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
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Politics - Defined
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Politics - Defined
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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.
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In the Beginning...
• Start from the HIGH ground
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Patient focused
Logical
Reduced burden
Simplification
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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
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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
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Gaining Support
• Constituents
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–
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Personal briefings
Community groups
Position papers
Media
• Especially Editorial Boards
– Log feedback
• Dispels the ‘in-the-dark’ argument
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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
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Volusia County Case Study
• Daytona Beach Area
• 450,000 residents
• 1 million visitors on average
– Beaches
• Major special events
– Bike Week
– Daytona 500
– Spring Break
Black College Reunion
Pepsi 400
Biketoberfest
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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”
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Volusia County Case Study
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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
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Volusia County Case Study
• Many issues like other communities
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Jurisdictional boundaries
FD’s want ambulance transport
Potential fractionalized system
No data collection - refused
Limited EMD
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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
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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”
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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.”
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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 a
minimum 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.”
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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”
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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…
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City Managers
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Feedback
• Process and form for specific
feedback
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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
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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
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Resources Consulted…
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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.”
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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)
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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
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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
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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
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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
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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
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Closest Unit is
Volusia County E-37
Next Closest Unit is
Seminole County Rescue
Next Closest Unit is
Volusia County E-36
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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
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Responses to Feedback:
Closest Unit Response
• Requires the cities to hire more staff
Department
Daytona Beach
Daytona Beach Shores
DeLand
Deltona
Edgewater
Holly Hill
New Smyrna Beach
Ormond Beach
Ponce Inlet
Port Orange
South Daytona
Volusia County Fire
Total
Stations
6
1
2
4
2
1
4
6
1
4
1
19
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Primary
Units
8
1
3
4
2
2
5
7
1
5
2
20
60
Unit Hours
On-Duty
70,080
8,760
26,280
35,040
17,520
17,520
43,800
61,320
8,760
43,800
17,520
175,200
525,600
Total
Average Time
Responses Per Response (1)
13,748
0.42
1,184
0.42
3,518
0.42
6,501
0.42
1,949
0.42
1,996
0.42
3,271
0.42
6,018
0.42
341
0.42
4,661
0.42
1,492
0.42
12,743
0.42
57,422
0.42
Hours on
% of Time
Responses On Responses
5,774
8.24%
497
5.68%
1,478
5.62%
2,730
7.79%
819
4.67%
838
4.78%
1,374
3.14%
2,528
4.12%
143
1.63%
1,958
4.47%
627
3.58%
5,352
3.05%
24,117
4.59%
Note 1: Average Incident time from CAD Records = 25 minutes, or 0.42 hours
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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
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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)
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• “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
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• “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
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Responses to Feedback:
Emergency Medical Dispatch
• Training and certification costs
– True IF the agency chooses to go inhouse
• 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
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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
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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
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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)
September 2002, Volusia Council of Governments, Inc., Comprehensive System Assessment for the
Volusia County Fire and EMS System; TriData Corporation, Arlington, VA
– “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.”
National EMS-C Data Analysis Resource Center; July 2003 Position Paper
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Responses to Feedback:
Data Collection
Chain of Survival
• “All EMS systems should assess their
performance through ongoing data
collection, evaluation, reporting and
standardization…”
American Heart Association Guidelines 2000 for CPR and Emergency Cardiac Care: International Consensus on Science, Part
12, p. 363
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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
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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
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
“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:
o A 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.
o Strong 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?’”
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“Six Minutes to Live or Die”; USA Today investigative report; July 28 – 30, 2003
PRIVATE FIRM TO DISPATCH DAYTONA FIRE AND EMS
John 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 05A
Fire/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.
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'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.
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Emergency pact: Countywide closest unit response a lifesaver
News-Journal Editorial – May 9, 2003; Page 04A
“City leaders balking at Volusia County's "nearest station" emergency response proposal may
see it as a bitter pill, but they know that swallowing it will save lives. In the last year,
firefighter/paramedics countywide saved 11 people in cardiac arrest during emergency
responses. Those 11 and their families surely appreciate the difference each minute of
response time can make. No one can be sure how many other lives would have been
saved had the proposed emergency medical services ordinance had been in place.
Emergency providers and policymakers speak supportively of the general principles in the
ordinance and say the devil’s in the details. But that’s not where the devil is. The devil’s in
every minute of obstinacy separating the closest paramedic from an injured or dying
person awaiting help.”
"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?’”
Mayor John Menino, City of Boston & former
President of the International League of51
Cities
The Bottom Line...
• Rhetoric vs. Reality
– Every citizen of Volusia County deserves
the fastest, highest quality emergency
medical service
– It’s NOT about territorial boundaries,
politics, or “home rule”
It IS about doing the right thing
for the PATIENT
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The Action...
• Public Hearing
– Packed Council Chambers
• All news outlets
• 200+ residents
– All FD Chiefs / City Managers
– Public statements 20:1 in favor
– Great Council comments
Ordinance Passed 6 - 1
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Epilogue...
• 3 COPCN applications since adoption
of new ordinance
– 1 fully complied with all provisions
– 1 hedged on the Medical Director
provision with a 30 day “opt-out”
• And they were issued a “30-day” COPCN
– 1 had Q/A issues
• COPCN conditional on Q/A milestones
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It Never Ends...
• Cities considering legal action
– Ordinance sets ‘unreasonable’ standards
– Have not found an “EMS Expert” to
support their claim so far
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Summary...
•
•
•
•
•
•
Take the High Ground - Always
Keep stakeholders informed
Constantly seek feedback
Realize some will never be happy
Consult experts
Use the media to get your message
out
• Thank everyone in writing...
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