing state or discipline-specific credentialing bodies towards national recognition for multi-jurisdictional response under mutual-aid agreements •Current credentialing bodies will continue to issue the credentials; however, those credentials will be entered into a national database and validated •The nationwide credentialing system will be used to request and credential people before they are placed in the role at an emergency scene or at the site of a disaster

provider feedback and access

•A quality-improvement program needs management support and marketing, and the best way to achieve this is to communicate the program and its results •Statistical information can be analyzed on a quarterly basis to produce trends in patient care and EMS operations •Results from quarterly audits will need to be provided to the QI committee and the EMS medical director •Evaluation of those results by the quality-improvement committee and the EMS medical director will be provided to EMS leadership and the EMS chief

automated resource management system

•A secure system that maintains an inventory of typed federal, state, local, and privately owned resources •Has four main functions: -Locating, requesting, ordering, and tracking resources •A long-term goal of ARMS is to expand to include GPS/GIS and mapping capabilities in the future •Will not play a role in prioritizing resources requested during multiple events

civil rights

•A significant rise in civil rights violations and wrongful deaths has emerged in EMS •Most of these cases involve a patient being restrained or handcuffed and not closely monitored by paramedics or law-enforcement officers

procurement process

•A simple approach to procurement is to apply the incident management system under the title of a procurement or specification committee •The committee will have an EMS leader that manages the process •The operations person will supervise, research and evaluation of the products •A planning section will create the request for proposal (RFP) or bid request •The logistics person will arrange for the testing and demonstration, and will make sure that coordination of facilities is achieved •Lastly, a finance person will qualify bidders, account for cost, monitor budgeting, and ensure payment and transfer of money •Each of these sections needs to be populated with field personnel and end users of the equipment •Timeline should be established and a budget arranged with a 10% to 15% emergency allocation or reserve fund for unforeseen issues •Notes and records need to be kept on the decision-making process

accident reports

•Accident history and repair cost need to be recorded, and a number of analysis reports produced

unified command and area command

•ICS incorporates a unified command (UC) and an optional area command when important elements need to be managed in multi-jurisdictional or multi-agency domestic incidents •UC is applied to assure participation of all agencies with jurisdictional authority, or functional responsibility for any or all aspects of an incident, as well as those able to provide specific resource support •The UC structure works best when the following conditions exist: -Contribute to the process of determining overall incident strategies and selecting objectives -Ensure that joint planning for tactical activities is accomplished in accordance with incident objectives -Ensure the integration of tactical operations -Approve, commit, and make optimum use of all assigned resources •An area command is established either to oversee the management of multiple incidents that are each being handled by a separate ICS organization, or to oversee the management of a very large incident that involves multiple ICS organizations, either of which is likely for incidents that are not site specific, geographically dispersed, or evolve over longer periods of time •Area command avoids unnecessary competition for the same resources, such as when there are a number of incidents in the same area and of the same type •Might include the activation of emergency operations centers and/or a unified command

verifying and maintaining checkout

•Accountability for the inspection and inventory of equipment and vehicles should be imbedded as part of an organization's culture •It is important for EMS leadership to instill in the company officers, paramedics, and EMT's that regular inspections need to be conducted every shift, cycle, and monthly by on-duty EMS personnel •Equipment check should be established as the first action at the start of the shift •Ensuring the equipment is ready for service should be reinforced during employee orientation, taught during in-service training, and included in management objectives as the very first thing to be done at the start of a shift •Routine inspections should be conducted every day, on every shift and equipment not used very often should be inspected monthly •Vehicle checkouts should be completed during every shift on mechanics as well as fluids, belts, and tires •Vehicles should be inspected on the outside for damage and leaks, and to ensure working lights and warning devices •Mileage and engine hours should be recorded daily •Critical medical equipment should be included on the vehicle-checkout list including oxygen, backboards, and soft supplies •Any equipment that requires batteries, such as suction devices, laryngoscope handles, and cardiac monitors must be checked before any vehicle is made available for a call •Responding to a call without working equipment has resulted in significant litigation and financial losses for EMS organizations •Two of the first items usually requested by attorneys in medical malpractice cases are the prehospital care reports and the vehicle checkout report •Regulatory inspections are inspections conducted by the government authority that licenses ambulances •The regulatory agency inspects the vehicles for items mandated by law or regulation •Frequently, expired drugs or equipment that is on a state inventory, yet rarely used within the agency, are found to be missing •Regulatory inspections also verify insurance coverage, proper licensing, and personnel certification •EMS employees should have their driver's licenses inspected regularly to identify those whose licenses who have been reported revoked or suspended •Any of the inspections can occur on a random basis •As a management tool, EMS leadership should conduct random audits or inspections to ensure compliance with check out procedures •Most accreditation agencies will conduct spot checks when conducting a site visit •Management must establish the importance of checkout procedures to avoid any errors or interruptions in EMS service

replacement considerations

•Agencies should have a written replacement policy that is calculated using economic factors such as depreciation cost, increasing maintenance cost, service life, and warranty limits •The goal is to reduce overall equipment costs •EMS vehicles and their equipment should be replaced if the annual maintenance cost plus trade-in/replacement value exceeds the cost of a new vehicle

vehicle incidents

•Ambulance personnel responding to or returning from an EMS call are four times more likely to be involved in a crash versus people in their own personal vehicles •Annually, there are approximately 12,000 ambulance crashes and 120 deaths per year •Often the injuries caused by the incident are more serious than those that generated the original call.

scoring and evaluating bids

•An easily understood scoring process is beneficial •A simple 100-point scoring system that weighs the specifications from most important to least important helps secure the best vendor •A point system needs to reflect each area, including finance, operations, background with customer service, vendor presentation, and functional ability •Field evaluations of equipment must be part of the process

sentinel events

•An unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof •It signals the need for immediate investigation and response •When a sentinel event, occurs an analysis and action plan should be done to correct the causes within 30 to 45 days

what causes QI efforts to fail

•Barriers to success in QI activities can be divided into three levels: -Knowledge, attitudes, and behaviors •Often the failure is in the leadership, and the lack of management buy-in is reflected by leadership's attitude toward the program •QI program can be seen as a cause for punitive actions to providers, which may cause EMS providers to develop an attitude that they need to cover themselves •Late feedback and not communicating the results devalues a quality- improvement program •Creating performance measures that are unattainable signals that the program is not important •Adult learners and employees in empowered organizations require feedback •Quality-improvement programs need to be included in the strategic planning and should be reviewed periodically for effectiveness

benchmarking

•Benchmarking -The process of identifying, understanding, and adapting outstanding practices form organizations anywhere in the world to help your organization improve its performance -A means for determining how well a unit or organization is performing compared with similar units in the organization or externally -Is about systematically learning from the best in business or government and using that information to improve one's own performance -An organization needs to understand the gap between its own performance and best practices and take actions to close that gap -Any aspect of an EMS operation can be benchmarked •Benchmarks have to be realistic, and setting the bar for attainment of a goal requires proficiency •Results have to provide opportunities to educate providers and staff •Everyone is accountable in a quality- improvement system, and evaluations need to be adjusted

cost per mile

•Cost per mile is calculated by taking the specific vehicle cost, including the fuel, insurance, maintenance, and indirect cost to support that vehicle in a budget cycle or calendar year, and dividing it by the annual mileage accumulated on that vehicle

quality assurance

•Defined as a system for the maintenance of medically correct and consistent level of pre-hospital care •Ideally, QA processes include: -Identification of errors or deficiency in patient care -Verification of proper completion of run reports •Ideally, QA processes include: -Verification of completion of prehospital personnel procedures and skills -Identification educational opportunities, including opportunities to improve writing, grammar, and spelling •Data collected on each run should include: -Dispatch and system response (times, and so on) -Patient prehospital treatment -Patient turnover status -Patient outcome (ED and post-ED) •The system must also include minimum and measurable performance standards

single command with assisting agencies

•In most command scenarios, EMS will be an assisting or cooperating agency •Under the ICS system, a single command may request help from other agencies for specific issues without developing a larger command structure •Assisting agency -An agency directly contributing tactical or service resources to another agency -A supporting agency is an agency supplying assistance other than direct tactical or support functions or resources to the incident-control effort

labor relations

•Landmark legal cases -The history of labor law in the United States can be traced back to the 1920s. -EMS managers and leaders most often will be operating with one of three unions: §The International Association of Firefighters (IAFF) §American Federation of State, County, and Municipal Workers (AFSME) §Teamsters Union •Labor acts -Railway Labor Act (1926) -Davis Bacon Act (1931) -Norris LaGuardia Act -Wagner Act §National Labor Relations Act

QI performance

•Developmental stages are: -Building potential for success by developing an awareness and appreciation that QI is a worthwhile endeavor -Expanding workforce knowledge of and capability in QI practices and techniques -Fully integrating the strategic quality- planning process and related quality-improvement actions into the daily EMS operation and education programs •Conduct QI courses for front-line employees, including listening techniques, sensitivity training, and cultural diversity •Establish patient-to-provider networks to provide effective, on-going communication for feedback and information gathering, (civic groups, call-in phone lines, surveys) •Solicit feedback through newsletters, Internet home-page postings, local television spots, and articles in local newspapers •Expanding knowledge -Emphasis is placed on ensuring that the entire workforce of an EMS organization or system is informed about and participates in the development of the strategic quality-improvement plan -Paramedics, and EMTs need a working knowledge of basic QI philosophy, tools, and techniques so they can be full partners in the strategic quality-improvement planning process -EMS workforce members should be able to identify their internal and external customers, how to measure the quality of the services provided or received, and how to identify and resolve quality problems in their own work •Full integration and monitoring -EMS workers must feel empowered to take action in work settings to identify, set up, and assesses new patient-care methods and approaches -EMS crews can take self-correcting action by assessing timely information on performance levels for IAFF or NHTSA key quality indicators -EMS management gives way to leadership that helps the workforce maintain and improve the quality of its work

dmat

•Disaster medical assistance teams (DMATs) -A group of professional and para-professional medical personnel designed to provide medical care during a disaster or other event -Each team has a sponsoring organization, such as a major medical center, public health or safety agency, non profit, public, or private organization that signs a memorandum of agreement (MOA) with the DHS -Sponsor organizes the team and recruits members, arranges training, and coordinates the dispatch of the team -To supplement the standard DMATs, there are highly specialized DMATs that deal with specific medical conditions such as crushing injury, burn, and mental-health emergencies •Deploy to disaster sites with sufficient supplies and equipment to sustain themselves for a period of 72 hours •Members are required to maintain appropriate certifications and licensure within their discipline •When members are activated as federal employees, their licensure and certification are recognized by all states

dumping

•Dumping is when a patient is transferred by one hospital to another for insurance reasons or the lack of ability to pay •Under EMTLA rules, a patient with an emergency medical condition that has not been stabilized cannot be transferred unless he or she has been offered stabilizing treatment and informed of the risk of transfer

facilities

•EMS facilities are often co-located within fire facilities •It is important to ensure that existing facilities are budgeted for maintenance and are on a replacement or rehab cycle much like EMS equipment •Any master plan that includes current EMS facilities should also be able to identify the city-, county-, or agency-owned land •The age, condition, and serviceability, should be evaluated against changing response patterns, street, traffic conditions, and demand patterns

ambulance specifications

•EMS managers and the organization should create specifications for EMS vehicles within the system An ambulanceis defined as a vehicle for emergency medical care that provides a driver's compartment; a patient compartment to accommodate an emergency medical technician or paramedic, and two litter patients so positioned that the primary patient can be given intensive life support during transit; equipment and supplies for emergency care at the scene as well as during transport; two-way radio communication; and, when necessary, equipment for light rescue/extrication procedures •Local health departments often have standards for EMS vehicles and mandated equipment, usually listed in the local board of health regulations or in an operating agreement •State EMS authorities usually have specifications for EMS vehicles that are reflected in state law or state statue •Federal Specification for the Star-of-Life Ambulance (KKK-A-1822E), prepared by the Government Services Administration in June 2002

medical equipment

•EMS managers will be responsible for the maintenance, specification, and purchase of biomedical equipment •Biomedical equipment is any medical device, medical supply, or tool used to take care of a patient •The cost-effectiveness of such equipment is rarely tracked or rationalized before budgeting •EMS agency defibrillators, ancillary equipment, biomedical services for preventive maintenance on defibrillators, routine non-warranty work, training equipment, and trainer/provider certification become part of the expense of implementing new equipment

due process and ems performance

•EMS operations at some point will need to discipline or discharge an employee from the organization •Some situations, such as criminal acts, serious property damage, and lack of honesty, require immediate action •Grievance -An official disagreement that is placed in writing -Grievances proceed to discussions between management and labor, and if both sides stand firm, the grievance will be placed in an alternative dispute-resolution system, sent to an arbitrator, or referred to mediation -If all of these processes fail to reach a mutual agreement, a grievance can be sent to district court to be ruled on by a judge

ems quality improvement

•EMS quality improvement officially began with an initiative from the NHTSA •"A Leadership Guide to Quality Improvement in Emergency Medical Services" •National seminars on basic quality improvement •Most EMS systems are operating under standards that where designed years ago with little or no scientific background to determine if the service was efficient and effective •EMS providers will be confronted with threats of reduction of service hours, staffing decreases, or budget reductions •It is important to evaluate the EMS system to determine the value of the service provided and to carefully examine the medicine for outcomes •Analysis of the quality of EMS services is either a qualitative or quantitative measurement •Quality improvement requires a genuine drive to provide good patient care; evaluate health-care costs; analyze policy, patients, and the system; and defend against litigation •Quality of care -The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge -Quality is often seen by the provider as getting what they want, and often that is a quick response and ride to the hospital -Many EMS organizations have attempted to establish quality measurements and standards §NFPA 1710, CAAS, ASTM F-30, and the American Heart Association, along with local and state health authorities, have attempted to establish consensus standards •Accreditation is a process by which an agency evaluates and recognizes a department or organization as meeting certain predetermined standards or qualifications •Quality improvement is a necessity for attaining accreditation from the Committee of Fire Accreditation International and from the Commission on Accreditation of Ambulance Services •It is important through a labor- management partnership that EMS agencies identify, define, and develop EMS system indicators of quality •A performance indicator is a point of comparison used to answer the question "how are we doing" for a specific issue •Key components of performance indicators focus on providers, standards of care, hiring processes, the training process, supervision, system certification, appropriateness of vehicles and equipment, hospital facilities, CQI programs/process, clinical education, and anything else that either directly or indirectly affects patient care •In EMS, quality becomes a measure of how well customers are treated clinically and how well their expectations of care and service are met •Patient care and operations in most systems are conducted by a retrospective process -More traditional approach to quality management -Tends to look back at system performance -Chart reviews are often the most common type of quality-assurance activity conducted in an EMS agency •Prospective activities include observing and conducting primary EMS and recertification training •Case reviews, clinical rotations, and quarterly skills practices are required to ensure skills and proficiency •Attendance at outside continuing- education conferences and ongoing modification in clinical protocols and policies are considered prospective •This includes research and following the medical advances and changes in the practice of EMS

collective bargaining

•In public-safety collective bargaining there are some different approaches to the labor contract •Most collective-bargaining agreements in EMS have formal written agreements often called clauses or articles •Collective bargaining creates the opportunity to negotiate how labor and employment processes are managed •It is a negotiation focused on solving problems and coming to reasonable agreements •When proposing contractual language, a few general rules should be followed: -Proposal should be written in clear, concise language, avoid long sentences, repetition, and lengthy paragraphs -Avoid using complicated legal terms and ambiguous wording, such as "in general," "whenever possible," and "except in emergencies" •When proposing contractual language, a few general rules should be followed: -Proposals should have documentation and examples to illustrate the problems -Ensure before a proposal goes forward that it is proofread and checked for accuracy

building a successful program

•Early stages of implementation of a quality-improvement process require strong leadership and commitment at the local, regional, and state level to: -Learn and understand quality-improvement strategies -Assess thoroughly the present situation of each EMS organization or system -Establish action plans for training and orientation in quality improvement •Service audit -An assessment of all services being provided by the organization -Analysis of the EMS system for strengths and weaknesses •Establishing goals -Establish achievable goals for every behavior inherent in the system -When goals that are compatible with your system do not exist as a local, state, or national written standard, you are faced with either guessing or studying available data •Identify and develop standards of care -EMS managers should look for recognized standards on a national level -EMS standards need to be designed based on the components that focus on measurements encompass, a structure, process, or outcome •Identify and develop standards of care §Structure results focus on the necessary resource components of the system §Process results examine the effectiveness of the design and delivery of work processes, productivity, and operational performance §Outcomes look at the effectiveness of patient care, support services, and fulfillment of public responsibilities •Objectives and performance indicators -Whether a standard is developed around a structure, process, or outcome, it must relate to the organization's objectives §Objectives are measurable statements that are consistent with the system's or agency's mission, vision, and key drivers •Objectives and performance indicators §Performance indicators sometimes are called key performance indicators or key drivers are quantifiable measurements that reflect the critical success factors of an EMS organization •The goals for a particular driver may change as the organization's goals change or as it gets closer to achieving a goal •Performance indicators are available to EMS agencies from NHTSA, IAFF, and the National EMS Management Association •Objectives and performance indicators §Performance indicators sometimes are called key performance indicators or key drivers are quantifiable measurements that reflect the critical success factors of an EMS organization •The International Association of Firefighters has a validated set of indicators free to IAFF fire services, and the NHSTA minimum data or NEMSIS set are available through the federal government

ethics in ems

•Ethics -Set of principles or standard of conduct term comes from the Greek word ethos, meaning character or custom •Ethics -There are commonly five ethical models: §Utilitarian, rights, fairness or justice, common good, and virtue •Utilitarian -Chooses actions that will produce the greatest good for the greatest number •Rights -Operates on the concept that people have free will to choose their actions -There are commonly five ethical models: §Utilitarian, rights, fairness or justice, common good, and virtue •Common good -Based on the belief that society is made up of individuals, and the ethical behavior of those individuals is linked to the community and bound by common interests and values •Fairness or justice ethical perspectives -Evaluates decision making on the fairness of an action and whether it treats everyone the same way or shows favoritism and discrimination -There are commonly five ethical models: §Utilitarian, rights, fairness or justice, common good, and virtue •Virtue -Uses certain ideals toward which people should strive, and which provide for the full development of each individual's humanity •Ethical conduct requires doing the right thing, whether someone is watching or not •Ethical conduct involves beliefs, values, standards, and the principles of honor and morality •Ethics is concerned with how one should behave, and values determine how a person actually does behave •When faced with a choice, EMS employees should ask several key questions. -What is the impact? -Is that impact safe, legal, within policy, and productive? -What is the cost of that impact? •When faced with a choice, EMS employees should ask several key questions. -What might be impacted? -What might be compromised? -How would my family feel if this decision on the news?

for labor standards

•Fair Labor Standards Act, 1938 -Established a minimum wage and protected employees from unpaid overtime -"7K exemption" §This provision states that fire and law-enforcement employees can work more than 40 hours without overtime pay §Defines an employee in fire-protection activities as one who has the legal authority and responsibility to engage in fire suppression •Juan Vela vs. City of Houston •Quirk vs. Baltimore County •Horan vs. King Co., Washington •Edwards vs. City of Memphis •Christensen vs. Harris County, Texas

cost tracking software

•Fleet Accounting Computer Tracking Systems (FACTS) or another computer-based system that tracks all information about vehicles, should be in place •The system links specific information on each vehicle with operational data, such as labor hours, costs of parts, and frequency of parts usage, so that the office can assess its performance against established targets •Most fleet-management software enables automated parts ordering and allows users to determine which parts are in stock •A fleet-management software system should use the information to calculate costs for vehicles by type and age, which helps planning for future purchases and maintenance •Fleet software systems allow EMS managers and front-line supervisors to collect and analyze performance data and establish benchmarks to continue improving competitiveness •EMS managers can use tracking programs to track the initial cost of the vehicle, set up a preventive-maintenance schedule, issue work orders, and do fuel and warranty tracking

immunity from liability

•Good Samaritan legislation -Reduces the liability of a would-be rescuer of a victim or injured person -Several conditions must be established to support a Good Samarian defense in a medical-liability case §The rescuer cannot seek compensation from the victim, act recklessly, or intentionally do wrong -Cases of gross negligence have often violated Good Samaritan standards and resulted in monetary awards against volunteers and other EMS providers •Gross negligence -A severe violation of the standard that is expected of a reasonable provider and is essentially similar to recklessness and willful and wanton misconduct •In many states, legislatures have enacted immunity laws for fire and EMS providers -To limit the liability or cap the awards settlement of lawsuits filed against government-operated EMS and fire agencies

ems all hazards approach

•Hazards analysis -All-hazards approach is a process by which hazards in a community are identified •Vulnerability analysis -Identify and quantify the persons or segments of the population that are vulnerable to the hazards •Risk analysis -Refine the projected vulnerabilities after mitigation actions have been identified -Once it is determined who is at risk from which identified hazards, you must prioritize planning efforts based on the most urgent needs •Plan components: -Hazards analysis -Vulnerability analysis -Basic plan consideration (e.g., scope, activation, authorities, and concepts of operations) -Resource identification -Support functions or mechanisms for resource deployment -Recovery activities

privacy law

•Health Insurance Portability and Accountability Act (HIPAA) -Has several key components that cover privacy, patient rights, and business administrative requirements

ambulance diversion

•Hospital diversion -A condition or event in which an ambulance is sent to another hospital instead of to the closest facility or hospital of choice -Has become a real problem in almost every EMS system •Hospital diversion -Is a detriment to patients and puts an undue strain on the EMS system when ambulances are not available for calls in their first-due district or high-priority staging location -Increases the time on task for an ambulance, increases response times, and often has some seasonal peaks

training and certification

•Managers overseeing fleet operations ideally need an associate's degree in management, automotive diesel technology, or a related field •Most require several years of hands-on experience in automotive maintenance and repair •A well-documented training program for your fleet-service people is a must if a vehicle is involved in an accident - law enforcement, lawyers, or regulatory agencies may examine your mechanics training records •Emergency Vehicle Technician Certification Commission -Certification is the minimum standard set in many states and is one of the most common ways for fire mechanics and emergency-vehicle technicians to demonstrate their qualifications to work on emergency vehicles •Other technicians and mechanics who service county and municipal fleets go on to achieve the highest EVT certification by taking both the EVTCC tests and seeking certification by the National Institute for Automotive Service Excellence (ASE) •Certificates demonstrate the skills and experience needed to perform high-quality maintenance and repair services; further, they instill confidence in the fleet's drivers and customers that the fleet operation is professionally run

arbitration and mediation

•Mediation or facilitation occurs when labor and management cannot agree on a solution to a problem -Mediation §A process by which a neutral third party is brought in to find common ground between to the two groups -Arbitration §A decision-making process by a neutral third party §Binding arbitration is often a clause placed in the contract or provided under state labor law that indicates a decision made by an arbitrator is final and binding on both parties

the law

•Medical-legal issues have become more and more significant to EMS managers and leaders •Criminal law -Laws established by legislatures to indicate public wrongs or crimes against the state -The federal, state, county, or city government prosecutes these actions or pubic wrongs •Criminal law -Violations of criminal law can result in fines, imprisonment, probation, or restricted action. •Civil law -Private law that is established between two recognizable parties, which may include corporations, partnerships, quasi-government structures, or other public entities •Civil law -This type of law usually involves a plaintiff and defendant -Based on torts or contracts and usually involving acts done by one person against another in a negligent or willful manner, causing an injury or loss

communication litigation

•Medical-priority dispatch remains a common source of bad press and litigation for EMS agencies •Most often litigation is the result of a lack of professionalism, burnout, and dispatcher abandonment by not providing pre-arrivals or by hanging up on the caller

medicare abuses

•Medicare fraud has become rampant in the health-care industry •Qui tam -Lawsuit is conducted under the False Claims Act of the Federal Medicare law -It is an action brought by an informer under federal statute that establishes a penalty for the commission or omissions of a certain act and provides that the same shall be recoverable in a civil action -Part of the money paid as the penalty go to the individual who blows the whistle, the remainder of the monies will go to the state or other institutions

metropolitan medical response system

•Metropolitan Medical Response System (MMRS) Program, 1996 -Currently is funded by the United States Department of Homeland Security (DHS) -The primary focus of the MMRS Program is to develop or enhance existing emergency preparedness systems to effectively respond to a public-health crisis, especially a weapons of mass destruction (WMD) event -Through preparation and coordination, local law-enforcement, fire, hazmat, EMS, hospital, public health, and other first- response personnel plan to more effectively respond in the first 48 hours of a public- health crisis •When EMS is summoned to a technical rescue incident, the minimum qualifications require rescuers to be certified at the BLS level and have rescue awareness training •All personnel at the site need to understand that they must operate under an incident management system •Awareness-level training -Represents the minimum capabilities of responders who in the course of their duties could be called upon to respond to or be first on scene of a technical-rescue incident. -At this level the EMS manager and field crew are generally not considered rescuers but rather support personnel for the operations •Operational-level training -Is designed for responders who will have the capability of hazard recognition, equipment use, and techniques necessary to conduct a technical rescue •The Federal system for Urban Search and Rescue (USAR) -Relies on local fire and EMS organizations to organize into 60- to 72-person FEMA USAR teams -There are 28 teams stationed throughout the United States -These teams require federally mandated training and a specialized equipment list -Requests for FEMA teams must go through a chain of command

mutual aid agreements

•Most organizations have mutual-aid or automatic-aid agreements with neighboring communities •These plans also identify specific authorities with regard to command, compensation, and liabilities •Automatic aid is sent by the dispatch center without a command officer's input and is done on a pre arranged matrix •These agreements specify that another agency will help and, in return, the other agency can expect help when necessary; or in some cases, there is state wide mutual aid that eliminates the need to have to renew signed agreements on an annual basis •Even with the best intentions, without detailed operational plans, execution of such agreements can be destroyed by personal interpretations or local politics and can have disastrous effects •Many parts of the country have only informal, "handshake" agreements •Some communities have signed agreements, but frequently there is little beyond the signatures that separate them from informal agreements, since many do not contain detailed plans, protocols, or training exercises to support their integration into an operational process

quality in EMS

•Most people in EMS come to work with the philosophy to do the best job possible •In most cases they never see results or are never given the feedback on their performance •Lack of feedback on performance creates apathy •Quality-improvement activities are essential to keep the workforce motivated, provide excellence in patient care, and reduce the risk to the organization •There are two key themes to keep in perspective when managing EMS quality-improvement activities: do the right thing, and do the right thing well •EMS quality-improvement activities need to be effective with regard to the tests, procedures, treatments, and services that are provided

ambulance types classes configurations

•The Federal standard uses three ambulance types, with further divisions into classes and floor configuration -Type I conventional truck, with cab chassis and a modular ambulance body §Type I ambulance can have an additional-duty (AD) unit when modified for neonatal, critical-care transports, and rescue or fire suppression package •The Federal standard uses three ambulance types, with further divisions into classes and floor configuration -Type I conventional truck, with cab chassis and a modular ambulance body §This is often referred to as a "medium duty" rescue in the fire service; The vehicle types are divided into class I or class II, representing two-wheeled and four-wheel drive, respectively •The Federal standard uses three ambulance types, with further divisions into classes and floor configuration -The Type II is a standard van with an integral cab-body ambulance §A type III ambulance is a cutaway van, cab-chassis with integrated modular ambulance body •The Federal standard uses three ambulance types, with further divisions into classes and floor configuration -The type III ambulance can also have a classification of additional duty (AD) §It is recommended in the federal standard that ALS ambulances be either type I or type II §Type I and III ambulances also have two standard configurations in the federal specification: "A" for ALS and "B" for BLS

first amendment rights

•The First Amendment protects freedom of speech, religion, and association •These are not unlimited rights, and only speech on matters of pubic concern is protected •If a public employee's speech is purely job related, it is not entitled to First Amendment protection •Legal counsel should be consulted before taking any disciplinary action against outspoken employees

jcaho

•The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) -Sets standards for health-care organizations -When a health-care organization seeks accreditation, it demonstrates commitment to giving safe, high-quality health care and to continually working to improve that care -Many of the CAHO principles have been applied to EMS, and it is a natural migration for CAHO standards to find their way from a physician medical director to an EMS agency

local emergency planning committee

•The Superfund Amendments and Reauthorization Act of 1986 (SARA) Title III, or the Emergency Planning and Community Right-to-Know Act •Requires governors of every state to establish a state emergency response commission (SERC) and to designate local emergency-planning committees (LEPC's) •The purpose of this law was to require emergency-planning efforts at the state and local levels, and to increase the public's awareness of hazardous chemicals within their communities •Depending on the state, the LEPC can be designated as the entire state, a portion of the state, or any county or other geographical designation

vehicle and equipment failures

•The annual critical vehicular failure (CVF) rate, or the average frequency at which something fails, should be calculated •This is done by identifying a specific mileage or operating-hour benchmarks for the entire fleet -A common benchmark is the number of incidents for the fleet every 100,000 miles, 1,000 engine hours, or 100,000 engine hours •Mileage and hour benchmarks work well, since wear and tear on equipment is based on use and not calendar days •Common areas to plan for in preventive maintenance are replacement of items such as tires, batteries, belts, fluids, brakes, and any other parts determined to need replacement on a scheduled or regular basis •A common rate of failure in public-safety or ambulance fleets suggest that out-of-service incidents occur at a rate of 0.87 vehicle failures per 100,000 fleet operating miles •A vehicle failure above this rate in pubic safety may indicate a vehicle should be taken out of service with a problem identified in a vehicle checkout •When performing a critical failure rate, the automotive industry tends to use three parameters for each failure - severity, occurrence, and detection - and gives each one a score between 1(not critical) and 10 (extremely critical) •Safety-analysis guidelines propose a scoring scheme along the following lines: -Severity: The hazards associated with each failure should be categorized into 10 different levels ranging from 1 (least severe) to 10 (most severe) based on safety and impact on the operation -Occurrence: Is the number of events and the probability of random failures in a given mileage benchmark or a specific number of hours of engine use; the occurrence of random faults should ideally be scored objectively using a percentage per certain hours or mileage -Detection: A meaningful interpretation of this number is a measure of the degree to which preventative systems and vehicle checkouts can be detected; it should be made up of the probability expressed in a percentage

fleet management and equipment

•The delivery of EMS services cannot be accomplished without technologically sophisticated medical equipment and state-of-the-art emergency vehicles •A number of factors must be considered in order to establish the cost of operating an EMS system -Direct services are the services provided to the public §This includes patient-care activities, public-education programs, preventive-maintenance programs, and special events •A number of factors must be considered in order to establish the cost of operating an EMS system -Functional services are those provided to the agency within and can include such services as yearly physicals, EAP, training, uniforms, office support, and utilities •A number of factors must be considered in order to establish the cost of operating an EMS system -An EMS manager must identify all the services provided by the organization as the first step in identifying and costing out each key aspect of the operation •Fleet administration requires EMS managers to supply vehicles and services to support fire and EMS activities •These services cover a wide range of job tasks -Logistics chief officer or front-line supervisor •An EMS manager must consider replacement policies, contracting and government bidding standards, whether to purchase or lease apparatus and equipment, and replacement criteria •A contingency plan should be put in place to provide reserve equipment or equipment on loan during planned and preventive maintenance •In the event that there is equipment failure, a procedure should be put in place for using reserve equipment, such as borrowing an ambulance or cardiac monitor from a neighboring department or perhaps a local vendor who will loan you a demo unit if your reserve unit is unavailable or you need additional resources

federal mutual aid initiatives

•The federal government has developed two projects that will help EMS service's ability to support the national response plan and implement concepts presented in the National Incident Management System •This initiative was authorized under Homeland Security Presidential Directive (HSPD-5) •The initiative will provide the nation with the highest capability to rapidly and easily exchange disaster resources during times of need •National Fire Service Interstate Mutual Aid System (IMAS) -The goal is to support the creation of formalized, comprehensive, and exercised intrastate mutual-aid plans. •Mutual Aid System Task Force (MASTF) -The goal is to bring a fire-service perspective to recommendations to improve the sharing of resources across state lines

specification process

•The first step in purchasing or leasing equipment is to create a procurement process for your agency, whether for a new ambulance or a cardiac monitor •Defining the specifications for the vehicle or equipment is really one small part of the process •More ownership and pride in the equipment when employees have input into the design and construction •Vendors normally provide a set of specifications and place in those specifications conditions or statements designed to exclude other vendors •Rarely is that set of specifications designed to a performance standard -In many cases, the vendors reserve the right to substitute or change the specifications •It is important to use the request for proposal (RFP) process and include key performance criteria and penalties if the equipment fails to meet those standards •Similar to construction contracts, bid specifications can include monetary penalties for late delivery or for not meeting performance criteria •When purchasing equipment, EMS managers ask for several different requests for proposals or contracts used by other agencies for purchases, and employ a committee to review the content and use the best of the content to create a custom request for proposal

national response plan assumptions

•The national response plan (NRP) -Assumes a disaster or emergency, such as an earthquake or act of terrorism, may occur with little or no warning at a time of day that produces maximum casualties -The plan also deals with other types of disasters, such as a hurricanes, that could result in a large number of casualties and cause widespread damage, and with the consequences of any event in which federal response assistance under the authorities of the Stafford Act is required -In all cases, the plan assumes that the response capability of an affected state will be overwhelmed •The planning function of operations -Immediately following a major disaster or emergency requiring federal response, primary agencies, when directed by FEMA, will take actions to identify requirements, and mobilize and deploy resources to the affected area to assist the state in its lifesaving and life‑protecting response efforts •Agencies have been grouped together under 15 emergency support functions (ESFs) to facilitate response assistance to the state •Requests for assistance will be channeled from local jurisdictions through the designated state agencies for action •Federal response assistance will be provided by an ESF to the state, or, at the state's request, directly to an affected local jurisdiction •A principal federal official (PFO) will be appointed by the president to coordinate the federal activities in each declared state •The PFO will work with the state coordination officer (SCO) to identify overall requirements, including unmet needs and evolving support requirements, and coordinate these requirements with the ESFs •The PFO also will coordinate public information, congressional liaison, community liaison, outreach, and donations activities, and will facilitate the provision of information and reports to appropriate users •The PFO may appoint a federal coordination officer (FCO) to head a regional interagency emergency response team (ERT), composed of ESF representatives and other support staff •The ERT provides initial response coordination with the affected state at the state EOC or other designated state facility and supports the FCO and ESF operations in the field •The PFO will coordinate response activities with the ESF representatives on the ERT to ensure that federal resources are made available to meet the requirements identified by the state •A national interagency emergency support team (EST) will operate at the Department of Homeland Security, FEMA headquarters, to provide support for the PFO and the ERT •The catastrophic disaster response group (CDRG) will operate at the national level to provide guidance and policy direction on response coordination and operational issues arising from PFO and ESF response activities •The CDRG also is supported by the EST and will operate from FEMA headquarters •Activities under the plan will be organized at various levels to provide partial response and recovery (using selected ESFs) or to provide full response and recovery (using all ESFs)

national level response structure

•The national‑level response structure is composed of the following specific elements: -Catastrophic disaster response group -Emergency support team -Agency operational centers •In addition to supporting EST activities at the FEMA EICC headquarters, departments and agencies will conduct national-level response activities at their own EOCs

hippa

•There are penalties for violating the confidential information of patients -The financial costs are divided among civil and criminal penalties -The civil penalties are $100 per violation and up to $25,000 per person, per year, for each violation -Criminal penalties can be assessed up to $50,000 and 1 year in prison -Penalties increase up to $100,000 and 5 years in prison for obtaining past medical history under false pretenses -An agency or individual can be fined up to $250,000 and given 10 years in prison for obtaining and disclosing past medical history with the intent to sell or use the information for commercial or personal gain or malicious harm •Administrative Simplification Compliance Act, 2001 -Mandated that new Medicare claims and billing had to be conducted electronically after October 16, 2003 -This was in response to HIPAA requiring electronic filing •Privacy officer -May be the EMS chief officer or an EMS supervisor -If there is no EMS officer, this responsibility must fall on the fire chief or agency executive to ensure compliance with the rules, or the agency could forfeit the right to bill Medicare

regional resource response plans

•These plans identify the method of mobilization, organization, and operation well in advance of the need •Plans identify financial considerations in advance, rather than at the time of need •Resource response plans are based heavily on the concepts of incident management •An agency requiring a specific resource contacts a lead organization (many times the state EOC) and places a request for a specific resource, task force, or strike team •This lead agency then determines the closest available source of the needed items from the membership of the plan and contacts one or more organizations to assemble what is needed •The requesting member can specify a unique resource at the time of the request •Could include EMS task forces, disaster medical assistance team, or an urban search and rescue team •Responding units should have a means of common communication between units capable of working outside their home jurisdictions -Known as interoperability

total quality management

•Total Quality Management (TQM) -A management system that focuses on continuously improving performance at every level of function, focusing on customer satisfaction -An EMS operation using TQM involves both leadership and employees -Assumes that most problems result from the inability of the system to perform, rather than the individual's inability to perform -In an EMS system, TQM requires three elements: §EMS managers and leaders must have an absolute commitment from the top §It must be easy to identify measurable and accurate indicators of quality §There must be involvement in the quality- improvement process by EMTs, paramedics, and support personnel in all quality-improvement methods

tiered or dual response agencies

•Turf issues also exist within organizations at the interdepartmental, opposing shift, and dual-response levels •A common place for disagreements is in combination career-and-volunteer agencies •A reasonable approach to improving this situation will involve having each group define its contribution to the whole mission and a facilitation of the contributions each group makes to the community •A basic understanding of teamwork and the expectations of the agency that everyone will "play well together" helps and must be delivered by the leaders of the organization •Of course, the leaders then need to walk the talk of getting along and using accepted behavior

vehicle inspections

•When accepting delivery of an ambulance, a series of procedures is recommended -A source inspection should be completed by EMS management or leadership prior to shipment from the manufacturer and should include workmanship, quality conformance, and a first-production inspection -First-production inspections ensure the manufacturer is conforming to the standards -This should be done at the manufacturing plant, and the cost of getting EMS managers to the factory should be borne by the manufacturer -A destination examination also should include a check of all ambulance controls, electrical systems and devices, door, windows, cabinets, and accessories, as well as a road test at highway speeds, a brake test, and a test for rattles and squeaks -Road test of new vehicles involves driving a total of 150 miles, with 75 miles of that on highways at a speed of 70 mph; 30 miles on city streets at 30 mph, 15 miles on gravel or dirt roads at 35 mph, and 5 miles on cross-county operations that are muddy or open field areas -A water spray test subjects the vehicle to a water spray at 25 psi for 15 minutes in order to look for any evidence of a leak -system should be pressurized to 150 psi with dry air or nitrogen and be able to hold that pressure for four hours -Have a checklist prepared in advance that details the tests and inspection points to be completed before acceptance of the vehicle -If a vehicle fails any of these tests and the vendor cannot fix the vehicle after a reasonable number of attempts, the EMS leadership should have the option to terminate the contract

interagency communications

•Whenever one system or agency comes up against another, there is a potential for challenges •Problems can range from basic interpersonal communications to more difficult inter professional issues, such as turf control, differences in procedures, differences in rank structure, or competition for funding •When interfacing with another system or agency, the goal of EMS members must be to avoid problems or adapt to the situation to achieve a cooperative working interface •The key issue is to ensure delivery of the best patient care possible •EMS managers are involved with rules, regulations, and other influences generated by external agencies and impacting upon their organization and personnel •Managers must know the extent of involvement and whether the particular agency has regulatory power over their operations •The best practice is to comply with applicable rules and regulations •If a situation arises that makes compliance difficult, the manager must work to achieve compliance or a reasonable solution to the problem •Failure to comply with applicable rules and regulations can cause administrative nightmares, preclude effective delivery of certain health-care services, and, in extreme cases, result in litigation and/or shut down the entire EMS system