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5 keys to EMS long-term system sustainability

Accountable EMS systems: Why they are different and misunderstood, and perform better


Accountable systems operate as public utility models (PUMs), failsafe franchises and other well-designed performance-based contracts.

Photo/Kurt Bresswein via TSN

By Jay Fitch, PhD

The recent death of Jack Stout caused me to reflect on the core design elements that were used in developing the public utility model for ambulance services [1]. Those same concepts were utilized by Fitch & Associates in developing accountable EMS systems for communities throughout the nation. Jack generously shared his ideas and, while the implementation strategies were slightly different, we always agreed on the guiding principles.

Accountable systems are different in structure and governance and have been frequently misunderstood by those who tried to implement the elements without external guidance. When the core elements have been implemented, systems have performed in an excellent manner over their more than 40-year history.

The following five factors are key to the long-term sustainability of an EMS system:

  1. Ambulance services must be held accountable. Systems must achieve clinical excellence, response time reliability, consumer satisfaction, economic efficiency and continuous improvement, simultaneously – to consistently provide excellent care for patients. With effective system design and meaningful performance-based agreements, ambulance services can be effective and efficient regardless of provider type, geography and demographics.
  2. Functional external oversight mechanisms exist. Performance accountability is promoted by providing authority and tools to replace a non-compliant provider without a service disruption. An autonomous oversight structure utilizing an arm’s length relationship with the actual service provider, regardless of provider type is required.
  3. Account for all service costs. In addition to direct operational and capital costs, an effective and efficient system accounts for all indirect overhead costs and appropriately benchmarks these routinely. Failure to do so puts both patients and taxpayers at risk in the long term.
  4. Require system features that ensure economic efficiency. Service volumes vary by hour and day. To reflect this reality, deployment should be based upon both geographic and “peak load staffing” (deploying the right number of units based upon historic demand) and “event driven redeployment” rather than static deployment alone (except in remote areas). To optimize productivity, the emergency provider should be allowed to provide non-emergency transportation services as appropriate. Employment practices and operational processes must optimize productivity and eliminate wasted resources, but also focus on retaining talent within the system. EMS emphasis on prevention and facilitating appropriate access to the larger healthcare system can reduce downstream healthcare costs.
  5. Ensure performance sustainability. Contractually required performance standards must be established, regardless of the service delivery model. Performance standards are established by independently benchmarking the clinical and financial performance against best practice standards/requirements of other high-performance systems of similar size and demographics. Service right extensions are earned by meeting or exceeding performance standards. Funding methods must encourage ongoing efficient performance and addresses costs of changing demographics and demand beyond the provider’s control. A well-designed performance agreement provides the processes necessary to continually monitor standards and upgrade requirements to the then current standard of care, maintain objective oversight and retain the ability to safely terminate the relationship if the provider fails to perform.

These five elements represent best practices in EMS system design. Accountable systems operate as public utility models (PUMs), failsafe franchises and other well-designed performance-based contracts. While systems like those listed below are often referenced, others also can incorporate these concepts. In fact, the remaining public utility model systems reflect the smallest market segment of accountable systems.


A key success factor for accountability is maintaining separate governance and oversight when communities elect to move away from the PUM model but still desire performance, economic stability and full accountability. The use of the five concepts not only improves accountability but also tends to insulate systems that can otherwise be buffeted by changing political winds.

Multiple entities have incorporated a number of the accountable system core elements as part of their system design. These include non-profits organizations, like MEDIC in Davenport, Iowa, and Advanced Medical Transport in Peoria, Illinois; hospital-based services, such as Northwell Health in Syosset, New York and University Medical Center EMS in Lubbock, Texas; as well as governmental agencies, including the Region of Niagara, Ontario, and the Province of Nova Scotia in Canada.

Another variation is to use a fire department not seeking to expand its transport role to oversee the ambulance contract in an accountable system model. This approach blends the fire service’s stability with the entrepreneurial advantages of a private service. Examples include Vancouver, Washington, and Tuscaloosa, Alabama, which both use the fire department in the primary oversite role. This variation also facilitates appropriate resource adjustment between fire response and private ambulance resources.

Some government entities have incorporated some accountable design elements or attempted to cut and paste others’ community-specific specifications to improve contracts with private ambulance services. Unfortunately, when well-intentioned individuals cherry pick provisions that they don’t fully understand, the outcome is usually less than optimal.

According to those knowledgeable of the system’s performance, Kansas City’s Metropolitan Ambulance Service Trust (MAST) performed in an exemplary manner for more than 30 years. Subsequent to the city’s decision to move the system to the fire department, the clinical and response time performance have never matched MAST’s previous record, costs have increased dramatically, and the system is far less transparent.

Incorrectly applying EMS system design elements to the requirements of a particular community can be likened to placing the wrong size tire on an ambulance. While it can be installed with some extra effort, over time, it typically wears poorly, or worse yet, causes a blowout. The same is true of EMS delivery models that are not expertly matched to the dynamics of the larger healthcare system and community they serve. It may function temporarily, but will likely not perform well over time and potentially suffer a catastrophic failure.

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For more than three decades, the Fitch & Associates team of consultants has provided customized solutions to the complex challenges faced by public safety organizations of all types and sizes. From system design and competitive procurements to technology upgrades and comprehensive consulting services, Fitch & Associates helps communities ensure their emergency services are both effective and sustainable. For ideas to help your agency improve performance in the face of rising costs, call 888-431-2600 or visit