What EMS chiefs need to know about economies of scale

How other volunteer organizations in the community leverage their size while still acting and feeling local

This is article is the third in a series from the National EMS Management Association that explores how principles of size and scale can be applied to EMS while maintaining a strong community connection. The first article introduced economies of scale. The second article describes how large community organizations leverage scale with volunteers. This final article explores how some innovative rural and volunteer EMS services, both domestic and international, have used scale to their advantage.     

By Sean Caffrey, NEMSMA

Rural and/or volunteer EMS organizations can leverage scale in the same way to improve training, purchasing and service delivery while being perceived as local. Many aspects of an EMS organization benefit from scale. Two very large volunteer organizations including the American Red Cross and the Boy Scouts of America, organizations likely active in your community, leverage the use of volunteers while maintaining a strong sense of local control.

Vertical integration
Perhaps the most common application of EMS economy of scale in the United States is vertical integration. Vertical integration is best described as multiple elements of public services, emergency services or health care services working together under a common umbrella. Vertical integration exists in almost every EMS system that is described as "-based" such as county-based, fire-based or hospital-based EMS.

In vertically integrated operations the EMS organization shares oversight, support functions and/or facilities and staff as part of a larger organization. Support functions can include such items as training, human resources, finance, information technology, dispatch, vehicle maintenance or purchasing.

Other economies, such as shared staffing, either paid or volunteer may also exist. Shared staffing is probably most common in fire-based organizations when personnel are cross-trained to provide both firefighting and EMS. It is likely there are thousands of volunteer fire departments that provide fire and EMS in the United States, although there is currently no great method to count them.

Horizontal integration
The combination of multiple EMS services that perform similar roles is another common application of scale in EMS. Large private ambulance firms such as AMR and Falck are examples of horizontally integrated organizations.

However, consolidation among smaller EMS agencies into larger consolidated services has occurred across the country. Smaller and/or regional organizations such as public-utility model and special districts often provide this type of integration by serving multiple jurisdictions as a single organization.

With ongoing local budgeting challenges, and declining reimbursement levels consolidations may increase in popularity, especially among nonprofit and local government EMS services. Rural and volunteer EMS services, should consider consolidation with neighbors as a potential option horizontal integration with similar services is often preferential to developing entirely new, and often more expensive, service models that may or may not rely on the use of volunteers.

What is less prevalent in EMS, however, is a focus on local control, particularly in large horizontally integrated EMS organizations. As we saw with the American Red Cross and the BSA, these community organizations, while national in scope, have developed governance systems to ensure local units and chapters have the autonomy needed to tailor and direct their programs based on local community needs. Many large EMS organizations, by contrast, often remain centralized in terms of leadership and structure and rely instead on contractual arrangements to ensure they are serving local needs.

Contracting, while often precise and prescriptive, is a less direct form of control and accountability than direct ownership and/or control by the local community itself. While this does not imply contracting is bad, it does beg the question of how EMS services should be optimally structured in order to provide efficient services while maintaining a strong connection to the local community.

Volunteer EMS organizations leveraging scale
Some of the best examples of volunteer organizations using scale to their advantage are in Australia. The Australian states of Western Australia, South Australia, Tasmania and the Northern Territory all operate statewide services with large volunteer components.

St. John’s Ambulance, an international organization, provides ambulance service to Western Australia and the Northern Territory which includes over 975,000 square miles, or one-third of the land mass of the continent. St. John’s operates ground and air services from 160 locations with over 3400 volunteers. Similar services, somewhat smaller in size, also exist in South Australia and Tasmania.

The general model of these services is to operate under a centralized administrative structure with a statewide dispatch center. Administration and logistics is provided service wide and extensive structures are in place to train and maintain the skills of volunteer ambulance officers. All rural and many suburban locations have volunteer staffing while urban areas are covered by paid staff. Mixed paid and volunteer crews staff rural stations and some suburban stations.

While not independent organizations, many individual community EMS stations are operated as brigades of volunteers that have autonomy over matters such as training and scheduling that are supported by the parent organizations. Many services also operate online systems to keep volunteers connected and informed across the network.

Virginia Beach EMS is one of the largest volunteer EMS organizations in the United States. Virginia Beach, a city of approximately 450,000 people covering 325 square miles, has about 43,000 ambulance calls per year.

Like a number of urban areas, Virginia Beach has seen significant growth in the past few decades. A strategic decision was made in the 1970s to maintain a volunteer EMS system supported by the city. The current system is a federation of multiple volunteer rescue squads that receive administrative support, including volunteer recruiting and training, from the city EMS department. Common dispatching, scheduling and reporting systems exist and a limited number of paid EMS providers fill gaps in volunteer coverage.

Key takeaways: Large-scale volunteer organizations
So what can we take from some these case studies involving Australia, Virginia Beach, the Boy Scouts or the American Red Cross? First, volunteer services do not need to be restricted to small services with limited capacity that serve only a small area. All of these models clearly demonstrate that volunteer organizations exist at large scales.

What is notable about both the Australian and the Virginia Beach examples is that these organizations provide high quality EMS services to their communities using volunteers. They provide services on par with any other type of EMS service and they are well run, well equipped, operationally efficient and clinically proficient. They are not "just volunteers" nor do they ask for, or require, special accommodations because of their volunteer status. Can your service say the same?

Secondly, these case studies further indicate that reliance exclusively on volunteers is unnecessary. Large-scale volunteer organizations have embraced organizational structures where paid staff are used to support and supplement volunteers. The basic approach is that volunteers are supported in doing what they signed up for — giving medical care to their neighbors — and not hassled with other administrative and logistical concerns.

Third, recruitment, initial training and ongoing training of volunteers are key facets of large-scale volunteer organizations both inside and outside of EMS.   

Fourth, the connection that many volunteer services have to the community they serve is probably a good thing. Volunteer organizations outside of EMS have worked to structure their organizations in such a way as to maintain those local connections, if not outright ownership by the community. The Virginia Beach EMS system is a group of community-based rescue squads working together with local government to develop a comprehensive and effective volunteer EMS delivery system.

Volunteer EMS leaders should ask how their organization can benefit from working with other organizations and how those organizations can benefit from scale. Could you share services or partner with other agencies to make your organization better?

Many EMS services already have, and there is probably a model out there that might work for your service. Also realize that the strategic use of paid professionals as administrators, educators, mechanics or field providers is a hallmark of many successful volunteer organizations. Finally, remember that a strong community connection has been important to your organization's past and will be essential to your successful future.

Good luck as you explore the possibilities! Share your successes, questions and ideas in the comments. 

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