Emergency Medical Services in the Rochester Region Of
Total Page：16
File Type：pdf, Size：1020Kb
EMERGENCY MEDICAL SERVICES IN THE ROCHESTER REGION OF NEW YORK STATE: ORGANIZATION, SERVICES AND SYSTEMS A Dissertation Presented to The Graduate Faculty of The University of Akron In Partial Fulfillment of the Requirements for the Degree Doctor of Philosophy Kenan S. Baldridge May 2007 EMERGENCY MEDICAL SERVICES IN THE ROCHESTER REGION OF NEW YORK STATE: ORGANIZATION, SERVICES AND SYSTEMS Kenan S. Baldridge Dissertation Approved: Accepted: _________________________________ ____________________________ Advisor Department Chair Dr. Raymond Cox III Dr. Sonia Alemagno _________________________________ _____________________________ Committee Member Dean of the College Dr. Ralph Hummel Dr. Ronald F. Levant _________________________________ ______________________________ Committee Member Dean of the Graduate School Dr. Nancy Grant Dr. George R. Newkome _________________________________ ______________________________ Committee Member Date Dr. Lawrence Keller _________________________________ Committee Member Dr. Dena Hanley ii ABSTRACT In 1966, the U.S. Department of Transportation published what was to become a landmark study: “Accidental Death and Disability, the Neglected Disease in Modern Society.” This work reviewed the then current state of affairs of prehospital medical care in the United States. It painted a horrendous picture concerning the quality of care rendered to American citizens during the time of an emergency. The information presented so astounded the federal government and the medical community that many efforts were undertaken to respond to the findings of the work. New York State responded to the report some eight years later with the enactment of the Emergency Medical Services Act of 1974. Known as “Article 30,” this act set out lofty, but vague, goals for improving the quality of emergency medical care provided to the general public. It is the thesis of this study that the organization design chosen and the implementation methods and tools employed, were grossly inadequate to the task. Add to this a meager allocation of resources, and the State’s response became pre-destined to fail. In the Rochester Region, formal groups associated with health care or ambulance response did little. A handful of local leaders acted on their own initiative to respond to iii the problem. A federal grant provided funding for a university-based program concerning data collection, “coordination” of pre-hospital programs, and medical training for ambulance attendants, though its reach was very limited. There was only limited regional effort to respond to the new State level EMS policy. EMS service levels remained dismally low in many parts of the state. The quality of care provided to the public was highly questionable for a significant number of patients treated. This work seeks to determine whether EMS service provision in the Rochester Region of New York State meets national quality standards on a consistent basis, the reasons why or why not, and how progress actually gets accomplished. The implementation of statewide policies requires many choices. These choices must address many levels of government and many steps in the implementation process. These include choices of goals to be achieved as well as which underlying technical theories are believed useable for obtaining them, whether to use an existing agency, or construct a new administrative organization or structure. Lastly, choices must be made as to which inputs, outputs and outcomes to measure for evaluation purposes, if any at all. At the state level, the legislature chose to use a new organizational strategy, that of the EMS council system, which it hoped would somehow lead to progress. Additional choices were made that meant there would be little regulation and no evaluation. This left the ultimate control over service provision and control in the hands of the local EMS providers. The quality of the service provided was determined at the local level. iv The research questions were answered. EMS service provision in the Rochester Region of New York State does not meet national quality standards for providing meaningful and effective emergency medical care on a consistent basis. The quality of the EMS service provider is determined in large part by the most influential officer(s) of the service. The key decisions about quality are largely retained by the organization itself, rather than outside forces. The primary reason the region does not meet national standards on a consistent basis is because the State constructed a “system architecture” for EMS in New York with an organization design that compares poorly to characteristics of effective organizations. This left the State with an ineffective administrative system architecture to implement its policies. The EMS Council system was a poor choice. The fact that any progress was made at all was the result of local, pioneering leadership. Progress in quality EMS service provision in the Rochester region was made despite the EMS council system and State policy rather than because of it. v ACKNOWLEDGEMENTS Many people contributed to the accomplishment of this Sisyphean labor. Several friends, teachers and fellow travelers in EMS all contributed in their own way, either with important information, insights or timely encouragement. Yet, two individuals stand out as having made the most important and significant contributions beyond all others. Dr. Raymond Cox contributed many hours of effort, boundless energy and long measures of persistence to help me overcome all the hurdles placed in my way by time or circumstance. His timely assistance and insightful reviews of my work helped me to achieve not only this particular work, but also the years of course work, exams and endless labors of research necessary to bring this all to a successful conclusion. Most of all, he is a man of honor and integrity who keeps his word. My loving and devoted wife, Lynne, deserves special mention for her years of support and tolerance while I undertook yet one more course, one more book, or one more draft of seemingly endless papers in order to conclude this endurance contest successfully. Her patience and undying support are most appreciated. vi TABLE OF CONTENTS Page LIST OF FIGURES ................................................................................................. x LIST OF MAPS ..................................................................................................... xii CHAPTER I. INTRODUCTION AND BACKGROUND .................................................. 1 Evolution of the Policy Environment........................................................................ 5 Why Study the Implementation of an EMS System in the Rochester Region? ........ 52 Notes ..................................................................................................................... 56 II. LITERATURE REVIEW ........................................................................... 58 Strategic Management and Policy Literature .......................................................... 59 Organization Design Literature – Structure ............................................................ 62 Organization Design Literature – Function............................................................. 66 Implementation Literature...................................................................................... 69 Emergency Medical Care Literature....................................................................... 73 The Evolution of EMS Concepts............................................................................ 76 Summary Points of Medical and EMS Literature.................................................... 99 The Learning Organization: Feedback & Change ................................................. 104 Research Hypothesis ............................................................................................ 110 Notes ................................................................................................................... 111 vii III. METHODOLOGY ................................................................................... 112 Research Tools & Techniques .............................................................................. 115 Important Research Questions.............................................................................. 118 Limitations of Data .............................................................................................. 128 IV. ANALYSIS.............................................................................................. 135 Question 1: Does EMS Service Provision in the Rochester Region of New York State Meet National Quality Standards on a Consistent Basis?................................................................................................ 135 Question 2: What is the Primary Reason the Rochester Region Does Not Meet National Standards on a Consistent Basis? ............................... 197 Question 3: Given What is Reviewed Above, a Pertinent Question is Why Any Progress Was Made At All? ....................................................... 218 Conclusions ......................................................................................................... 235 Notes ................................................................................................................... 239 V. SUMMARY AND CONCLUSIONS........................................................ 241 Review of Central Themes ..................................................................................