RE: SSM from Canadian Emergency News

September 28, 2005

The disappointing about all this is that lots of people still kneel at the

feet of Stout. How long will it take them to realize that he is a charlatan

and that his theories are mush?

And when will EMS Providers finally realize that Stout's theories are flawed,

and that they must discard them?

Not until there are a lot of retirements, deaths, and firings. Stout people

are everywhere. They are sitting on promotion boards, hiring boards, and

firing boards. It's amazing that one guy with NO EMS credentials could have

influenced EMS to the extent that he has, all through a flawed, unproven

concept.

But he has done that, and his sycophants remain. Because they know that his

concepts are for making money, not for patient care. Show me ONE Stoutian

manager who gives a shit about the employees, and I'll buy you the dinner of

our choice. They don't exist. There is nobody in management of a Stout based

system who gives a rats ass about the rank and file employee. I challenge

any of them to prove otherwise.

GG.

> Fire stations (according to urban planners) are placed based on population

> density, access to major thoroughfares, and projected growth. As a fire

> station gets busier, the station is reassessed. If needed, additional

> stations are added or additional personnel/equipment is added to the station

> in question. Twice in my career we ran 29 emergency calls in 24 hours (in an

> era where there were only 6 ambulances. I don't think any single ambulance

> could handle 30 as you state, In FDNY they work 8 hour shifts.

>

> In SSM, you look at 20 weeks of data and try and predict when and where a

> call will occur. That is many steps beyond placement of a fire station and

> many steps beyond the supporting science. We know (by scientific study) that

> EMS calls are more frequent in lower socioeconomic areas and in areas where

> the elderly live. Most established hospitals are in these parts of town. So,

> on a moderately busy night in an SSM system, the first trip to the hospital

> is often followed by continuous calls the rest of the evening because every

> time you clear the hospital you are, by definition, the closest unit per the

> CAD. If you don't get that early transport, you spend the rest of the shift

> posting as you are farthest from the call.

>

> And what about disasters? Does DFR close down some downtown stations at

> night because the population has travelled to the suburbs? No, in these

> cases the apparatus backs up busier areas. In an SSM, they say, well things

> are quiet, let's only have X number of ambulances during certain slow hours.

> But, what happens when the system gets busy or a storm or disaster strikes?

> It is a fallacy and a fraud to tell anybody that you can, with any degree of

> certainty, predict where and when an EMS call will occur and therefore place

> an ambulance nearby to save time. For every call the posted ambulance is

> close to, there is another call it is farther from.

>

> Thus, comparing SSM to fire station location or even fluid system deployment

> is an apples and orange comparison. That is why Stout had to write a

> follow-up in JEMS on his SSM concept when none of the fire departments who

> operate EMS bought his dog and pony show.

>

> BEB

>

> _____

>

> From: [mailto: ] On

> Behalf Of THEDUDMAN@...

> Sent: Wednesday, September 28, 2005 10:57 PM

> To:

> Subject: Re: SSM from Canadian Emergency News

>

> Funny thing is Mike...you just described the SSM programs as it was

> originally defined and implemented in many systems...so if an ambulance is

> in a brick and mortar building on a street corner where it can get to the

> most calls the fastest is totally different than a unit parked in a parking

> lot catty-corner to this location...yeah...I see that.

>

> You know, there was research that caused a great stir about 6 weeks ago

> saying we shouldn't intubate pediatric patients because paramedics in a

> study group of patients couldn't intubate them...so everyone gets upset and

> says don't throw it out because some folks can't do it...that is my point on

> SSM...don't throw it out because many people who have no clue about how it

> works put some " flexible deployment " system into place and call it SSM and

> use and abuse crews with it...in systems where it works, employees are a

> part of the system design, and workloads and shift lengths are taken into

> consideration....it works very well.

>

> There is no secret to it...you use the same science that is used to place

> brick and mortar stations in place, put shorter shift units there (and maybe

> even have stations like some systems do) and allow personnel to go home and

> sleep in their own beds at the end of every shift instead of working a 24

> hour shift and running 30 calls...the same people who " use and abuse " crews

> in SSM models would do the same thing in static systems too...that is why

> the problem isn't with flexible deployment it is with the yahoo's who don't

> understand it and don't take care of their employees.

>

> Like pediatric intubations...don't throw the baby out with the bath

> water...(no pun intended).

>

> Dudley

>

> Re: SSM from Canadian Emergency News

> >

> > My partner and I are EMS consultants and we never recommend SSM. We

> always

> > point out the things that Dr. Bledsoe has stated, and attempt to undo the

> > damage that has been done by folks like Stout and his followers.

> >

> > Gene Gandy

> > HillGandy Associates

> > EMS Consultants

> >

> > > why I ask if it has been tried and tried in EMS do " consultants "

> continue

> > > to push the idea that SSM is the way? If these people were true

> statisticians

> >

> > > they would know by now that this has failed time and time again.

> > >

> > > SSM from Canadian Emergency News

> > >

> > > The Fallacy of System Status Management (SSM)

> > >

> > > By Dr. E. Bledsoe

> > >

> > > The concept of System Status Management (SSM) was

> introduced

> > > to

> > > EMS in the May, 1983 issue of JEMS magazine. <outbind://38/#_edn1> [1]

> > > Stout

> > > was a research fellow at the University of Oklahoma in the late 1970s

> and

> > > a

> > > part of a team of economists and behavioral scientists that was

> organized

> > > to

> > > perform a theoretical analysis of the prehospital care " industry. " The

> > > team,

> > > known as the Health Policy Research Team, was funded by a grant from

> the

> > > Kerr Foundation. The team was headed by Stout. However, Stout

> subsequently

> > > left the university and founded an EMS consulting firm known as The

> Fourth

> > > Party. The Fourth Party specialized in the development of " high

> > > performance

> > > EMS systems " which meant they primarily used the Public Utility Model

> > > (PUM)

> > > as a template for system design. Approximately 15 U.S. EMS systems

> adopted

> > > the PUM. However, there have been no new PUMs developed in the last 20

> > > years

> > > and several of the established PUMs have suffered significant

> financial

> > > problems, high employee turnover, and similar issues.

> <outbind://38/#_edn2>

> > >

> > > [2]

> > >

> > > The SSM theory was first applied to EMS operations in

> Tulsa

> > > and

> > > Oklahoma City and later to several other Midwestern U.S. cities.

> Later,

> > > several of the various components of " high performance EMS " were

> adopted

> > > by

> > > systems that do not use the PUM. Several EMS systems in Canada have

> > > adopted

> > > SSM. It is important to point out that virtually all EMS systems and

> fire

> > > departments have had deployment plans. That is, when several units in

> a

> > > particular part of town are busy, other units are routed toward that

> part

> > > of

> > > town in order to decrease response times in case a call is received.

> Stout

> > > took this one step further. He wrote, " System status management refers

> to

> > > the formal or informal systems protocols and procedures which

> determine

> > > where the remaining ambulances will be when the next call comes in. "

> > > Stout

> > > recommended that one look at both historic and geographic data in

> order to

> > > predict where the next ambulance call may occur and direct ambulances

> in

> > > that direction. He suggested that EMS follows a " weekly cycle " and SSM

> > > should target that. Typically, 20 weeks of historic and geographic

> call

> > > data

> > > are kept in the computer-aided dispatch (CAD) system. From this,

> > > ambulances

> > > are placed based upon perceived need. The foundation of SSM is to

> develop

> > > a

> > > system status management plan.

> > >

> > > In 1986, Stout further detailed the use of CAD to enhance

> SSM.

> > > <outbind://38/#_edn3> [3] He stated, " My own opinion is that it

> becomes

> > > impossible to reliably handle SSM controls on a manual basis when your

> pea

> > > k

> > > load coverage exceeds seven or eight units. After that level, you need

> > > automation. "

> > >

> > > The advantages of SSM, as detailed by Stout, are:

> > >

> > > * Reduce non-emergency service delays

> > > * Equalize service among neighborhoods

> > > * Safely " make room " for non-emergency service production at low

> > > marginal cost

> > > * Reduce the use of on-call crews

> > > * Reduce the frequency of post-to-post moves

> > > * Equalize workloads among crews

> > > * Differentiate workloads of 24-hour crews from those of short

> shift

> > > crews.

> > > * Furnish better mutual aid service

> > > * Reduce use of mutual aid service

> > > * Cut overtime

> > > * Employee schedules more convenient to crews

> > > * Battle " cream-skimmers " working your market.

> > > * Cut production costs without hurting response time performance.

> > >

> > > In 1989, in response to criticism of SSM, Stout published another

> article

> > > in

> > > JEMS that supposedly debunked the 6 " so-called " myths of SSM.

> > > <outbind://38/#_edn4> [4]

> > >

> > > Fallacies

> > >

> > > With this introduction in mind, let's look at the fallacies of this

> plan.

> > >

> > > 1. No peer review publications. System status management was

> > > introduced

> > > in several issues of the Journal of Emergency Medical Services (JEMS).

> > > JEMS

> > > is a U.S. EMS trade magazine and not peer-reviewed. A literature

> search

> > > failed to identify any scientific paper detailing the effectiveness of

> > > SSM.

> > > Several papers are written in scientific journals-but each is written

> > > under

> > > the premise that SSM is a proven system. <outbind://38/#_edn5> [5],

> > > <outbind://38/#_edn6> [6] The burden of proof for a particular system

> or

> > > practice is upon the proponents of such a system. With SSM, many in

> EMS

> > > adopted it at face value because it " intuitively " made sense or they

> were

> > > dazzled by suggested cost savings and improvements in efficiency.

> > > 2. Calls are predictable. It is intuitive that there will be more

> EMS

> > > calls during times when there are more cars on the road. And, it is

> > > intuitive that accidents are more likely to occur on roads. Thus, it

> makes

> > > sense to have an adequate number of ambulances during drive time and

> to

> > > position those ambulances where they can rapidly access major

> > > thoroughfares.

> > > Now, this is where SSM falls apart. It is statistically impossible,

> with

> > > ANY

> > > degree of accuracy, to predict where an ambulance call will occur

> (either

> > > geographically or temporally) based upon 20 weeks of data. In

> discussing

> > > the

> > > concept of SSM with 2 statisticians who hold doctorates, I asked how

> many

> > > weeks of data would be necessary to make an EMS call (or trend)

> prediction

> > > with any degree of scientific accuracy for a city the size of Fort

> Worth

> > > Texas (approximately 800,000 people). One said 20 years and the other

> said

> > > 100 years. Both pointed to the inability of weather service to

> accurately

> > > predict the high temperature for a day. With over 100 years of data,

> > > meteorologists can predict, with limited scientific accuracy, what the

> > > high

> > > temperature for a given day will be. Despite this, they are often

> wrong.

> > > And, they are dealing with a single variable!

> > >

> > > The ability to predict where and when a call will occur is

> > > nothing more than the statistical term probability. By definition,

> > > probability is a numerical quantity that expresses the likelihood of

> an

> > > event and is written as:

> > >

> > > Pr {E}

> > >

> > > The probability Pr {E} is always a number between 0 and 1. For

> example,

> > > each

> > > time you toss a coin in the air it will fall heads or tails. If the

> coin

> > > is

> > > not bent, it will equally fall heads and tails:

> > >

> > > However, with SSM we are using multiple random variables. The mean of

> a

> > > discrete random variable (Y) is defined as:

> > >

> > > where all the y1's are the values that the variable takes on and

> the

> > > sum is taken over all possible values. The mean of a random variable

> is

> > > also known as the expected value and is often written as E(Y) (thus

> > > E(Y)

> > > = .)

> > >

> > > Consider trying to predict where a call will occur in Fort

> > > Worth, Texas. Say, for example, there are 200,000 addresses in the

> CAD.

> > > There are 1,440 minutes in a day. Thus, what are the chances of making

> a

> > > calculation with this many variables that is nothing more than chance?

> The

> > > answer? Virtually impossible-even with a super computer. Furthermore,

> if

> > > an

> > > EMS system ever gathered enough historic and geographic data to make a

> > > prediction as to call time a location, the socioeconomic status of the

> > > city

> > > will have changed making the predictions irrelevant.

> > >

> > > 3. Reduce non-emergency service delays. In theory, SSM is designed to

> > > reduce non-emergent delays. However, in most systems that use SSM,

> > > non-emergency delays remain a major problem. The categorization of

> calls

> > > (and the low priority of non-emergency calls) continues to bump

> > > non-emergency calls down while ambulances are posted to perceived need

> > > areas

> > > in the event an emergency call comes in.

> > >

> > > 4. Equalize service among neighborhoods. This is one of the biggest

> > > fallacies of SSM. We know, from empiric studies, that ambulance demand

> is

> > > higher in low socioeconomic areas and areas where large numbers of

> elderly

> > > people live (also often low socioeconomic areas). Cadigan and Bugarin

> > > found

> > > that differences in EMS demand are related to median income,

> percentage of

> > > the population more than 65 years of age, and percentage of people

> living

> > > below the poverty level. Increased EMS demand was found in areas where

> a

> > > significant percentage of the population is greater than 65 years of

> age

> > > or

> > > living below the poverty level. <outbind://38/#_edn7> [7] Thus, if SSM

> is

> > > working as it should (diverting ambulances from predicted low call

> volume

> > > areas to predicted high call volume areas), ambulances should be

> routinely

> > > diverted from the younger and more affluent areas of town to regions

> where

> > > the population is older and living below the poverty level. This, in

> fact,

> > > discriminates against parts of town that use EMS infrequently (and

> parts

> > > of

> > > town where the majority of taxes are paid).

> > >

> > > 5. Safely " make room " for non-emergency service production at low

> > > marginal cost. In the U.S., reimbursement is better (and more

> reliable)

> > > for

> > > non-emergency calls than emergency calls. However, in Canada, the

> > > differences in reimbursement are much less. Thus, SSM will not

> > > significantly

> > > benefit Canadian EMS systems from this perspective.

> > > 6. Reduce the use of on-call crews. Here, Stout is being honest.

> SSM

> > > is

> > > designed to reduce staffing. More importantly, it is designed to

> reduce

> > > costs as posting ambulances from a central facility decreases the need

> for

> > > brick and mortar stations-a significant cost for EMS systems. This is

> > > particularly true for " for-profit " EMS systems in the U.S. that must

> also

> > > pay property taxes (ad-valorem) on brick and mortar stations

> (governmental

> > > agencies do not have to pay taxes). Looking beyond the smoke and

> mirrors,

> > > one of the main purposes of SSM is to get as much work as possible out

> of

> > > a

> > > subset of employees before bringing in back-up personnel which may

> cost

> > > overtime.

> > > 7. Reduce the frequency of post-to-post moves. Another fallacy!

> It is

> > > not uncommon for an EMS unit to travel 100-200 miles in a day and only

> run

> > > 3

> > > calls-the remainder of the time moving from post-to-post. Remember,

> the

> > > CAD

> > > cares not about the crew-only the location of the ambulance.

> > > 8. Equalize workloads among crews. If the system is not busy, SSM

> can

> > > equalize the workload. However, if the system is busy, EMS units that

> are

> > > busy stay busy. In many cities, hospitals are located downtown or in

> lower

> > > socioeconomic areas. Thus, every time a crew takes a patient to the

> > > hospital, they are closer to the next call when they clear the

> hospital.

> > > This is why some crews will run emergency calls all day while another

> crew

> > > does nothing but posts.

> > > 9. Differentiate workloads of 24-hour crews from those of short

> shift

> > > crews. This sounds good on paper. But, the CAD does not know a 24-hour

> > > crew

> > > from another crew. It simply selects the next closest ambulance

> > > regardless.

> > > 10. Furnish better mutual aid service. In the PUM, EMS systems

> are

> > > often

> > > financially penalized when they provide mutual aid-especially if it

> delays

> > > response times in their primary response area. Thus, systems using SSM

> are

> > > often reluctant to enter into mutual aid agreements with surrounding

> > > agencies. When this does occur, mutual aid is provided to the system

> using

> > > SSM more than system ambulances responding to neighboring communities

> > > (which

> > > are often suburbs).

> > > 11. Reduce use of mutual aid service. This is a non-sequitur.

> Stout

> > > wants to furnish better mutual aid service and, at the same time,

> reduce

> > > the

> > > use of mutual aid. The latter is the real preference as using mutual

> aid

> > > may

> > > be accompanied by a financial penalty. Thus, in many SSM systems, when

> the

> > > system reaches capacity-ambulances are asked to use lights and sirens

> to

> > > decrease transport times instead of asking for help from neighboring

> > > agencies.

> > > 12. Cut overtime. This is absolutely a goal. Cutting overtime

> cuts

> > > expenses. However, it fails to take into consideration other factors.

> > > Using

> > > a weekly cycle, the EMS system using SSM may drop the number of

> ambulances

> > > on a Saturday. But, if the weather on that day happens to turn bad, or

> a

> > > localized disaster occurs, personnel must be called in.

> > > 13. Employee schedules more convenient to crews. I dare you to

> find

> > > an

> > > SSM system where people like the schedules. Sometimes the schedules

> are

> > > contrary to the normal circadian rhythm and, other times, the schedule

> is

> > > so

> > > awkward that people have trouble adapting. For example, going in at

> 7:00

> > > PM

> > > and working until 3:00 AM is more stressful than typical 12-hour or

> 8-hour

> > > shifts.

> > > 14. Battle " cream-skimmers " working your market. This is more a

> U.S.

> > > phenomenon, But, as stated above, part of the goal of SSM is to keep

> " for

> > > profit " ambulances out of the non-emergency transfer market. In fact,

> most

> > > PUMs have exclusivity agreements where they are the only service used

> to

> > > transport any patient within the city. This leads to the problems with

> > > non-emergency patients already described.

> > > 15. Cut production costs without hurting response time

> performance.

> > > There is some truth here. Production costs are cut at the expense of

> > > personnel! Ambulances and personnel are relatively inexpensive

> (compared

> > > to

> > > brick and mortar stations). Thus, push personnel and the ambulances to

> > > their

> > > maximum-after all, they are expendable. It is no wonder that the

> incidence

> > > of back pain in Ottawa increased by 71% following the implementation

> of

> > > SSM.

> > > <outbind://38/#_edn8> [8] Furthermore, EMS personnel in Ottawa spent

> 51%

> > > of

> > > their time roaming.

> > >

> > > Summary

> > >

> > > Thus, to my colleagues in Canada, do not make the same mistake we have

> in

> > > the States. SSM is a bad idea and totally based on pseudoscience. It

> is

> > > promoted by consultants and experts who have never taken a look at the

> > > science (or lack thereof) behind the practice. Canada has a good EMS

> > > system

> > > and low employee turnover. SSM will drive away personnel in Canada as

> it

> > > has

> > > in the U.S. Consider this, why has not a single major fire department

> in

> > > the

> > > US (including those who operate the ambulance service) adopted SSM?

> The

> > > reason is obvious. They looked and did not find the system sound.

> Don't be

> > > dazzled by statistics and buzz words. The consultants will tell you

> that

> > > once SSM was instituted in Tulsa, Oklahoma, the response time

> decreased

> > > from

> > > 6 minutes 46 seconds to 6 minutes 9 seconds (statitistically

> > > significant-but

> > > not clinically significant). At the same time, maintenance costs

> increased

> > > by 38% and miles travelled increased by 19%. <outbind://38/#_edn9> [9]

> > > They

> > > always seem to leave that last part out. <outbind://38/#_edn10> [10]

> > >

> > > References

> > >

> > > _____

> > >

> > > <outbind://38/#_ednref1> [1] Stout JL. System Status Management: The

> > > Strategy of Ambulance Placement. Journal of Emergency Medical Services

> > > (JEMS. 1983;9(5):22-32,

> > >

> > > <outbind://38/#_ednref2> [2] Stout J. The public utility model, Part

> I:

> > > Measuring your system. Journal of Emergency Medical Services (JEMS).

> > > 1980;6(3):22-25.

> > >

> > > <outbind://38/#_ednref3> [3] Stout JL. Computer-Aided What? Journal of

> > > Emergency Medical Services (JEMS). 1986;12(12):89-94.

> > >

> > > <outbind://38/#_ednref4> [4] Stout JL. System Status Management: The

> Fact

> > > Is, It's Everywhere. Journal of Emergency Medical Services (JEMS).

> > > 1989;14(4):65-71

> > >

> > > <outbind://38/#_ednref5> [5] Stout JL, Pepe PE, Mosseso VN Jr. All

> > > advanced

> > > life support versus tiered response ambulances. Prehospital Emergency

> > > Care.2000:4(1):1-6

> > >

> > > <outbind://38/#_ednref6> [6] Hauswald M, Drake C. Innovations in

> emergency

> > > medical services. Emergency Medicine Clinics of North America.

> > > 1990;8(1):135-144

> > >

> > > <outbind://38/#_ednref7> [7] Cadigan RT, Bugarin CE. Predicting demand

> for

> > > emergency ambulance service. ls of Emergency Medicine.

> > > 1989;18:618-621.

> > >

> > > <outbind://38/#_ednref8> [8] Morneau PM, Stothart JP. My aching back:

> Th

> > > effects of system status management and ambulance design on EMS

> personnel.

> > > Journal of Emergency Medical Services (JEMS);1999:24(8):36-40

> > >

> > > <outbind://38/#_ednref9> [9] Hough TH. A View from the Street: System

> > > Status Management. Journal of Emergency Medical Services (JEMS).

> > > 1986;12(12):48-50

> > >

> > > <outbind://38/#_ednref10> [10] Bledsoe BE. EMS Myth # 7: System Status

> > > Management lowers response time and enhances patient care. Emergency

> > > Medical

> > > Services. 2003;32(9):158-159

> > >

September 28, 2005

Whatever! You think what you think. I think what I think. I don't

really give a rat's ass what you think.

You'll live with your system configuration as you want it to be. I have

nothing to do with it, so I don't have anything to say about it. If it's

great,

so be it, if it's sorry, then you'll have to deal with that.'

Gene G.

September 28, 2005

Whatever! You think what you think. I think what I think. I don't

really give a rat's ass what you think.

You'll live with your system configuration as you want it to be. I have

nothing to do with it, so I don't have anything to say about it. If it's

great,

so be it, if it's sorry, then you'll have to deal with that.'

Gene G.

September 28, 2005

Funny thing is Mike...you just described the SSM programs as it was originally

defined and implemented in many systems...so if an ambulance is in a brick and

mortar building on a street corner where it can get to the most calls the

fastest is totally different than a unit parked in a parking lot catty-corner to

this location...yeah...I see that.

You know, there was research that caused a great stir about 6 weeks ago saying

we shouldn't intubate pediatric patients because paramedics in a study group of

patients couldn't intubate them...so everyone gets upset and says don't throw it

out because some folks can't do it...that is my point on SSM...don't throw it

out because many people who have no clue about how it works put some " flexible

deployment " system into place and call it SSM and use and abuse crews with

it...in systems where it works, employees are a part of the system design, and

workloads and shift lengths are taken into consideration....it works very well.

There is no secret to it...you use the same science that is used to place brick

and mortar stations in place, put shorter shift units there (and maybe even have

stations like some systems do) and allow personnel to go home and sleep in their

own beds at the end of every shift instead of working a 24 hour shift and

running 30 calls...the same people who " use and abuse " crews in SSM models would

do the same thing in static systems too...that is why the problem isn't with

flexible deployment it is with the yahoo's who don't understand it and don't

take care of their employees.

Like pediatric intubations...don't throw the baby out with the bath water...(no

pun intended).

Dudley

Re: SSM from Canadian Emergency News

>

> My partner and I are EMS consultants and we never recommend SSM. We always

> point out the things that Dr. Bledsoe has stated, and attempt to undo the

> damage that has been done by folks like Stout and his followers.

>

> Gene Gandy

> HillGandy Associates

> EMS Consultants

>

> > why I ask if it has been tried and tried in EMS do " consultants " continue

> > to push the idea that SSM is the way? If these people were true

statisticians

>

> > they would know by now that this has failed time and time again.

> >

> > SSM from Canadian Emergency News

> >

> > The Fallacy of System Status Management (SSM)

> >

> > By Dr. E. Bledsoe

> >

> > The concept of System Status Management (SSM) was introduced

> > to

> > EMS in the May, 1983 issue of JEMS magazine. <outbind://38/#_edn1> [1]

> > Stout

> > was a research fellow at the University of Oklahoma in the late 1970s and

> > a

> > part of a team of economists and behavioral scientists that was organized

> > to

> > perform a theoretical analysis of the prehospital care " industry. " The

> > team,

> > known as the Health Policy Research Team, was funded by a grant from the

> > Kerr Foundation. The team was headed by Stout. However, Stout subsequently

> > left the university and founded an EMS consulting firm known as The Fourth

> > Party. The Fourth Party specialized in the development of " high

> > performance

> > EMS systems " which meant they primarily used the Public Utility Model

> > (PUM)

> > as a template for system design. Approximately 15 U.S. EMS systems adopted

> > the PUM. However, there have been no new PUMs developed in the last 20

> > years

> > and several of the established PUMs have suffered significant financial

> > problems, high employee turnover, and similar issues.

<outbind://38/#_edn2>

> >

> > [2]

> >

> > The SSM theory was first applied to EMS operations in Tulsa

> > and

> > Oklahoma City and later to several other Midwestern U.S. cities. Later,

> > several of the various components of " high performance EMS " were adopted

> > by

> > systems that do not use the PUM. Several EMS systems in Canada have

> > adopted

> > SSM. It is important to point out that virtually all EMS systems and fire

> > departments have had deployment plans. That is, when several units in a

> > particular part of town are busy, other units are routed toward that part

> > of

> > town in order to decrease response times in case a call is received. Stout

> > took this one step further. He wrote, " System status management refers to

> > the formal or informal systems protocols and procedures which determine

> > where the remaining ambulances will be when the next call comes in. "

> > Stout

> > recommended that one look at both historic and geographic data in order to

> > predict where the next ambulance call may occur and direct ambulances in

> > that direction. He suggested that EMS follows a " weekly cycle " and SSM

> > should target that. Typically, 20 weeks of historic and geographic call

> > data

> > are kept in the computer-aided dispatch (CAD) system. From this,

> > ambulances

> > are placed based upon perceived need. The foundation of SSM is to develop

> > a

> > system status management plan.

> >

> > In 1986, Stout further detailed the use of CAD to enhance SSM.

> > <outbind://38/#_edn3> [3] He stated, " My own opinion is that it becomes

> > impossible to reliably handle SSM controls on a manual basis when your pea

> > k

> > load coverage exceeds seven or eight units. After that level, you need

> > automation. "

> >

> > The advantages of SSM, as detailed by Stout, are:

> >

> > * Reduce non-emergency service delays

> > * Equalize service among neighborhoods

> > * Safely " make room " for non-emergency service production at low

> > marginal cost

> > * Reduce the use of on-call crews

> > * Reduce the frequency of post-to-post moves

> > * Equalize workloads among crews

> > * Differentiate workloads of 24-hour crews from those of short shift

> > crews.

> > * Furnish better mutual aid service

> > * Reduce use of mutual aid service

> > * Cut overtime

> > * Employee schedules more convenient to crews

> > * Battle " cream-skimmers " working your market.

> > * Cut production costs without hurting response time performance.

> >

> > In 1989, in response to criticism of SSM, Stout published another article

> > in

> > JEMS that supposedly debunked the 6 " so-called " myths of SSM.

> > <outbind://38/#_edn4> [4]

> >

> > Fallacies

> >

> > With this introduction in mind, let's look at the fallacies of this plan.

> >

> > 1. No peer review publications. System status management was

> > introduced

> > in several issues of the Journal of Emergency Medical Services (JEMS).

> > JEMS

> > is a U.S. EMS trade magazine and not peer-reviewed. A literature search

> > failed to identify any scientific paper detailing the effectiveness of

> > SSM.

> > Several papers are written in scientific journals-but each is written

> > under

> > the premise that SSM is a proven system. <outbind://38/#_edn5> [5],

> > <outbind://38/#_edn6> [6] The burden of proof for a particular system or

> > practice is upon the proponents of such a system. With SSM, many in EMS

> > adopted it at face value because it " intuitively " made sense or they were

> > dazzled by suggested cost savings and improvements in efficiency.

> > 2. Calls are predictable. It is intuitive that there will be more EMS

> > calls during times when there are more cars on the road. And, it is

> > intuitive that accidents are more likely to occur on roads. Thus, it makes

> > sense to have an adequate number of ambulances during drive time and to

> > position those ambulances where they can rapidly access major

> > thoroughfares.

> > Now, this is where SSM falls apart. It is statistically impossible, with

> > ANY

> > degree of accuracy, to predict where an ambulance call will occur (either

> > geographically or temporally) based upon 20 weeks of data. In discussing

> > the

> > concept of SSM with 2 statisticians who hold doctorates, I asked how many

> > weeks of data would be necessary to make an EMS call (or trend) prediction

> > with any degree of scientific accuracy for a city the size of Fort Worth

> > Texas (approximately 800,000 people). One said 20 years and the other said

> > 100 years. Both pointed to the inability of weather service to accurately

> > predict the high temperature for a day. With over 100 years of data,

> > meteorologists can predict, with limited scientific accuracy, what the

> > high

> > temperature for a given day will be. Despite this, they are often wrong.

> > And, they are dealing with a single variable!

> >

> > The ability to predict where and when a call will occur is

> > nothing more than the statistical term probability. By definition,

> > probability is a numerical quantity that expresses the likelihood of an

> > event and is written as:

> >

> > Pr {E}

> >

> > The probability Pr {E} is always a number between 0 and 1. For example,

> > each

> > time you toss a coin in the air it will fall heads or tails. If the coin

> > is

> > not bent, it will equally fall heads and tails:

> >

> > However, with SSM we are using multiple random variables. The mean of a

> > discrete random variable (Y) is defined as:

> >

> > where all the y1's are the values that the variable takes on and the

> > sum is taken over all possible values. The mean of a random variable is

> > also known as the expected value and is often written as E(Y) (thus

> > E(Y)

> > = .)

> >

> > Consider trying to predict where a call will occur in Fort

> > Worth, Texas. Say, for example, there are 200,000 addresses in the CAD.

> > There are 1,440 minutes in a day. Thus, what are the chances of making a

> > calculation with this many variables that is nothing more than chance? The

> > answer? Virtually impossible-even with a super computer. Furthermore, if

> > an

> > EMS system ever gathered enough historic and geographic data to make a

> > prediction as to call time a location, the socioeconomic status of the

> > city

> > will have changed making the predictions irrelevant.

> >

> > 3. Reduce non-emergency service delays. In theory, SSM is designed to

> > reduce non-emergent delays. However, in most systems that use SSM,

> > non-emergency delays remain a major problem. The categorization of calls

> > (and the low priority of non-emergency calls) continues to bump

> > non-emergency calls down while ambulances are posted to perceived need

> > areas

> > in the event an emergency call comes in.

> >

> > 4. Equalize service among neighborhoods. This is one of the biggest

> > fallacies of SSM. We know, from empiric studies, that ambulance demand is

> > higher in low socioeconomic areas and areas where large numbers of elderly

> > people live (also often low socioeconomic areas). Cadigan and Bugarin

> > found

> > that differences in EMS demand are related to median income, percentage of

> > the population more than 65 years of age, and percentage of people living

> > below the poverty level. Increased EMS demand was found in areas where a

> > significant percentage of the population is greater than 65 years of age

> > or

> > living below the poverty level. <outbind://38/#_edn7> [7] Thus, if SSM is

> > working as it should (diverting ambulances from predicted low call volume

> > areas to predicted high call volume areas), ambulances should be routinely

> > diverted from the younger and more affluent areas of town to regions where

> > the population is older and living below the poverty level. This, in fact,

> > discriminates against parts of town that use EMS infrequently (and parts

> > of

> > town where the majority of taxes are paid).

> >

> > 5. Safely " make room " for non-emergency service production at low

> > marginal cost. In the U.S., reimbursement is better (and more reliable)

> > for

> > non-emergency calls than emergency calls. However, in Canada, the

> > differences in reimbursement are much less. Thus, SSM will not

> > significantly

> > benefit Canadian EMS systems from this perspective.

> > 6. Reduce the use of on-call crews. Here, Stout is being honest. SSM

> > is

> > designed to reduce staffing. More importantly, it is designed to reduce

> > costs as posting ambulances from a central facility decreases the need for

> > brick and mortar stations-a significant cost for EMS systems. This is

> > particularly true for " for-profit " EMS systems in the U.S. that must also

> > pay property taxes (ad-valorem) on brick and mortar stations (governmental

> > agencies do not have to pay taxes). Looking beyond the smoke and mirrors,

> > one of the main purposes of SSM is to get as much work as possible out of

> > a

> > subset of employees before bringing in back-up personnel which may cost

> > overtime.

> > 7. Reduce the frequency of post-to-post moves. Another fallacy! It is

> > not uncommon for an EMS unit to travel 100-200 miles in a day and only run

> > 3

> > calls-the remainder of the time moving from post-to-post. Remember, the

> > CAD

> > cares not about the crew-only the location of the ambulance.

> > 8. Equalize workloads among crews. If the system is not busy, SSM can

> > equalize the workload. However, if the system is busy, EMS units that are

> > busy stay busy. In many cities, hospitals are located downtown or in lower

> > socioeconomic areas. Thus, every time a crew takes a patient to the

> > hospital, they are closer to the next call when they clear the hospital.

> > This is why some crews will run emergency calls all day while another crew

> > does nothing but posts.

> > 9. Differentiate workloads of 24-hour crews from those of short shift

> > crews. This sounds good on paper. But, the CAD does not know a 24-hour

> > crew

> > from another crew. It simply selects the next closest ambulance

> > regardless.

> > 10. Furnish better mutual aid service. In the PUM, EMS systems are

> > often

> > financially penalized when they provide mutual aid-especially if it delays

> > response times in their primary response area. Thus, systems using SSM are

> > often reluctant to enter into mutual aid agreements with surrounding

> > agencies. When this does occur, mutual aid is provided to the system using

> > SSM more than system ambulances responding to neighboring communities

> > (which

> > are often suburbs).

> > 11. Reduce use of mutual aid service. This is a non-sequitur. Stout

> > wants to furnish better mutual aid service and, at the same time, reduce

> > the

> > use of mutual aid. The latter is the real preference as using mutual aid

> > may

> > be accompanied by a financial penalty. Thus, in many SSM systems, when the

> > system reaches capacity-ambulances are asked to use lights and sirens to

> > decrease transport times instead of asking for help from neighboring

> > agencies.

> > 12. Cut overtime. This is absolutely a goal. Cutting overtime cuts

> > expenses. However, it fails to take into consideration other factors.

> > Using

> > a weekly cycle, the EMS system using SSM may drop the number of ambulances

> > on a Saturday. But, if the weather on that day happens to turn bad, or a

> > localized disaster occurs, personnel must be called in.

> > 13. Employee schedules more convenient to crews. I dare you to find

> > an

> > SSM system where people like the schedules. Sometimes the schedules are

> > contrary to the normal circadian rhythm and, other times, the schedule is

> > so

> > awkward that people have trouble adapting. For example, going in at 7:00

> > PM

> > and working until 3:00 AM is more stressful than typical 12-hour or 8-hour

> > shifts.

> > 14. Battle " cream-skimmers " working your market. This is more a U.S.

> > phenomenon, But, as stated above, part of the goal of SSM is to keep " for

> > profit " ambulances out of the non-emergency transfer market. In fact, most

> > PUMs have exclusivity agreements where they are the only service used to

> > transport any patient within the city. This leads to the problems with

> > non-emergency patients already described.

> > 15. Cut production costs without hurting response time performance.

> > There is some truth here. Production costs are cut at the expense of

> > personnel! Ambulances and personnel are relatively inexpensive (compared

> > to

> > brick and mortar stations). Thus, push personnel and the ambulances to

> > their

> > maximum-after all, they are expendable. It is no wonder that the incidence

> > of back pain in Ottawa increased by 71% following the implementation of

> > SSM.

> > <outbind://38/#_edn8> [8] Furthermore, EMS personnel in Ottawa spent 51%

> > of

> > their time roaming.

> >

> > Summary

> >

> > Thus, to my colleagues in Canada, do not make the same mistake we have in

> > the States. SSM is a bad idea and totally based on pseudoscience. It is

> > promoted by consultants and experts who have never taken a look at the

> > science (or lack thereof) behind the practice. Canada has a good EMS

> > system

> > and low employee turnover. SSM will drive away personnel in Canada as it

> > has

> > in the U.S. Consider this, why has not a single major fire department in

> > the

> > US (including those who operate the ambulance service) adopted SSM? The

> > reason is obvious. They looked and did not find the system sound. Don't be

> > dazzled by statistics and buzz words. The consultants will tell you that

> > once SSM was instituted in Tulsa, Oklahoma, the response time decreased

> > from

> > 6 minutes 46 seconds to 6 minutes 9 seconds (statitistically

> > significant-but

> > not clinically significant). At the same time, maintenance costs increased

> > by 38% and miles travelled increased by 19%. <outbind://38/#_edn9> [9]

> > They

> > always seem to leave that last part out. <outbind://38/#_edn10> [10]

> >

> > References

> >

> > _____

> >

> > <outbind://38/#_ednref1> [1] Stout JL. System Status Management: The

> > Strategy of Ambulance Placement. Journal of Emergency Medical Services

> > (JEMS. 1983;9(5):22-32,

> >

> > <outbind://38/#_ednref2> [2] Stout J. The public utility model, Part I:

> > Measuring your system. Journal of Emergency Medical Services (JEMS).

> > 1980;6(3):22-25.

> >

> > <outbind://38/#_ednref3> [3] Stout JL. Computer-Aided What? Journal of

> > Emergency Medical Services (JEMS). 1986;12(12):89-94.

> >

> > <outbind://38/#_ednref4> [4] Stout JL. System Status Management: The Fact

> > Is, It's Everywhere. Journal of Emergency Medical Services (JEMS).

> > 1989;14(4):65-71

> >

> > <outbind://38/#_ednref5> [5] Stout JL, Pepe PE, Mosseso VN Jr. All

> > advanced

> > life support versus tiered response ambulances. Prehospital Emergency

> > Care.2000:4(1):1-6

> >

> > <outbind://38/#_ednref6> [6] Hauswald M, Drake C. Innovations in emergency

> > medical services. Emergency Medicine Clinics of North America.

> > 1990;8(1):135-144

> >

> > <outbind://38/#_ednref7> [7] Cadigan RT, Bugarin CE. Predicting demand for

> > emergency ambulance service. ls of Emergency Medicine.

> > 1989;18:618-621.

> >

> > <outbind://38/#_ednref8> [8] Morneau PM, Stothart JP. My aching back: Th

> > effects of system status management and ambulance design on EMS personnel.

> > Journal of Emergency Medical Services (JEMS);1999:24(8):36-40

> >

> > <outbind://38/#_ednref9> [9] Hough TH. A View from the Street: System

> > Status Management. Journal of Emergency Medical Services (JEMS).

> > 1986;12(12):48-50

> >

> > <outbind://38/#_ednref10> [10] Bledsoe BE. EMS Myth # 7: System Status

> > Management lowers response time and enhances patient care. Emergency

> > Medical

> > Services. 2003;32(9):158-159

> >

September 28, 2005